WURZBACH NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #6) reviewed for injuries of unknown origin reporting, in that:<BR/>Resident #6 was assessed with a large bruise from her chest to her under arm and continued to her back, which was not investigated and not reported to the state agency and Resident #6's Guardian as an injury of unknown origin. <BR/>This failure could place Resident(s) at risk for harm by further exposure to injuries without proper investigation and reporting. <BR/>The findings included:<BR/>A record review of Resident #6's admission Record, dated 02/28/2023, revealed an admission date of 11/30/2018, with diagnoses which included Alzheimer's disease [causes the brain to shrink and brain cells to eventually die] and dementia [a range of conditions that affect the brain's ability to think, remember, and function normally]. Further review revealed Resident #6 was represented by a Guardian [Guardian Q]. <BR/>A record review of Resident #6 quarterly MDS, dated [DATE], revealed Resident #6 was an [AGE] year-old female who could usually understand some conversations, could usually make herself understood, given time; however, Resident #6 was assessed to have severe cognitive impairment with short- and long-term memory problems. <BR/>A record review of Resident #6's medical records revealed a Weekly Skin Observation Tool, dated 01/27/2023, Observations; does Resident have any observed skin issues? No. <BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, c/o [complaint of] pain to RT [right] shoulder. PRN [as needed] tramadol and muscle pain cream applied. Notified [Nurse Practitioner P] Xray ordered to RT. Shoulder claim #XXXXXXXX.<BR/>A record review of Resident #6's Weekly Skin Observation Tool, dated 01/30/2023, revealed, Observations; does Resident have any observed skin issues? Yes .site: right shoulder bruising .<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, [Resident #6 Family Member] on premises to visit [Resident #6] this nurse notified him of some bruising to RT [right] shoulder and c/o [complaint of] pain and Xray was ordered [Resident #6 Family Member] got upset and stated the reason why she is here is to protect her and her [Resident #6 Family Member] kept asking her what happened she said I don't know then [Resident #6 Family Member] asked who hurt you [?] and she responded no one hurt her she does not know what happened. Call placed to [Guardian Q] mailbox full.<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN R, Resident is day 2/3 bruise to R [right] axilla site [arm pit]. Site is c [with] swelling, warmth and discoloration. Localized inflammation to site. Noted to grimace upon assessment c [with] Tylenol regiment offered per this nurse and resident refusing x2 [twice] attempts. Allow this nurse to slightly prop arm on pillow. Resident observed to touch site often. Pleasantly confused to baseline. Receptive to staff assessment. Routine X-ray results in with right shoulder demonstrating no acute fracture. No joint discoloration. mild Bony demineralization. unremarkable soft tissues. there is severe AC joint [shoulder joint] and mild glenohumeral [the joint that connects the body to the arm] arthritis manifested by joint space narrowing, subchondral sclerosis, and degenerative spurring. will follow up with team health as indicated.<BR/>A record review of Resident #6's medical records revealed a Nurse Practitioner's Progress Note, dated 01/31/2023, authored by Nurse Practitioner P, revealed, Chief complaint / nature of presenting problem: follow up done on large bruising to chest and underarm area reported by nursing today. patient is unable to recall events. She can verbalize needs and report concerns to nurses. Patient is not currently on blood thinners. no falls reported. Have met with director of nursing / administrator to discuss further. Plan: hematoma / ecchymosis [bruising] to chest yellowish in color. Patient is unable to recall how she got it. No falls or trauma reported by nursing. Marking may be associated with gait belt for transfers as it goes around chest and underarms. Patient denied pain at this time. Will monitor for now.<BR/>During an interview and record review on 02/28/2022 at 01:25 PM Resident #6's Guardian, Guardian Q, stated she was not aware Resident #6 had an injury of unknow origin. Guardian Q stated she would have expected the facility to have reported any injury, especially a large bruise of unknown origin to her and possibly to the police. Guardian Q stated she could be contacted by cell phone, text message, and or her email. Guardian Q and surveyor confirmed contact information held by the facility as accurate. Guardian Q stated if by chance she missed a cell call she could have been contacted by email and or text message. <BR/>During an interview on 02/28/2023 at 02:15 PM LVN G stated she had assessed Resident #6 with a bruise to her right under arm and chest and reported the bruise to Nurse Practitioner P and RN F. LVN stated she wrote a progress note in Resident #6's medical record. LVN G stated the bruise was of unknown origin and Resident #6 could not state how she developed the bruise. LVN G stated she had not considered Resident #6's bruise a reportable event. LVN G stated she now understands, due to reflection of the incident, Resident #6's injury of unknown origin was a reportable event she should have reported to the Administrator. <BR/>During an interview on 03/02/2023 at 07:56 AM, Resident #6's Family Member stated they spoke with LVN G and stated, it's not right she [Resident #6] had a bruise. Resident #6's Family Member stated they had a concern, no one could explain how this happened [bruise]. Resident #6's Family Member stated Resident #6 claimed, I don't know how the bruise came to be. Resident #6's Family Member stated no one has reported to him the results of how this [bruise] happened. <BR/>During an interview on 03/03/2023 at 08:30 AM, the Administrator stated he did not believe Resident #6's injury of unknown origin was not a reportable incident due to Resident #6's own report that no one hurt her, even though the surveyor reminded the Administrator of a record review of Resident #6's diagnoses of Alzheimer's disease and dementia. <BR/>A record review of the facility's Recognizing Signs and Symptoms of Abuse / Neglect policy, dated April 2021, revealed, All types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse / neglect to their supervisor or to the director of nursing services immediately. Policy interpretation and implementation: The following are signs and symptoms of abuse / neglect there should be promptly reported. this listing is not all inclusive. other signs and symptoms are actual abuse /neglect may be apparent . signs of physical abuse: injuries that are non-accidental or unexplained . bruises, including those found in unusual locations such as the head neck lateral locations on the arms or posterior trunk and torso . signs of sexual abuse: bruises around the breast, general area or inner thighs .<BR/>A record review of the facility's Abuse, neglect, exploitation and misappropriation prevention program policy, dated April 2021, revealed, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Policy interpretation and implementation . the resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: staff; other residents . identify and investigate all possible incidents of abuse neglect, mistreatment for misappropriation of resident property .investigate and report any allegations within time frames required by federal requirement .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be free of misappropriation of resident property and exploitation for 2 of 4 residents (Resident #5 and Resident #6) reviewed for misappropriation and exploitation.<BR/>The facility failed to ensure Resident #5 and Resident #6's pain medications were secured and not lost.<BR/>These failures could place residents who received pain medications at risk of decreased quality of life, misappropriation of property and distress. <BR/>The findings included:<BR/>1. Record review of Resident #5's face sheet dated 3/9/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included osteomyelitis (infection of the bone usually caused by bacteria that can cause pain, selling and redness throughout the affected area), peripheral vascular disease (condition in which the blood vessels become narrowed or blocked and affects the blood flow to the legs, feed and sometimes arms), diabetes with neuropathy (condition where high blood sugar levels cause nerve damage), pain in right foot, and chronic ulcer (a long-lasting open wound or sore that does not heal within a typical timeframe due to underlying health conditions, such as diabetes) of the right foot.<BR/>Record review of Resident #5's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, experienced pain occasionally, and received opioid medications.<BR/>Record review of Resident #5's comprehensive care plan with revision dated 1/30/25 revealed the resident had acute/chronic pain related to surgical incision/wound with interventions that included to administer analgesics as ordered, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. <BR/>Record review of Resident #5's MAR (Medication Administration Record) for February 2025 included the following:<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, Give 1 tablet by mouth every 4 hours as needed for pain with start date 11/4/24 and no stop date. Further review of the MAR revealed the resident received one dose on 2/25/25 at 7:16 p.m. <BR/>- Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen), Give 2 tablets by mouth every 6 hours as needed for Pain until Hydrocodone comes in, with start date 11/4/24 and no stop date. Further review of the MAR revealed did not receive any does of the Tylenol Extra Strength for the month of February.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALERT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with order date 2/5/25 and no stop date. Further review of the MAR revealed the resident scored a 0, indicating no pain recorded for every shift, except 2/24/25 with a score of 4 recorded on the evening shift, and 2/26/25-2/27/25 with a score of 3 recorded on the day shift.<BR/>Record review of Resident #5's MAR for March 2025 included the following:<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth every 4 hours as needed for pain with start date 11/4/24 and no end date. Further review of the MAR revealed the resident did not receive any doses of the HYDROcodone-Acetaminophen.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALERT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no stop date. Further review of the MAR revealed the resident rated 0 for pain level during all three shifts for the month.<BR/>-Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen), Give 2 tablet by mouth every 6 hours as needed for Pain until Hydrocodone comes in, with start date 11/4/24 and no end date. Further review of the MAR revealed the resident received the Tylenol Extra Strength on 3/5/25 at 12:00 a.m., and again on 3/6/25 at 12:27p.m.<BR/>2. Record review of Resident #6's face sheet dated 3/9/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (symptoms associated with a decline in memory, reasoning and other cognitive abilities severe enough to interfere with daily life), bipolar disorder (mental health condition characterized by extreme mood swings), primary osteoarthritis of knee (degenerative joint disease that affects the same joints on both sides of the body), and age-related osteoporosis (condition characterized by a gradual decrease in bone mineral density and mas leading to weakened bones that are more susceptible to fractures) without current pathological fracture.<BR/>Record review of Resident #6's most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and did not receive antipsychotic or opioid medications.<BR/>Record review of Resident #6's comprehensive care plan with revision date 11/18/24 revealed the resident had osteoporosis with a history of fractures and interventions that included to give analgesics as needed for pain and medications as ordered.<BR/>Record review of Resident #6's MAR for February 2025 included the following:<BR/>- Tramadol HCL Oral Tablet 50 mg, Give 1 tablet by mouth every 6 hours as needed for pain, with start date 11/7/24 and no end date<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-300 MG, Give 1 tablet by mouth every 6 hours as needed for pain with start dated 11/7/24 and discontinue date 2/14/25. Further review of the MAR revealed the resident was not given any HYDROcodone-Acetaminophen during that timeframe.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALEFT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUMENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no end date. Further review of the MAR revealed the resident rated a pain level of 6 on 2/19/25 during the day shift and was administered Tramadol 50 mg used as needed for pain.<BR/>Record review of Resident #6's MAR for March 2025 included the following:<BR/>- Tramadol HCL Oral Tablet 50 mg, Give 1 tablet by mouth every 6 hours as needed for pain, with start date 11/7/24 and no end date. Further review of the MAR revealed the resident did not receive any doses of Tramadol up until the investigation on 3/9/25.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALEFT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUMENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no end date. Further review of the MAR revealed the resident rated a pain level of 0 from 3/1/25 up until the investigation on 3/9/25.<BR/>Record review of the facility provider investigation report written by the facility Administrator, dated 3/12/25 revealed in part, .Staff member reported suspicion of missing narcotics to the DON .Provider Response: Investigation initiated immediately .6 individuals (RN D, RN G, LVN H, LVN K, LVN L and LVN M) were identified to have come in contact during the period that medication went missing, and were sent for UA's [urinalysis] to screen for opioids all with negative findings .In investigation we have found that 208 Norco 10/325 mg tablets, and 15 Phenobarbital Tablets were diverted .<BR/>During a joint interview on 3/8/25 at 9:31 a.m., the Administrator and the DON revealed they were trying to put a timeline together regarding a possible drug diversion. The DON stated he had received a phone call on 3/4/25 at approximately 11:26 p.m. from RN G regarding suspicion of a drug diversion. The DON stated, RN G informed him a blister pack of narcotics belonging to Resident #5 was not in the medication cart that RN G had seen the previous evening. The DON stated the missing blister pack was Resident #5's HYDROcodone-Acetaminophen. The DON stated, RN G assumed responsibility for the medication cart from RN D for two consecutive shifts, 3/3/25 and 3/4/25. The DON stated the facility operated on three shifts, and acknowledged RN D had worked two double shifts on 3/3/25 and 3/4/25 and on both shifts handed over the medication cart to RN G. The Administrator stated an investigation was initiated the following morning on 3/5/25 and it was determined there were 30 doses of HYDROcodone-Acetaminophen missing for Resident #5. After further investigation, the DON stated, he did a look back of the staff who were responsible for the medication cart identified with Resident #5's missing HYDROcodone-Acetaminophen. The DON stated, RN D, RN G, LVN H, LVN K, LVN L and LVN M were identified having worked from the medication cart with Resident #5's medications and had them drug tested. The Administrator stated the police were notified and a police report was completed. The Administrator and the DON acknowledged the missing HYDROcodone-Acetaminophen that belonged to Resident #5 was never found. The DON stated he further expanded his investigation to include narcotics delivered to the facility for February 2025. The DON acknowledged there were additional narcotics the facility could not account for Resident #6. The DON stated, he determined there were 118 doses of HYDROcodone-Acetaminophen missing for Resident #6. The DON further stated 15 doses of phenobarbital could not be accounted for out of 45 doses delivered on 2/12/25. The DON and Administrator acknowledged the HYDROcodone-Acetaminophen missing for Resident #6 and the phenobarbital doses were never found. The Administrator and the DON stated Resident #5 and Resident #6's narcotics were replaced at no cost to the resident and if the residents had complained of pain, HYDROcodone-Acetaminophen doses were available in the emergency kit if the resident required it. The DON and the Administrator stated they believed RN D was responsible for the drug diversion associated with Resident #5's medications and LVN F was responsible for Resident #6's missing medications.<BR/>During an observation and interview on 3/8/25 at 11:49 a.m., Resident #5 stated he received pain medications and did not recall having been told by facility staff he did not have any pain medications available. Resident #5 was observed with a bandage on the right lower foot. Resident #5 further stated he asked for pain medication, maybe once or twice and received them pretty quick. <BR/>During an observation and interview on 3/8/25 at 12:43 p.m., Resident #6 was seen sitting up in the dining room eating lunch without assistance. Resident #6 did not appear to be in any obvious distress or discomfort but was unable to answer any questions.<BR/>During a telephone interview on 3/8/25 at 1:06 p.m., RN G stated he reported to the DON a possible drug diversion on 3/4/25 at approximately 11:00 p.m. RN G stated he made rounds and was in the process of providing wound care to Resident #5 and asked the resident if he wanted anything for pain. RN G stated Resident #5 was given a choice of HYDROcodone-Acetaminophen or regular acetaminophen. RN G stated Resident #5 asked for the HYDROcodone-Acetaminophen but was unsure if the medication had been discontinued since it had been a while since he (Resident #5) had gotten it. RN G stated, when he returned to the medication cart to retrieve it, there was none in the cart. RN G stated Resident #5 approved taking regular acetaminophen. RN G stated, I know he (Resident #5) had that medication. On Tuesday morning (3/4/25), it was just me and RN D had been working the unit three days in a row. RN G stated, he believed Resident #5's HYDROcodone-Acetaminophen had been discontinued but not until I needed it I realized something was off.<BR/>During a telephone interview on 3/8/25 at 1:45 p.m., LVN F stated she had worked for the facility for approximately a month and self-terminated. LVN F stated she was not working at the facility on 2/17/25 during the time the facility determined a drug diversion. LVN F stated she did not recall ever having given Resident #6 any medications.<BR/>During a follow up telephone interview on 3/9/25 at 10:05 a.m., LVN F stated she recalled signing for delivered medications, including narcotics, and would have signed for the shipment from the pharmacy driver via an electronic signature. LVN F stated, the medications delivered were verified by a second nurse and both nurses would then have to sign the narcotic log associated with the medication, place the narcotic log in the binder and put the narcotic medications in the medication cart. LVN F denied taking any medications, including narcotics while employed at the facility.<BR/>During a telephone interview on 3/9/25 at 4:12 p.m., RN D acknowledged she worked double shifts on 3/3/25 and 3/4/25 and did a medication narcotic count with RN G at the end of the shift. RN D stated, I have not had medications missing, but I have heard of other carts missing medications. <BR/>During a follow up telephone interview on 3/9/25 at 4:43 p.m., RN D stated she had not given Resident #5 any pain medications, and the resident asked for them few and far between. RN D stated Resident #5 had HYDROcodone-Acetaminophen scheduled as needed and had been trying to have the medication placed on a schedule instead of as needed when the residents used to complain of pain but then I backed off. RN D stated she was not aware of a discrepancy with Resident #5's medications. RN D further stated, If the (narcotic) count was off, I would not accept it and call the DON. That has never happened to me. RN D denied taking any medications, including narcotics from residents at the facility.<BR/>Record review of the e-mail received on 3/12/25 at 3:34 p.m. from the Administrator revealed the drug test results for RN D, RN G, LVN H, LVN K, LVN L and LVN M were negative.<BR/>Record review of the facility policy and procedure provided by the Administrator, titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC), dated 8/29/24 revealed in part, .2.1 Incidents that a NF Must Report to HHSC .Misappropriation .Drug Theft .HHSC rules define misappropriation as, 'the taking, secretion, misapplication, deprivation, transfer, or attempted transfer to any person not entitled to receive property, real, or personal, or anything of value belonging to or under the legal control of a resident without the effective consent of the resident or other appropriate legal authority, or the taking of any action contrary to any duty imposed by federal or state law prescribing conduct relating to the custody or disposition of property of a resident .CMS defines misappropriation of resident property as, 'the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent' .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #6) reviewed for injuries of unknown origin reporting, in that:<BR/>Resident #6 was assessed with a large bruise from her chest to her under arm and continued to her back, which was not investigated and not reported to the state agency and Resident #6's Guardian as an injury of unknown origin. <BR/>This failure could place Resident(s) at risk for harm by further exposure to injuries without proper investigation and reporting. <BR/>The findings included:<BR/>A record review of Resident #6's admission Record, dated 02/28/2023, revealed an admission date of 11/30/2018, with diagnoses which included Alzheimer's disease [causes the brain to shrink and brain cells to eventually die] and dementia [a range of conditions that affect the brain's ability to think, remember, and function normally]. Further review revealed Resident #6 was represented by a Guardian [Guardian Q]. <BR/>A record review of Resident #6 quarterly MDS, dated [DATE], revealed Resident #6 was an [AGE] year-old female who could usually understand some conversations, could usually make herself understood, given time; however, Resident #6 was assessed to have severe cognitive impairment with short- and long-term memory problems. <BR/>A record review of Resident #6's medical records revealed a Weekly Skin Observation Tool, dated 01/27/2023, Observations; does Resident have any observed skin issues? No. <BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, c/o [complaint of] pain to RT [right] shoulder. PRN [as needed] tramadol and muscle pain cream applied. Notified [Nurse Practitioner P] Xray ordered to RT. Shoulder claim #XXXXXXXX.<BR/>A record review of Resident #6's Weekly Skin Observation Tool, dated 01/30/2023, revealed, Observations; does Resident have any observed skin issues? Yes .site: right shoulder bruising .<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, [Resident #6 Family Member] on premises to visit [Resident #6] this nurse notified him of some bruising to RT [right] shoulder and c/o [complaint of] pain and Xray was ordered [Resident #6 Family Member] got upset and stated the reason why she is here is to protect her and her [Resident #6 Family Member] kept asking her what happened she said I don't know then [Resident #6 Family Member] asked who hurt you [?] and she responded no one hurt her she does not know what happened. Call placed to [Guardian Q] mailbox full.<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN R, Resident is day 2/3 bruise to R [right] axilla site [arm pit]. Site is c [with] swelling, warmth and discoloration. Localized inflammation to site. Noted to grimace upon assessment c [with] Tylenol regiment offered per this nurse and resident refusing x2 [twice] attempts. Allow this nurse to slightly prop arm on pillow. Resident observed to touch site often. Pleasantly confused to baseline. Receptive to staff assessment. Routine X-ray results in with right shoulder demonstrating no acute fracture. No joint discoloration. mild Bony demineralization. unremarkable soft tissues. there is severe AC joint [shoulder joint] and mild glenohumeral [the joint that connects the body to the arm] arthritis manifested by joint space narrowing, subchondral sclerosis, and degenerative spurring. will follow up with team health as indicated.<BR/>A record review of Resident #6's medical records revealed a Nurse Practitioner's Progress Note, dated 01/31/2023, authored by Nurse Practitioner P, revealed, Chief complaint / nature of presenting problem: follow up done on large bruising to chest and underarm area reported by nursing today. patient is unable to recall events. She can verbalize needs and report concerns to nurses. Patient is not currently on blood thinners. no falls reported. Have met with director of nursing / administrator to discuss further. Plan: hematoma / ecchymosis [bruising] to chest yellowish in color. Patient is unable to recall how she got it. No falls or trauma reported by nursing. Marking may be associated with gait belt for transfers as it goes around chest and underarms. Patient denied pain at this time. Will monitor for now.<BR/>During an interview and record review on 02/28/2022 at 01:25 PM Resident #6's Guardian, Guardian Q, stated she was not aware Resident #6 had an injury of unknow origin. Guardian Q stated she would have expected the facility to have reported any injury, especially a large bruise of unknown origin to her and possibly to the police. Guardian Q stated she could be contacted by cell phone, text message, and or her email. Guardian Q and surveyor confirmed contact information held by the facility as accurate. Guardian Q stated if by chance she missed a cell call she could have been contacted by email and or text message. <BR/>During an interview on 02/28/2023 at 02:15 PM LVN G stated she had assessed Resident #6 with a bruise to her right under arm and chest and reported the bruise to Nurse Practitioner P and RN F. LVN stated she wrote a progress note in Resident #6's medical record. LVN G stated the bruise was of unknown origin and Resident #6 could not state how she developed the bruise. LVN G stated she had not considered Resident #6's bruise a reportable event. LVN G stated she now understands, due to reflection of the incident, Resident #6's injury of unknown origin was a reportable event she should have reported to the Administrator. <BR/>During an interview on 03/02/2023 at 07:56 AM, Resident #6's Family Member stated they spoke with LVN G and stated, it's not right she [Resident #6] had a bruise. Resident #6's Family Member stated they had a concern, no one could explain how this happened [bruise]. Resident #6's Family Member stated Resident #6 claimed, I don't know how the bruise came to be. Resident #6's Family Member stated no one has reported to him the results of how this [bruise] happened. <BR/>During an interview on 03/03/2023 at 08:30 AM, the Administrator stated he did not believe Resident #6's injury of unknown origin was not a reportable incident due to Resident #6's own report that no one hurt her, even though the surveyor reminded the Administrator of a record review of Resident #6's diagnoses of Alzheimer's disease and dementia. <BR/>A record review of the facility's Recognizing Signs and Symptoms of Abuse / Neglect policy, dated April 2021, revealed, All types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse / neglect to their supervisor or to the director of nursing services immediately. Policy interpretation and implementation: The following are signs and symptoms of abuse / neglect there should be promptly reported. this listing is not all inclusive. other signs and symptoms are actual abuse /neglect may be apparent . signs of physical abuse: injuries that are non-accidental or unexplained . bruises, including those found in unusual locations such as the head neck lateral locations on the arms or posterior trunk and torso . signs of sexual abuse: bruises around the breast, general area or inner thighs .<BR/>A record review of the facility's Abuse, neglect, exploitation and misappropriation prevention program policy, dated April 2021, revealed, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Policy interpretation and implementation . the resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: staff; other residents . identify and investigate all possible incidents of abuse neglect, mistreatment for misappropriation of resident property .investigate and report any allegations within time frames required by federal requirement .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #2) reviewed for accidents and supervision.<BR/>1. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing on the evening of 09/24/2024. <BR/>The noncompliance was identified as PNC . The IJ began on 9/24/2024 and ended on 9/25/2024. The facility had corrected the noncompliance before the survey began.<BR/>2. CNA A transferred Resident #2 from the bed to the resident's wheelchair without using a lift on 08/15/2024. It caused Resident #2's toenail to catch on the floor, injuring her nailbed and removing her whole toenail on her left great toe.<BR/>The noncompliance was identified as PNC. The noncompliance began on 08/15/2024 and ended on 08/16/2024. The facility had corrected the noncompliance before the survey began<BR/>This deficient practice could place residents at-risk of harm, serious injury, or death. <BR/>The findings included:<BR/>1. Record review of Resident #1's admission record, 03/07/2025, reflected that Resident #1 was a [AGE] year-old male initially admitted on [DATE], with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and type 2 diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy). <BR/>Record review of Resident #1's quarterly MDS assessment, dated 09/20/2024, reflected that Resident #1 had a BIMS score of 2, indicating severely impaired cognition. The MDS assessment further reflected that wandering behavior was not exhibited by Resident #1. <BR/>Record review of Resident #1's Wandering Assessment with a completion date of 09/06/2024 reflected him to be ambulatory without a history of wandering and a score of 9, indicating the resident was At Risk to Wander. <BR/>Record review of Resident #1's wandering risk scale assessment dated [DATE] reflected that the resident had no history of wandering. <BR/>Record review of Resident #1's nursing note, dated 9/24/2024 at 6:25 PM, reflected, Resident observed by this writer walking with walker toward Exit. Name called multiple time. Resident keep walking [sic]. CNA came out of room right beside exit door at same time resident attempted to push door open. This writer was headed that way. This writer asked CNA to ask resident if he was in pain - Resident did say yes. At [6:05 PM] Pain medication given per PRN order. Resident was redirected away from exit. Went walking down the hall. <BR/>Record review of Facility Provider Investigation Report, undated, reflected that on 09/24/2024 around 6:45 PM, Resident #1 was found approximately .2 miles from the facility in a parking lot down the street by the Admissions Coordinator, who put the resident in his vehicle after completing a quick assessment for injuries and brought him back to the facility. The Provider Investigation Report further reflected that through investigation, it was determined that Resident #1 had likely exited through the front door after being let out by an unknown visitor to the facility.<BR/>Interview on 03/04/2025 at 1:45 PM, Admissions Coordinator stated he was on his way home from working at the facility when he saw the resident on the corner of an intersection approximately .2 miles from the front door of the facility. <BR/>Interview on 03/04/2025 at 2:15 PM, LVN C stated that Resident #1 was attempting to leave through a fire door on A Hall, and after providing him pain medication and dinner it seemed as though he had calmed down and was not wandering anymore. LVN C stated she did the assessment after the resident came back after the elopement event and had worked with him prior to the event. LVN C stated she did not see him ever attempt elopement before and that the resident did not wander any more than the average resident prior to the event. <BR/>Interview on 03/04/2025 at 2:36 PM, the DON stated Resident #1 was not an elopement risk prior to this incident. The DON stated in-servicing had been completed after the incident on elopement.<BR/>Interview on 03/04/2025 at 2:40 PM, the Regional Corporate Nurse stated that there had not been an elopement at the facility since the incident.<BR/>Interview on 03/04/2025 at 3:00 PM, the ADM stated he was not working at the facility at the time of the incident, and that he began as Administrator of the facility in December of 2024. <BR/>The Administrator was notified on 03/05/2024 at 5:25 PM, a past non-compliance IJ situation had been identified due to the above failure.<BR/>The facility implemented the following interventions.<BR/>Record review of Resident #1's Care Plan, undated, reflected that the facility enhanced Resident #1's to include transferred to memory care unit 9/24/2024 d/t elopement from facility with interventions to include monitoring wandering patterns and document wandering behavior and attempted diversional interventions in behavior log. <BR/>Further record review of the facilities provider investigation report reflected that after the incident, the facility reported the incident to the state, implemented frequent monitoring, updated the resident's care plan, and moved the resident to the secured unit in the building with family/RP consent due to wandering behaviors and elopement. <BR/>Record review of in-service training documentation, dated 09/25/2024, reflected that 100% of facility staff were in-serviced on elopement, wandering, and responding to alarming doors. All new hires are also in serviced as part of the new hire onboarding process. 10% of staff were interviewed on in-servicing on elopements. <BR/>Record review of facility Incidents and Accidents report, dated encompassing 03/04/2024 through 03/04/2025 reflected that no other resident had eloped apart from the incident on 09/24/2024. <BR/>Interview with DON on 03/04/2024 at 2:36 PM, stated everyone's wandering assessments were reviewed to ensure accuracy and stated they have a receptionist at the front door until 5:00 pm and at 5:00 pm the doors automatically lock and staff has to open it for anyone to get in or out and staff were educated on ensuring residents aren't following anyone out of the door. The DON stated that no other resident had eloped prior to or since the incident with Resident #1 on 09/24/2024. <BR/>Observation on 03/04/2024 at 2:45 PM near the entrance to the facility revealed a sign informing guests not to open the door for anyone outside of their party. <BR/>Interview on 03/05/2025 at 10:47 AM, RN D stated she is not familiar with the incident but was trained on elopement at the time of hire and has been in-serviced on wandering and elopement since the incident in September of 2024. RN D stated if she saw a resident exhibiting exit seeking behaviors, she would redirect the resident and inform her ADON and/or DON. <BR/>Interview on 03/05/2024 at 11:24 AM, LVN E stated she had been in-serviced on elopements and wandering after the incident with Resident #1 in September of 2024. LVN E stated that if a resident's wandering behaviors or exit seeking behaviors change from their baseline to inform the ADON or DON and begin more frequent visual checks on the resident.<BR/>Interview on 03/07/2025 at 10:44 AM, CNA F stated she had been trained on wandering and elopements, particularly after the incident with Resident #1 in September of 2024. CNA F stated that if she saw a resident attempting to leave the facility through any door she would redirect the resident and inform the charge nurse and/or ADON of the behavior of the resident. <BR/>Facility policy titled, Wandering and Elopements, dated revised March 2022, reflected, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The Facility Wandering and Elopements Policy then detailed the procedures for identifying residents at risk for elopement, locating a missing resident, and procedure for post-elopement. <BR/>The noncompliance was identified as PNC . The IJ began on 9/24/2024 and ended on 9/25/2024. The facility had corrected the noncompliance before the survey began<BR/>2. Record review of Resident #2's face sheet, dated 03/07/2025, reflected the resident was an [AGE] year-old female and originally admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (destroy memory and thinking skills), type 2 diabetes mellitus (not control blood sugar levels), and heart failure.<BR/>Record review of Resident #2's quarterly MDS, dated [DATE], reflected the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was dependent (helper does ALL the effort) sit to lying, bed-to-chair transfer, and tub/shower transfer, and that the resident was not physically able to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, toilet transfer, or walk 10 feet.<BR/>Record review of Resident #2's care plan, dated 03/07/2025, reflected Resident #2, requires substantial/dependent assistance by staff to move between surfaces. Assist x 2 with hoyer. with an initiated date of 08/12/2024. <BR/>Record review of the Facility Provider Investigation Report, dated 08/20/2024, reflected that at approximately 11:00 AM on 08/15/2024, CNA A transferred Resident #2 without a hoyer lift, by himself, by holding the resident under her arms and moving her. During this transfer, Resident #2 sustained an injury to her left foot. <BR/>Record review of Resident #2's progress note on 08/15/2024 at 11:29 AM reflected, Acetaminophen tablet 500MG given for pain, pain due to left big toe injury results pending further review of progress note reflects that on 08/15/2024 at 1:30 PM an assessment was completed and Resident #2's left big toenail was lifted and bleeding, and there was redness to her hips and ribs.<BR/>Record review of Resident #2's incident report, dated 8/15/2024 at 1:30 PM reflected that the resident had bleeding to left great toe, which was injured during a transfer, and PRN pain medication was provided.<BR/>Record review of the facility in-service training report, dated 08/16/2025, reflected the facility provided in-services to all nursing and maintenance staff regarding Transfer Status to include how to find each residents inidvidual transfer status and how to appropriately transfer residents. <BR/>Interview on 03/05/2025 at 10:47 AM, RN D stated she was trained on transfer status and is familiar with different residents need for different transfer status, to include rechecking transfer status for change in condition. RN D stated staff are frequently observed for competencies on transferring residents appropriately. <BR/>Interview on 03/05/2024 at 11:24 AM, LVN E stated she had been in-serviced on transfer status and ensuring residents are appropriately transferred based on their plan of care. <BR/>Interview on 03/07/2025 at 10:44 AM, CNA F stated she had been trained on transfer status and how to find what type of transfer a resident needs. CNA F was able to show the surveyors how to find out a residents transfer status in the EHR of the resident and was able to describe the procedure of different types of transfers to include hoyer transfers. <BR/>Record review of staff competencies reviewed on transfer status after the incident reflected no concerns with competencies. <BR/>Record review of the CNA A's employee profile reflected the facility terminated CNA A's employment on 08/15/2024. <BR/>Record review of Podiatry Visit Notes, dated 08/16/2024, reflected that the podiatrist saw Resident #2 the day after the incident occurred and removed her left big toenail, which was no longer connected to the toe. <BR/>Observation of transfer on 03/05/2025 at 10:30 AM reflected no concerns for the hoyer transfer of Resident #7 observed. Hoyer transfer was observed with 2 staff members operating the hoyer lift and no injuries to the resident as a result. <BR/>Record review of Resident #7's Care Plan reflected that Resident #7 needed to be assisted with transfers with 2 staff members using a hoyer lift. <BR/>Interview on 03/05/2025 at 3:00 PM, the ADM stated he was not working at the facility at the time of the incident, and that he began as Administrator of the facility in December of 2024. <BR/>Interview on 03/05/2025 at 5:00 PM, with the DON and RNC, the DON stated CNA A had not reported the injury to the nurse, and the family had informed the nurse of the injury when they noticed it within minutes of the injury occurring. The DON stated he believes CNA A did not realize there was an injury but did not know why he would have the resident sit on the edge of the bed to dress her. The DON stated Resident #2 saw podiatry the next morning with no concerns. The DON stated the expectation is that staff transfer residents as is appropriate and on the resident's plan of care. The DON stated the risk to residents could include injury for not being appropriately transferred . <BR/>The noncompliance was identified as PNC. The noncompliance began on 08/15/2024 and ended on 08/16/2024. The facility had corrected the noncompliance before the survey began

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents (Resident #5 and #6) reviewed for pharmacy services.<BR/>1. The facility failed to ensure Resident #5's pain medications were acquired and dispensed per physician's orders.<BR/>2. The facility failed to ensure Resident #6's pain medications were acquired and dispensed per physician's orders.<BR/>This failure could place residents at risk of not receiving their prescribed medications and a decreased quality of life. <BR/>The findings included:<BR/>Record review of the facility provider investigation report written by the facility administrator, dated 3/6/25, reflected: A drug diversion has been identified. Review of the facility provider investigation report revealed a medication audit identified Resident #5 and Resident #6 had narcotic medications missing. The report further revealed the residents were assessed for pain with no deviation from baseline noted, no missing doses were noted, and back up medication was used from the facility emergency kit. The facility identified 6 nursing staff responsible for medications administered to Resident #5 and Resident #6 (RN D, RN G, LVN H, LVN K, LVN L and LVN M). <BR/>1. Record review of Resident #5's face sheet dated 3/9/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included osteomyelitis (infection of the bone usually caused by bacteria that can cause pain, selling and redness throughout the affected area), peripheral vascular disease (condition in which the blood vessels become narrowed or blocked and affects the blood flow to the legs, feed and sometimes arms), diabetes with neuropathy (condition where high blood sugar levels cause nerve damage), pain in right foot, and chronic ulcer (a long-lasting open wound or sore that does not heal within a typical timeframe due to underlying health conditions, such as diabetes) of the right foot.<BR/>Record review of Resident #5's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively intact for daily decision-making skills, experienced pain occasionally, and received opioid medications.<BR/>Record review of Resident #5's comprehensive care plan with revision dated 1/30/25 revealed the resident had acute/chronic pain related to surgical incision/wound with interventions that included to administer analgesics as ordered, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. <BR/>Record review of Resident #5's MAR (Medication Administration Record) for February 2025 included the following:<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, Give 1 tablet by mouth every 4 hours as needed for pain with start date 11/4/24 and no stop date. Further review of the MAR revealed the resident received one dose on 2/25/25 at 7:16 p.m. <BR/>- Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen), Give 2 tablets by mouth every 6 hours as needed for Pain until Hydrocodone comes in, with start date 11/4/24 and no stop date. Further review of the MAR revealed did not receive any does of the Tylenol Extra Strength for the month of February.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALERT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with order date 2/5/25 and no stop date. Further review of the MAR revealed the resident scored a 0, indicating no pain recorded for every shift, except 2/24/25 with a score of 4 recorded on the evening shift, and 2/26/25-2/27/25 with a score of 3 recorded on the day shift.<BR/>Record review of Resident #5's MAR for March 2025 included the following:<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth every 4 hours as needed for pain with start date 11/4/24 and no end date. Further review of the MAR revealed the resident did not receive any doses of the HYDROcodone-Acetaminophen.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALERT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no stop date. Further review of the MAR revealed the resident rated 0 for pain level during all three shifts for the month.<BR/>-Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen), Give 2 tablet by mouth every 6 hours as needed for Pain until Hydrocodone comes in, with start date 11/4/24 and no end date. Further review of the MAR revealed the resident received the Tylenol Extra Strength on 3/5/25 at 12:00 a.m., and again on 3/6/25 at 12:27p.m.<BR/>2. Record review of Resident #6's face sheet dated 3/9/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (symptoms associated with a decline in memory, reasoning and other cognitive abilities severe enough to interfere with daily life), bipolar disorder (mental health condition characterized by extreme mood swings), primary osteoarthritis of knee (degenerative joint disease that affects the same joints on both sides of the body), and age-related osteoporosis (condition characterized by a gradual decrease in bone mineral density and mas leading to weakened bones that are more susceptible to fractures) without current pathological fracture.<BR/>Record review of Resident #6's most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and did not receive antipsychotic or opioid medications.<BR/>Record review of Resident #6's comprehensive care plan with revision date 11/18/24 revealed the resident had osteoporosis with a history of fractures and interventions that included to give analgesics as needed for pain and medications as ordered.<BR/>Record review of Resident #6's MAR for February 2025 included the following:<BR/>- Tramadol HCL Oral Tablet 50 mg, Give 1 tablet by mouth every 6 hours as needed for pain, with start date 11/7/24 and no end date<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-300 MG, Give 1 tablet by mouth every 6 hours as needed for pain with start dated 11/7/24 and discontinue date 2/14/25. Further review of the MAR revealed the resident was not given any HYDROcodone-Acetaminophen during that timeframe.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALEFT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUMENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no end date. Further review of the MAR revealed the resident rated a pain level of 6 on 2/19/25 during the day shift and was administered Tramadol 50 mg used as needed for pain.<BR/>Record review of Resident #6's MAR for March 2025 included the following:<BR/>- Tramadol HCL Oral Tablet 50 mg, Give 1 tablet by mouth every 6 hours as needed for pain, with start date 11/7/24 and no end date. Further review of the MAR revealed the resident did not receive any doses of Tramadol up until the investigation on 3/9/25.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALEFT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUMENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no end date. Further review of the MAR revealed the resident rated a pain level of 0 from 3/1/25 up until the investigation on 3/9/25.<BR/>During an interview on 3/8/25 at 8:26 a.m., RN I stated the process for avoiding a drug diversion required for nursing staff to count the narcotics in the medication cart with the next shift to ensure the medications were accounted for. RN I further stated, if there was a discrepancy with the narcotic count, the incoming nurse would not accept the keys to the medication cart and report to the DON for an investigation. RN I stated, a (narcotic) count is done every time (at shift change).<BR/>During an interview on 3/8/25 at 9:05 a.m., Med Aide J stated, the process for avoiding a drug diversion required for the nursing staff to count the narcotics in the medication cart with the next shift to ensure the medications were accounted for. Med Aide J stated, I would never accept the keys (to the medication cart) from somebody who did not count (narcotics) with me, you never know what they did. Not acceptable. Med Aide J stated she was not allowed to given pain medications when needed because only a nurse can make the assessment but was allowed to administer scheduled pain medications.<BR/>During an interview on 3/8/25 at 9:31 a.m., the DON stated, our policy, when narcotics are delivered, two nurses must sign for it (the narcotic delivery). The DON further stated, the delivery sheet/manifest (a detailed list of the items delivered) had to be signed by two nurses and then the delivery sheet/manifest would be filed in the medical records box after the medications were received. The DON acknowledged the facility identified a drug diversion on 3/5/25 in which Resident #5's and Resident #6's pain medications for HYDROcodone-Acetaminophen were missing from the medication cart. The DON acknowledged the facility did not have a process for checking to ensure the delivery sheet/manifest had two nurse signatures. <BR/>During an interview on 3/8/25 at 1:06 p.m., RN G stated the facility policy, when receiving medication deliveries, including narcotics, was for two nurses to sign the delivery sheet/manifest, place the narcotic log associated with the medication prescribed to the resident in the narcotic log, and place the medications in the medication cart. RN G further stated the delivery sheet/manifest was filed in a folder that used to be at the nurse's station. RN G stated the file for the delivery sheet/manifest had been gone for a while and (the delivery sheet/manifest) have been going to the shredder. I can't say if that was a good idea. RN G stated, the DON had only been employed since last year, so it's not like everybody has been doing that (checking for the delivery sheet/manifest), we used to file all that stuff, but then they (the file) disappeared. <BR/>During a telephone interview on 3/8/25 at 1:45 p.m., LVN F stated protocol for accepting a medication delivery, including narcotics would be to sign for the delivery on the pharmacy delivery driver's phone and then she would sign the delivery sheet/manifest. LVN F stated, the delivery sheet/manifest were supposed to be filed and it was a reference to show the medications were delivered. LVN F stated, the narcotic log once completed or the delivery sheet/manifest were never placed in the shredder, that is not protocol. <BR/>During an interview on 3/8/25 at 2:00 p.m., LVN H stated, once the pharmacy delivered medications, including narcotics, the receiving nurse signed electronically for the delivery on the pharmacy delivery driver's phone, and then the delivery sheet/manifest was supposed to be signed by two nurses confirming the order of medication was received. LVN H stated, the delivery sheet/manifest was filed in a binder that was at the nurse's station. LVN H stated, we have always had that binder, it has never gone away. LVN H stated, then the narcotic log was supposed to be signed by two nurses and placed in the narcotic log and the medication was stored in the locked box in the medication cart. LVN H stated it was not acceptable for one person to sign the narcotic sheet because a second person was needed to witness the medication was received. LVN H stated, once the narcotic log was zeroed out (completed) and the narcotic log was marked zero, I would take the narcotic log and place it in the medical records box and then throw the empty med card/blister pack away but tear the resident's information and put in the shredder and the empty blister pack was thrown in the trash. LVN H further stated, I would say the packing slips (delivery sheet/manifest) need to be saved, but the pharmacy has proof when we signed their phone that the product was delivered.<BR/>During an interview on 3/8/25 at 3:44 p.m., the ADON stated it was facility protocol, when the pharmacy delivered medications, including narcotics, the delivery sheet/manifest was supposed to be signed by one nurse for regular medications and two nurses for the narcotics. The ADON stated, once the delivery sheet/manifest was signed by two nurses, it was supposed to be delivered to the ADON to audit for signatures. The ADON stated, we do know we lost medications. I think part of the failure of the process was when the nurses stopped being accountable for the packing slips. But when you are no longer held accountable for what you receive that could be a very big problem. If the resident did not receive their medications when they needed them because they were unavailable their pain could not have been controlled and that is a serious problem.<BR/>During a telephone interview on 3/9/25 at 4:12 p.m., RN D stated, protocol for receiving medications, including narcotics were for the nurse receiving the medications to electronically sign for them on the pharmacy driver's phone. RN D stated, then the medication packets were opened, check what was delivered and then double check the delivery with a second nurse. RN D stated the count sheets (narcotic logs) were supposed to be signed by two nurses and placed in the narcotic log with the medication cart and place the narcotics in the lock box inside the medication cart. RN D stated she typically took the delivery sheet/manifest and placed it in the shred box. RN D stated, I was never told what to do with it (the delivery sheet/manifest) so I just put it in the shred box, whether it was a narcotic or regular medication. I've never worked like that before, so it was pretty much I didn't know what to do with it, had never been told what to do with it and just put it in the shredder box. Once the count sheets are zeroed out, we wrap the empty blister pack with the zeroed-out count sheet and put it back in the cart. <BR/>Record review of the facility policy and procedure titled Policies and Procedures for Pharmacy Services, undated revealed in part, .Delivery, Receipt and Storage of Medication .Upon delivery by the pharmacy, the facility nurse or designee will sign the electronic delivery receipt device and assume responsibility for the receipt, proper storage, and distribution of the medications .The facility staff should notify the pharmacy immediately of any discrepancy of the medications received (damage, erroneous, or missing items) .The pharmacy will send scheduled medications sign off of sheets for each scheduled medication. The scheduled medication inventory sheet should be completed for each dose administration. The scheduled medication inventory sheet should be archived upon completion of the medication supply .Drug Diversion .The facility will comply with all federal, state, and local laws as it pertains to controlled substances .The facility must have a system that records receipt, usage, and disposition of all controlled substances in sufficient detail that permits for an accurate reconciliation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 3 (Resident #3, #6, and #8) of 54 residents who resided on A and B hall reviewed for call lights. In that:<BR/>Resident #3 had no access to his call light which had been clipped to the privacy curtain at the foot of his bed.<BR/>Resident # 6 had no access to her call light which was on the floor under the roommate's bed and on the floor next to her bed.<BR/>Resident #8 had no access to her call light which was on the floor under the foot of her bed.<BR/>This deficient practice could place residents not being able to use call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>Record review of Resident's #3's face sheet, revealed he was a [AGE] year-old male, admitted on [DATE]. He had diagnoses that included: anxiety disorder and Epilepsy (a brain disorder that causes seizures).<BR/>Record review of Resident #3's quarterly MDS dated [DATE], revealed a BIMS score of 13 indicating intact cognition. The MDS reflected Resident #3 needed supervision with transfers and partial assistance with toileting and dressing. <BR/>Record review of Resident #3's care plan, revised 8/22/2023 with a target date of 06/05/2024, revealed Resident #3 was a high fall risk related to a history of seizures and poor safety awareness. An intervention, dated 8/29/2023, stated be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Record review of Resident #3's Fall Risk Evaluation, dated 04/06/2024, indicated resident was a high fall risk and stated Resident #3 had 1-2 falls in the past 3 months. The Fall Risk Evaluation instructions revealed that a score of 10 or greater was considered a High Risk for falls. Resident # 3's score was 19.<BR/>Observation and interview on 04/15/2024 at 3:15 p.m., Resident #3 was lying in bed with the call light attached to the privacy curtain behind the foot of the bed. Resident #3 stated his call light should have been on his bed where he can reach it. He stated he did not place the call light on the privacy curtain and stated that he used his call light to reach staff if he needed assistance with anything.<BR/>Record review of Resident #6's face sheet revealed she was a [AGE] year-old female, admitted on [DATE]. She had diagnoses that included: Anxiety Disorder, Seizures (a sudden, uncontrolled electrical disturbance in the brain which can causes changes in behavior, movements, or feelings) and schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and characterized by symptoms such as delusions and hallucinations).<BR/>Record review of Resident #6's quarterly MDS, dated [DATE], revealed a BIMS score of 12 indicating mild cognitive impairment. The MDS indicated Resident #6 required moderate to maximum assistance with dressing and bed mobility and was dependent for assistance with transfers. <BR/>Record review of Resident #6's care plan, revised 11/24/2023 with a target date of 05/21/2024, revealed resident was a high fall risk related to weakness, confusion, and poor impulse control. An intervention, dated 12/14/2022, stated be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Record review of Resident #6's Fall Risk Evaluation, dated 03/06/2024, indicated Resident #6 was a high fall risk. The Fall Risk Evaluation instructions revealed that a score of 10 or greater was considered a High Risk for falls. Resident # 6's score was 14.<BR/>Observation and interview on 04/15/2024 at 12:45 p.m., Resident #6 was lying in bed with her call light underneath her roommate's bed. Resident #6 stated she did not realize her call light was not on her bed. She stated she did not place it on the floor, and she stated staff usually place her call light within reach. Resident #6 stated she used the call light to call for help.<BR/>Observation and interview on 4/15/2024 at 3:35 p.m., Resident #6 was lying in bed with her call light on the floor by the left side of her bed. Resident #6 stated she did not realize her call light was on the floor. She stated she did not place it on the floor, and she stated staff usually place her call light within reach. Resident #6 stated she used the call light to call for help.<BR/>Observation on 04/15/2024 at 3:38 p.m., Resident #6 heard from the doorway of her room yelling help, I need help. Upon entering resident room with RN MDS, resident stated I need my call light.<BR/>During an interview, 04/15/2024 at 3:42pm, RN MDS said Resident #6's call light was on the floor beside the bed. RN MDS stated call lights should be within a resident's reach and stated staff are responsible for making sure the call lights are within reach. RN MDS stated it is important to keep the call lights within reach and that it could be detrimental for a resident to not have the call light in reach.<BR/>Record review of Resident #8's face sheet revealed she was a [AGE] year-old female, admitted on [DATE]. Resident #8's diagnoses included: Alzheimer's Disease (a progressive disease that affects memory and other important mental functions).<BR/>Record review of Resident #8's quarterly MDS, dated [DATE], revealed she had short term and long-term memory deficits and a severe impairment for cognitive decision-making skills. The MDS revealed Resident #8 is dependent on staff for all ADL's. <BR/>Record review of Resident #8's care plan, revised 08/27/2023 and target date 04/23/2024, revealed resident was a high fall risk related to confusion, incontinence, poor communication/comprehension, vision/hearing problems, unsteady trunk control, cognitive impairment, and history of falls. An intervention, dated 08/27/2023, stated be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Record review of Resident #8's Fall Risk Evaluation, dated 02/06/2024, revealed resident was a high fall risk. The Fall Risk Evaluation instructions revealed that a score of 10 or greater was considered a High Risk for falls. Resident # 8's score was 24.<BR/>Observation on 04/15/2024 at 3:40 p.m., revealed Resident #8 lying in bed with her call light on the floor under the foot of her bed.<BR/>During an interview on 04/15/2024 at 3:42 p.m., RN MDS said Resident #8's call light was on the floor under the resident's bed. <BR/>During an interview on 04/15/2024 at 4:50 p.m., CNA A stated resident call lights should be within reach when a resident is in their bed. He stated the CNA's, nurses and any staff who enter the room are responsible for making sure the call lights are in reach. CNA A stated it was important to keep the call lights in reach because a resident could fall or become soiled if they laid there too long. CNA A revealed he had received training in facility orientation he attended when hired two weeks ago. <BR/>During an interview on 04/16/2024 at 2:20 p.m., the DON stated call lights should be in reach of a resident and it was the responsibility of all staff to make sure they were in reach. She stated it was important to keep the call lights in reach of a resident because they could fall or lots of things could happen. The DON stated staff were trained on call light placement during in-services and we check them daily and talk to staff if we find one not close to a resident. <BR/>Record review of facility policy, Strategies for Reducing the Risk of Falls, revised 04/2022, stated call light within reach was a strategy to an environmental risk factor.<BR/>Record review of facility policy, Falls Prevention-Potential Interventions, revised 04/2022, stated call light as an intervention with a description of placed within reach at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #2) reviewed for accidents and supervision.<BR/>1. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing on the evening of 09/24/2024. <BR/>The noncompliance was identified as PNC . The IJ began on 9/24/2024 and ended on 9/25/2024. The facility had corrected the noncompliance before the survey began.<BR/>2. CNA A transferred Resident #2 from the bed to the resident's wheelchair without using a lift on 08/15/2024. It caused Resident #2's toenail to catch on the floor, injuring her nailbed and removing her whole toenail on her left great toe.<BR/>The noncompliance was identified as PNC. The noncompliance began on 08/15/2024 and ended on 08/16/2024. The facility had corrected the noncompliance before the survey began<BR/>This deficient practice could place residents at-risk of harm, serious injury, or death. <BR/>The findings included:<BR/>1. Record review of Resident #1's admission record, 03/07/2025, reflected that Resident #1 was a [AGE] year-old male initially admitted on [DATE], with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and type 2 diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy). <BR/>Record review of Resident #1's quarterly MDS assessment, dated 09/20/2024, reflected that Resident #1 had a BIMS score of 2, indicating severely impaired cognition. The MDS assessment further reflected that wandering behavior was not exhibited by Resident #1. <BR/>Record review of Resident #1's Wandering Assessment with a completion date of 09/06/2024 reflected him to be ambulatory without a history of wandering and a score of 9, indicating the resident was At Risk to Wander. <BR/>Record review of Resident #1's wandering risk scale assessment dated [DATE] reflected that the resident had no history of wandering. <BR/>Record review of Resident #1's nursing note, dated 9/24/2024 at 6:25 PM, reflected, Resident observed by this writer walking with walker toward Exit. Name called multiple time. Resident keep walking [sic]. CNA came out of room right beside exit door at same time resident attempted to push door open. This writer was headed that way. This writer asked CNA to ask resident if he was in pain - Resident did say yes. At [6:05 PM] Pain medication given per PRN order. Resident was redirected away from exit. Went walking down the hall. <BR/>Record review of Facility Provider Investigation Report, undated, reflected that on 09/24/2024 around 6:45 PM, Resident #1 was found approximately .2 miles from the facility in a parking lot down the street by the Admissions Coordinator, who put the resident in his vehicle after completing a quick assessment for injuries and brought him back to the facility. The Provider Investigation Report further reflected that through investigation, it was determined that Resident #1 had likely exited through the front door after being let out by an unknown visitor to the facility.<BR/>Interview on 03/04/2025 at 1:45 PM, Admissions Coordinator stated he was on his way home from working at the facility when he saw the resident on the corner of an intersection approximately .2 miles from the front door of the facility. <BR/>Interview on 03/04/2025 at 2:15 PM, LVN C stated that Resident #1 was attempting to leave through a fire door on A Hall, and after providing him pain medication and dinner it seemed as though he had calmed down and was not wandering anymore. LVN C stated she did the assessment after the resident came back after the elopement event and had worked with him prior to the event. LVN C stated she did not see him ever attempt elopement before and that the resident did not wander any more than the average resident prior to the event. <BR/>Interview on 03/04/2025 at 2:36 PM, the DON stated Resident #1 was not an elopement risk prior to this incident. The DON stated in-servicing had been completed after the incident on elopement.<BR/>Interview on 03/04/2025 at 2:40 PM, the Regional Corporate Nurse stated that there had not been an elopement at the facility since the incident.<BR/>Interview on 03/04/2025 at 3:00 PM, the ADM stated he was not working at the facility at the time of the incident, and that he began as Administrator of the facility in December of 2024. <BR/>The Administrator was notified on 03/05/2024 at 5:25 PM, a past non-compliance IJ situation had been identified due to the above failure.<BR/>The facility implemented the following interventions.<BR/>Record review of Resident #1's Care Plan, undated, reflected that the facility enhanced Resident #1's to include transferred to memory care unit 9/24/2024 d/t elopement from facility with interventions to include monitoring wandering patterns and document wandering behavior and attempted diversional interventions in behavior log. <BR/>Further record review of the facilities provider investigation report reflected that after the incident, the facility reported the incident to the state, implemented frequent monitoring, updated the resident's care plan, and moved the resident to the secured unit in the building with family/RP consent due to wandering behaviors and elopement. <BR/>Record review of in-service training documentation, dated 09/25/2024, reflected that 100% of facility staff were in-serviced on elopement, wandering, and responding to alarming doors. All new hires are also in serviced as part of the new hire onboarding process. 10% of staff were interviewed on in-servicing on elopements. <BR/>Record review of facility Incidents and Accidents report, dated encompassing 03/04/2024 through 03/04/2025 reflected that no other resident had eloped apart from the incident on 09/24/2024. <BR/>Interview with DON on 03/04/2024 at 2:36 PM, stated everyone's wandering assessments were reviewed to ensure accuracy and stated they have a receptionist at the front door until 5:00 pm and at 5:00 pm the doors automatically lock and staff has to open it for anyone to get in or out and staff were educated on ensuring residents aren't following anyone out of the door. The DON stated that no other resident had eloped prior to or since the incident with Resident #1 on 09/24/2024. <BR/>Observation on 03/04/2024 at 2:45 PM near the entrance to the facility revealed a sign informing guests not to open the door for anyone outside of their party. <BR/>Interview on 03/05/2025 at 10:47 AM, RN D stated she is not familiar with the incident but was trained on elopement at the time of hire and has been in-serviced on wandering and elopement since the incident in September of 2024. RN D stated if she saw a resident exhibiting exit seeking behaviors, she would redirect the resident and inform her ADON and/or DON. <BR/>Interview on 03/05/2024 at 11:24 AM, LVN E stated she had been in-serviced on elopements and wandering after the incident with Resident #1 in September of 2024. LVN E stated that if a resident's wandering behaviors or exit seeking behaviors change from their baseline to inform the ADON or DON and begin more frequent visual checks on the resident.<BR/>Interview on 03/07/2025 at 10:44 AM, CNA F stated she had been trained on wandering and elopements, particularly after the incident with Resident #1 in September of 2024. CNA F stated that if she saw a resident attempting to leave the facility through any door she would redirect the resident and inform the charge nurse and/or ADON of the behavior of the resident. <BR/>Facility policy titled, Wandering and Elopements, dated revised March 2022, reflected, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The Facility Wandering and Elopements Policy then detailed the procedures for identifying residents at risk for elopement, locating a missing resident, and procedure for post-elopement. <BR/>The noncompliance was identified as PNC . The IJ began on 9/24/2024 and ended on 9/25/2024. The facility had corrected the noncompliance before the survey began<BR/>2. Record review of Resident #2's face sheet, dated 03/07/2025, reflected the resident was an [AGE] year-old female and originally admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (destroy memory and thinking skills), type 2 diabetes mellitus (not control blood sugar levels), and heart failure.<BR/>Record review of Resident #2's quarterly MDS, dated [DATE], reflected the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was dependent (helper does ALL the effort) sit to lying, bed-to-chair transfer, and tub/shower transfer, and that the resident was not physically able to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, toilet transfer, or walk 10 feet.<BR/>Record review of Resident #2's care plan, dated 03/07/2025, reflected Resident #2, requires substantial/dependent assistance by staff to move between surfaces. Assist x 2 with hoyer. with an initiated date of 08/12/2024. <BR/>Record review of the Facility Provider Investigation Report, dated 08/20/2024, reflected that at approximately 11:00 AM on 08/15/2024, CNA A transferred Resident #2 without a hoyer lift, by himself, by holding the resident under her arms and moving her. During this transfer, Resident #2 sustained an injury to her left foot. <BR/>Record review of Resident #2's progress note on 08/15/2024 at 11:29 AM reflected, Acetaminophen tablet 500MG given for pain, pain due to left big toe injury results pending further review of progress note reflects that on 08/15/2024 at 1:30 PM an assessment was completed and Resident #2's left big toenail was lifted and bleeding, and there was redness to her hips and ribs.<BR/>Record review of Resident #2's incident report, dated 8/15/2024 at 1:30 PM reflected that the resident had bleeding to left great toe, which was injured during a transfer, and PRN pain medication was provided.<BR/>Record review of the facility in-service training report, dated 08/16/2025, reflected the facility provided in-services to all nursing and maintenance staff regarding Transfer Status to include how to find each residents inidvidual transfer status and how to appropriately transfer residents. <BR/>Interview on 03/05/2025 at 10:47 AM, RN D stated she was trained on transfer status and is familiar with different residents need for different transfer status, to include rechecking transfer status for change in condition. RN D stated staff are frequently observed for competencies on transferring residents appropriately. <BR/>Interview on 03/05/2024 at 11:24 AM, LVN E stated she had been in-serviced on transfer status and ensuring residents are appropriately transferred based on their plan of care. <BR/>Interview on 03/07/2025 at 10:44 AM, CNA F stated she had been trained on transfer status and how to find what type of transfer a resident needs. CNA F was able to show the surveyors how to find out a residents transfer status in the EHR of the resident and was able to describe the procedure of different types of transfers to include hoyer transfers. <BR/>Record review of staff competencies reviewed on transfer status after the incident reflected no concerns with competencies. <BR/>Record review of the CNA A's employee profile reflected the facility terminated CNA A's employment on 08/15/2024. <BR/>Record review of Podiatry Visit Notes, dated 08/16/2024, reflected that the podiatrist saw Resident #2 the day after the incident occurred and removed her left big toenail, which was no longer connected to the toe. <BR/>Observation of transfer on 03/05/2025 at 10:30 AM reflected no concerns for the hoyer transfer of Resident #7 observed. Hoyer transfer was observed with 2 staff members operating the hoyer lift and no injuries to the resident as a result. <BR/>Record review of Resident #7's Care Plan reflected that Resident #7 needed to be assisted with transfers with 2 staff members using a hoyer lift. <BR/>Interview on 03/05/2025 at 3:00 PM, the ADM stated he was not working at the facility at the time of the incident, and that he began as Administrator of the facility in December of 2024. <BR/>Interview on 03/05/2025 at 5:00 PM, with the DON and RNC, the DON stated CNA A had not reported the injury to the nurse, and the family had informed the nurse of the injury when they noticed it within minutes of the injury occurring. The DON stated he believes CNA A did not realize there was an injury but did not know why he would have the resident sit on the edge of the bed to dress her. The DON stated Resident #2 saw podiatry the next morning with no concerns. The DON stated the expectation is that staff transfer residents as is appropriate and on the resident's plan of care. The DON stated the risk to residents could include injury for not being appropriately transferred . <BR/>The noncompliance was identified as PNC. The noncompliance began on 08/15/2024 and ended on 08/16/2024. The facility had corrected the noncompliance before the survey began

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated this was not possible or the resident preferences indicated otherwise for 1 of 5 Residents (Residents #16) whose records were reviewed for nutrition status maintenance. <BR/>The facility failed measuring Resident #16's weight when the resident was re-admitted to the facility on [DATE], and the physician order said, Measuring weight upon admission/re-admission and every week for 4 weeks. <BR/>These failures could affect residents at risk for losing weight and result in unplanned weight loss and a decline in the resident's overall health.<BR/>The findings were:<BR/>Record review of Resident #16's face sheet, dated 06/13/2025, revealed the resident was [AGE] years old male and originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnosis of pneumonitis due to inhalation of food and vomit (complication of pulmonary aspiration or the inhalation of food, liquid, or vomit inti the lungs), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), dysphagia (difficulty swallowing), heart failure (the heart muscle does not pump blood as well as it should), and edema (swelling caused by fluid trapped in your tissues). <BR/>Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS was 0 out of 15 which indicated the resident had severe cognitive impairment, and the resident required supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as resident completes activities) to eating and dependent (helper does all of the effort) to sit to stand and chair to bed transfer. <BR/>Record review of Resident #16's comprehensive care plan, dated 04/12/2023, revealed The resident is able to feed self with setup, cuing direction. Does not like staff assistance and The resident has potential nutritional problem related to severe intellectual disabilities and history of dysphagia - weight is expected to fluctuate due to being on a diuretic, and weight loss may be due to recent hospitalization and recent downgrade in diet. For interventions - monitor/document/report any sign and symptom of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss, and weight: upon admission/readmission and every week for 4 weeks. <BR/>Record review of Resident #16's physician order, dated 05/28/2025, revealed Pureed diet and thin liquid diet and weight upon admission/readmission and every week for 4 weeks.<BR/>Record review of Resident #16's weight log revealed the resident's weight on 06/05/2025 was 162.4 pounds, and weight on 06/12/2025 was 164.6 pounds. There was no weight on re-admission date, which was on 05/28/2025. <BR/>Record review of Resident #16's nursing note for readmission assessment, dated 05/28/2025, revealed the facility nurse did not measure Resident #16's weight on 05/28/2025. The facility nurse measured the resident's weight on 06/05/2025 (162.4 pounds) and 06/12/2025 (164.6 pounds). <BR/>Interview on 06/12/2025 at 3:46 p.m. ADON-B stated the nurse who conducted re-admission assessment on 05/28/2025 did not measure Resident #16's weight per the physician order, and the nurse was an agency nurse and not work anymore. ADON-B said she did not know what reason the nurse did not measure Resident #16's weight on 05/28/2025 (re-admission date), the nurse should have measured the resident's weight as the physician order, and if the facility did not know the resident's weight correctly, the resident might have unplanned weight loss and a decline in the resident's overall health.<BR/>Record review of the facility policy, titled Weight System, dated 04/2022, revealed Residents are weighted at admission, readmission, and per physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident, who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 20 residents reviewed for respiratory care. (Resident #240)<BR/>The facility did not ensure Resident #240 had orders for the administration of oxygen. <BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. <BR/>Findings included:<BR/>Record review Resident #240's face sheet dated 04/24/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), atrial fibrillation (irregular heart beat), COPD (lung disease) and falls. <BR/>Record review of Resident #240's EMR reflected he did not have a complete MDS assessment.<BR/>Record review of care plan dated 04/22/24 reflected Resident #240 had cardiac disease with intervention to administer oxygen as ordered per physician. Resident #240 had altered respiratory status/difficulty breathing with interventions oxygen settings: O2 via (specify: nasal prongs/mask) at (specify) L (specify freq.) Humidified (specify). <BR/>During observations Resident #240 had oxygen in progress as follows:<BR/>04/23/24 at 10:15 AM O2 on via oxygen concentrator at 4lpm via nasal cannula<BR/>04/24/24 at 09:00 AM O2 on via oxygen concentrator at 4lpm via nasal cannula<BR/>04/25/24 at 10:00 AM O2 on via oxygen concentrator at 4lpm via nasal cannula<BR/>During an interview on 04/23/24 at 10:15 AM with Resident #240, he stated he was admitted with oxygen and wears it all the time. He stated he was not sure how many liters it was to be set on.<BR/>Record review of Resident #240's physician's order listing report dated 04/23/24 reflected no order of oxygen. <BR/>During an interview on 04/25/24 at 02:00 PM with the DON, she stated any resident using oxygen must have a physician order. She stated all nursing staff had been trained to obtain orders and put them in the EMR. She stated the nurses was responsible for physician orders and she was responsible for monitoring orders. She stated nurses can place oxygen in emergency situations using nursing judgement but would need to get a physician order once the resident was stable. She stated Resident #240 did not have any orders for oxygen. She stated she was not sure why it was missed. She stated the oxygen orders should have been entered on day of admission. She stated the potential negative outcome could be a resident hyperventilated or had breathing difficulties. <BR/>During an interview on 04/25/24 at 04:00 PM with the ADM, she stated residents on oxygen does require an order. She stated the charge nurse, admission nurse and DON was responsible for obtaining the order. She stated staff had been trained on obtaining orders. She stated she was not sure why it was missed. She stated they review all new admissions during stand-up morning meeting to go over all orders and concerns. She stated the potential negative outcome could be a resident not getting what they need as for as oxygen was concerned. <BR/>Record review facility policy title Oxygen administration dated October 2010 reflected the following:<BR/>Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration.<BR/>Preparation<BR/>1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents (Resident #5 and #6) reviewed for pharmacy services.<BR/>1. The facility failed to ensure Resident #5's pain medications were acquired and dispensed per physician's orders.<BR/>2. The facility failed to ensure Resident #6's pain medications were acquired and dispensed per physician's orders.<BR/>This failure could place residents at risk of not receiving their prescribed medications and a decreased quality of life. <BR/>The findings included:<BR/>Record review of the facility provider investigation report written by the facility administrator, dated 3/6/25, reflected: A drug diversion has been identified. Review of the facility provider investigation report revealed a medication audit identified Resident #5 and Resident #6 had narcotic medications missing. The report further revealed the residents were assessed for pain with no deviation from baseline noted, no missing doses were noted, and back up medication was used from the facility emergency kit. The facility identified 6 nursing staff responsible for medications administered to Resident #5 and Resident #6 (RN D, RN G, LVN H, LVN K, LVN L and LVN M). <BR/>1. Record review of Resident #5's face sheet dated 3/9/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included osteomyelitis (infection of the bone usually caused by bacteria that can cause pain, selling and redness throughout the affected area), peripheral vascular disease (condition in which the blood vessels become narrowed or blocked and affects the blood flow to the legs, feed and sometimes arms), diabetes with neuropathy (condition where high blood sugar levels cause nerve damage), pain in right foot, and chronic ulcer (a long-lasting open wound or sore that does not heal within a typical timeframe due to underlying health conditions, such as diabetes) of the right foot.<BR/>Record review of Resident #5's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively intact for daily decision-making skills, experienced pain occasionally, and received opioid medications.<BR/>Record review of Resident #5's comprehensive care plan with revision dated 1/30/25 revealed the resident had acute/chronic pain related to surgical incision/wound with interventions that included to administer analgesics as ordered, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. <BR/>Record review of Resident #5's MAR (Medication Administration Record) for February 2025 included the following:<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, Give 1 tablet by mouth every 4 hours as needed for pain with start date 11/4/24 and no stop date. Further review of the MAR revealed the resident received one dose on 2/25/25 at 7:16 p.m. <BR/>- Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen), Give 2 tablets by mouth every 6 hours as needed for Pain until Hydrocodone comes in, with start date 11/4/24 and no stop date. Further review of the MAR revealed did not receive any does of the Tylenol Extra Strength for the month of February.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALERT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with order date 2/5/25 and no stop date. Further review of the MAR revealed the resident scored a 0, indicating no pain recorded for every shift, except 2/24/25 with a score of 4 recorded on the evening shift, and 2/26/25-2/27/25 with a score of 3 recorded on the day shift.<BR/>Record review of Resident #5's MAR for March 2025 included the following:<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth every 4 hours as needed for pain with start date 11/4/24 and no end date. Further review of the MAR revealed the resident did not receive any doses of the HYDROcodone-Acetaminophen.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALERT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no stop date. Further review of the MAR revealed the resident rated 0 for pain level during all three shifts for the month.<BR/>-Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen), Give 2 tablet by mouth every 6 hours as needed for Pain until Hydrocodone comes in, with start date 11/4/24 and no end date. Further review of the MAR revealed the resident received the Tylenol Extra Strength on 3/5/25 at 12:00 a.m., and again on 3/6/25 at 12:27p.m.<BR/>2. Record review of Resident #6's face sheet dated 3/9/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (symptoms associated with a decline in memory, reasoning and other cognitive abilities severe enough to interfere with daily life), bipolar disorder (mental health condition characterized by extreme mood swings), primary osteoarthritis of knee (degenerative joint disease that affects the same joints on both sides of the body), and age-related osteoporosis (condition characterized by a gradual decrease in bone mineral density and mas leading to weakened bones that are more susceptible to fractures) without current pathological fracture.<BR/>Record review of Resident #6's most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and did not receive antipsychotic or opioid medications.<BR/>Record review of Resident #6's comprehensive care plan with revision date 11/18/24 revealed the resident had osteoporosis with a history of fractures and interventions that included to give analgesics as needed for pain and medications as ordered.<BR/>Record review of Resident #6's MAR for February 2025 included the following:<BR/>- Tramadol HCL Oral Tablet 50 mg, Give 1 tablet by mouth every 6 hours as needed for pain, with start date 11/7/24 and no end date<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-300 MG, Give 1 tablet by mouth every 6 hours as needed for pain with start dated 11/7/24 and discontinue date 2/14/25. Further review of the MAR revealed the resident was not given any HYDROcodone-Acetaminophen during that timeframe.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALEFT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUMENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no end date. Further review of the MAR revealed the resident rated a pain level of 6 on 2/19/25 during the day shift and was administered Tramadol 50 mg used as needed for pain.<BR/>Record review of Resident #6's MAR for March 2025 included the following:<BR/>- Tramadol HCL Oral Tablet 50 mg, Give 1 tablet by mouth every 6 hours as needed for pain, with start date 11/7/24 and no end date. Further review of the MAR revealed the resident did not receive any doses of Tramadol up until the investigation on 3/9/25.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALEFT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUMENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no end date. Further review of the MAR revealed the resident rated a pain level of 0 from 3/1/25 up until the investigation on 3/9/25.<BR/>During an interview on 3/8/25 at 8:26 a.m., RN I stated the process for avoiding a drug diversion required for nursing staff to count the narcotics in the medication cart with the next shift to ensure the medications were accounted for. RN I further stated, if there was a discrepancy with the narcotic count, the incoming nurse would not accept the keys to the medication cart and report to the DON for an investigation. RN I stated, a (narcotic) count is done every time (at shift change).<BR/>During an interview on 3/8/25 at 9:05 a.m., Med Aide J stated, the process for avoiding a drug diversion required for the nursing staff to count the narcotics in the medication cart with the next shift to ensure the medications were accounted for. Med Aide J stated, I would never accept the keys (to the medication cart) from somebody who did not count (narcotics) with me, you never know what they did. Not acceptable. Med Aide J stated she was not allowed to given pain medications when needed because only a nurse can make the assessment but was allowed to administer scheduled pain medications.<BR/>During an interview on 3/8/25 at 9:31 a.m., the DON stated, our policy, when narcotics are delivered, two nurses must sign for it (the narcotic delivery). The DON further stated, the delivery sheet/manifest (a detailed list of the items delivered) had to be signed by two nurses and then the delivery sheet/manifest would be filed in the medical records box after the medications were received. The DON acknowledged the facility identified a drug diversion on 3/5/25 in which Resident #5's and Resident #6's pain medications for HYDROcodone-Acetaminophen were missing from the medication cart. The DON acknowledged the facility did not have a process for checking to ensure the delivery sheet/manifest had two nurse signatures. <BR/>During an interview on 3/8/25 at 1:06 p.m., RN G stated the facility policy, when receiving medication deliveries, including narcotics, was for two nurses to sign the delivery sheet/manifest, place the narcotic log associated with the medication prescribed to the resident in the narcotic log, and place the medications in the medication cart. RN G further stated the delivery sheet/manifest was filed in a folder that used to be at the nurse's station. RN G stated the file for the delivery sheet/manifest had been gone for a while and (the delivery sheet/manifest) have been going to the shredder. I can't say if that was a good idea. RN G stated, the DON had only been employed since last year, so it's not like everybody has been doing that (checking for the delivery sheet/manifest), we used to file all that stuff, but then they (the file) disappeared. <BR/>During a telephone interview on 3/8/25 at 1:45 p.m., LVN F stated protocol for accepting a medication delivery, including narcotics would be to sign for the delivery on the pharmacy delivery driver's phone and then she would sign the delivery sheet/manifest. LVN F stated, the delivery sheet/manifest were supposed to be filed and it was a reference to show the medications were delivered. LVN F stated, the narcotic log once completed or the delivery sheet/manifest were never placed in the shredder, that is not protocol. <BR/>During an interview on 3/8/25 at 2:00 p.m., LVN H stated, once the pharmacy delivered medications, including narcotics, the receiving nurse signed electronically for the delivery on the pharmacy delivery driver's phone, and then the delivery sheet/manifest was supposed to be signed by two nurses confirming the order of medication was received. LVN H stated, the delivery sheet/manifest was filed in a binder that was at the nurse's station. LVN H stated, we have always had that binder, it has never gone away. LVN H stated, then the narcotic log was supposed to be signed by two nurses and placed in the narcotic log and the medication was stored in the locked box in the medication cart. LVN H stated it was not acceptable for one person to sign the narcotic sheet because a second person was needed to witness the medication was received. LVN H stated, once the narcotic log was zeroed out (completed) and the narcotic log was marked zero, I would take the narcotic log and place it in the medical records box and then throw the empty med card/blister pack away but tear the resident's information and put in the shredder and the empty blister pack was thrown in the trash. LVN H further stated, I would say the packing slips (delivery sheet/manifest) need to be saved, but the pharmacy has proof when we signed their phone that the product was delivered.<BR/>During an interview on 3/8/25 at 3:44 p.m., the ADON stated it was facility protocol, when the pharmacy delivered medications, including narcotics, the delivery sheet/manifest was supposed to be signed by one nurse for regular medications and two nurses for the narcotics. The ADON stated, once the delivery sheet/manifest was signed by two nurses, it was supposed to be delivered to the ADON to audit for signatures. The ADON stated, we do know we lost medications. I think part of the failure of the process was when the nurses stopped being accountable for the packing slips. But when you are no longer held accountable for what you receive that could be a very big problem. If the resident did not receive their medications when they needed them because they were unavailable their pain could not have been controlled and that is a serious problem.<BR/>During a telephone interview on 3/9/25 at 4:12 p.m., RN D stated, protocol for receiving medications, including narcotics were for the nurse receiving the medications to electronically sign for them on the pharmacy driver's phone. RN D stated, then the medication packets were opened, check what was delivered and then double check the delivery with a second nurse. RN D stated the count sheets (narcotic logs) were supposed to be signed by two nurses and placed in the narcotic log with the medication cart and place the narcotics in the lock box inside the medication cart. RN D stated she typically took the delivery sheet/manifest and placed it in the shred box. RN D stated, I was never told what to do with it (the delivery sheet/manifest) so I just put it in the shred box, whether it was a narcotic or regular medication. I've never worked like that before, so it was pretty much I didn't know what to do with it, had never been told what to do with it and just put it in the shredder box. Once the count sheets are zeroed out, we wrap the empty blister pack with the zeroed-out count sheet and put it back in the cart. <BR/>Record review of the facility policy and procedure titled Policies and Procedures for Pharmacy Services, undated revealed in part, .Delivery, Receipt and Storage of Medication .Upon delivery by the pharmacy, the facility nurse or designee will sign the electronic delivery receipt device and assume responsibility for the receipt, proper storage, and distribution of the medications .The facility staff should notify the pharmacy immediately of any discrepancy of the medications received (damage, erroneous, or missing items) .The pharmacy will send scheduled medications sign off of sheets for each scheduled medication. The scheduled medication inventory sheet should be completed for each dose administration. The scheduled medication inventory sheet should be archived upon completion of the medication supply .Drug Diversion .The facility will comply with all federal, state, and local laws as it pertains to controlled substances .The facility must have a system that records receipt, usage, and disposition of all controlled substances in sufficient detail that permits for an accurate reconciliation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored properly in the medication cart for 1 (Station A) of 3 medication treatment carts observed for drug storage. <BR/>The facility failed to ensure 5 insulin pens were dated when opened. <BR/>This failure could result in harm due to resident received expired medications. <BR/>The findings were:<BR/>Record review Resident #4's face sheet dated 04/24/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (cognitive loss), diabetes (high blood sugar), and major depressive disorder (mental illness, feeling of sadness). <BR/>Record review of Resident #4's quarterly MDS assessment, dated 02/22/24 revealed a BIMS score of 12, which indicated cognition was moderately impaired. Section N - medications reflected Resident #4 had received insulin injections during the last 7 days. <BR/>Record review of Resident #4's care plan dated 03/07/24 reflected a focus area Resident #4 had diabetes with intervention for diabetes mediations as ordered by doctor. <BR/>Record review of Resident #4's physician order listing report dated 04/24/24 reflected an order for Basaglar Kwik pen solution pen-injection 100 unit/ml - inject 40 units subcutaneously in the evening for uncontrolled DM dated 2/27/24 and 40 units subcutaneously in the morning for uncontrolled DM dated 4/10/24. An order for NovoLog Flex Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale dated 01/25/24 . <BR/>Record review Resident #4's treatment administration record dated 04/24/24 reflected Resident #4 received Basaglar 40 units in the morning on 4/1/24 through 4/24/24 and Basaglar 40 units in the evening on 04/01/24 through 04/23/24. Resident #4 received Novolog per sliding scale on 04/01/24 through 04/24/24. <BR/>Observation on 04/24/24 at 09:30 AM during the medication cart inspection on Station A revealed Basaglar Kwik Pen and NovoLog Flex pen with Resident #4's name on the label and no open date on the pens. <BR/>Record review Resident #31s face sheet dated 04/24/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (cognitive loss), diabetes (high blood sugar), COPD (lung disease) and major depressive disorder (mental illness, feeling of sadness). <BR/>Record review of Resident #31's comprehensive MDS assessment, dated 02/08/24 revealed a BIMS score of 00, which indicated cognition was severely impaired. Section N - medications reflected Resident #31 had received insulin injections during the last 7 days. <BR/>Record review of Resident #31's care plan dated 03/01/24 reflected a focus area Resident #31 had diabetes with intervention for diabetes mediations as ordered by doctor. <BR/>Record review of Resident #31's physician order listing report dated 04/24/24 reflected an order for Humulin N Kwik Pen Subcutaneous Suspension Pen-injector 100 UNIT/ML (Insulin NPH (Human) (Isophane)) Inject 50 unit subcutaneously in the morning for uncontrolled DM dated 3/9/24 and 15 units subcutaneously in the evening for uncontrolled DM dated 03/25/24.<BR/>Record Review of Resident #31's treatment administration record dated 04/24/24 reflected Resident #31 received Humulin N 50 units in the morning on 04/01/24 through 04/24/24 and Humulin N 15 units in the evening on 04/01/24 through 04/23/24. <BR/>Observation on 04/24/24 at 09:30 AM during the medication cart inspection on Station A revealed Humulin N Kwik pen with Resident #31's name on the label and no open date on the pen. <BR/>Record review Resident #53's face sheet dated 04/24/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (cognitive loss), heart failure, diabetes (high blood sugar), hypertension (high blood pressure) and major depressive disorder (mental illness, feeling of sadness). <BR/>Record review of Resident #53's quarterly MDS assessment, dated 03/05/24 revealed a BIMS score of 14, which indicated cognition was intact. Section N - medications reflected Resident #4 had received insulin injections during the last 7 days. <BR/>Record review of Resident #53's care plan dated 03/05/24 reflected a focus area Resident #53 had diabetes with intervention for diabetes mediations as ordered by doctor. <BR/>Record review of Resident #53's physician order listing report dated 04/24/24 reflected an order for Lantus pen injector - inject 20 units subcutaneously at bedtime for diabetes dated 2/13/24 and Lantus pen injector - inject 50 units subcutaneously one time a day for diabetes dated 3/30/24 . <BR/>Record review of Resident #53's treatment administration record dated 04/24/24 reflected Resident #53 received Lantus 20 units at bedtime on 04/01/24 through 04/23/24 and Lantus 50 units in the morning on 04/01/24 through 04/24/24. <BR/>Observation on 04/24/24 at 09:30 AM during the medication cart inspection on Station A revealed Lantus pen injector with Resident #53's name on the label and no open date on the pen. <BR/>Record review Resident #82's face sheet dated 04/24/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure, heart failure, and Alzheimer's disease (cognitive loss). <BR/>Record review of Resident #82's quarterly MDS assessment, dated 03/08/24 revealed no BIMS score, but indicated cognition was severely impaired. Section N - medications reflected Resident #4 had received insulin injections during the last 7 days. <BR/>Record review of Resident #82's care plan dated 04/04/24 reflected a focus area Resident #4 had diabetes with intervention for diabetes mediations as ordered by doctor. <BR/>Record review of Resident #82's physician order listing report dated 04/24/24 reflected an order for insulin glargine subcutaneous solution 100unit/ml - inject 10 units subcutaneously at bedtime for diabetes dated 2/27/24 .<BR/>Record review of Resident #82 treatment administration record dated 04/24/24 reflected Resident #82 received insulin glargine 10 units at bedtime on 04/01/24 through 04/23/24.<BR/>Observation on 04/24/24 at 09:30 AM during the medication cart inspection on Station A revealed insulin glargine pen with Resident #82's name on the label and no open date on the pens. <BR/>During an interview on 04/24/24 at 09:50 AM with the ADON, he stated all insulin pens should be dated when opened. He stated it was the nurse's responsibility to date the pen when opened. He stated he did not know why the pens were not dated. He stated the potential negative outcome could be given a resident insulin past the expiration date. He stated he was trained to date insulin pens on the day it was opened. <BR/>During an interview on 04/25/24 at 02:00 PM with the DON, she stated all insulin pens should have a date on them when opened. She stated all staff have been trained to date multiuse pens when opened. She stated the nurses, ADON and DON were responsible to monitoring the medication carts and medication dates. She stated the potential negative outcome could be administering old or expired medications. <BR/>During an interview on 04/25/24 at 04:15 PM with the ADM , she stated insulin pens should be dated when opened. She stated all nurses had been trained. She stated the nurse, medication aide, ADON and DON were responsible for making sure medications were dated. She stated the potential negative outcome could be giving a resident a medication that was expired or past date it can be given. <BR/>Record review of facility policy titled Administering Medications dated April 2019 reflected the following:<BR/>Policy Statement - medications are administered in a safe and timely manner, and as prescribed. <BR/>Policy Interpretation and Implementation<BR/>12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container .<BR/>Record review of facility policy titled Medication and Preparation Administration, undated reflected the following:<BR/>9.1 Prior to Medication Administration .<BR/>The following general recommendations should be utilized during preparation of medication: .<BR/>Facility staff should plan an opened-on date on the medication label for medications with limited expiration date upon opening .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #16) of 20 residents reviewed for medical records.<BR/>The facility failed to ensure facility nurses documented Resident #16's mechanically altered diet correctly on 06/08/2025's Weekly Swallowing/Nutritional Status. <BR/>This failure placed resident at risk for missed treatment and care which could result in decline in health and well-being.<BR/>Findings included:<BR/>Record review of Resident #16's face sheet, dated 06/13/2025, revealed the resident was a [AGE] year old male and originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit (complication of pulmonary aspiration or the inhalation of food, liquid, or vomit inti the lungs), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), dysphagia (difficulty swallowing), heart failure (the heart muscle does not pump blood as well as it should), and edema (swelling caused by fluid trapped in your tissues). <BR/>Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS was 0 out of 15 indicated the resident had severe cognitive impairment, and the resident required supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as resident completes activities) to eating and dependent (helper does all of the effort) to sit to stand and chair to bed transfer. Further record review of the MDS revealed the resident was receiving Mechanically altered diet. <BR/>Record review of Resident #16's comprehensive care plan, dated 04/12/2023, revealed The resident is able to feed self with setup, cuing direction. Does not like staff assistance and The resident has potential nutritional problem related to severe intellectual disabilities and history of dysphagia - Provide and serve diet as ordered of pureed diet and thin liquid for diet. <BR/>Record review of Resident #16's physician order, dated 05/28/2025, revealed Pureed diet and thin liquid diet.<BR/>Record review of Resident #16's Swallowing/Nutritional Status Weekly, dated 06/08/2025, revealed regarding to the question Has the resident required a mechanically altered diet in the past 7 days? (for example, pureed food, thickened liquids), the facility nurses answered No.<BR/>Observation on 06/10/2025 at 12:45 p.m. revealed Resident #16 received pureed diet with thin liquids per the physician order at the main dining room. <BR/>Interview on 06/13/2025 at 12:30 p.m. with ADON-B stated Resident #16's Weekly Swallowing/Nutritional Status on 06/08/2025 was inaccurate because Resident #16 was receiving pureed and thin liquid diet as ordered; therefore, the answered should have been Yes. ADON-B said she did not know what reason facility nurses documented inaccurately, but the resident's medical document should be accurate because inaccurate medical record might cause incorrect care to the resident, and the facility did not have policy regarding accurate clinical records.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable disease and infections for 2 of 2 (Residents #12 and #67) observed for care in that:<BR/>1. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #12.<BR/>2. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #67.<BR/>This failure can affect residents in the facility who received incontinent care and could result in spread of infections.<BR/>The findings were:<BR/>1. Record review of Resident #12's admission Record (03/03/2023) revealed an admission date of 01/17/2023 with diagnoses of Irritable bowel syndrome (disorder that affects the stomach and intestines, also called the gastrointestinal tract) with Diarrhea and Cerebral Infarction, unspecified.<BR/>Record review of Resident #12's careplan (01/17/2023) revealed activities of daily care deficit due to immobility and required one person assist for toileting. <BR/>Record review of Resident #12's MDS (01/31/2023) revealed she was always incontinent and was total dependent with toileting. Further record review revealed she required one person assistance.<BR/>During observation on 02/28/2023 beginning at 08:53 a.m., CNA A provided incontinent care for Resident # 12. Further observation revealed Resident #12 had a bowel movement. CNA A washed her hands and donned a pair of gloves. CNA A wipe Resident #12's perineal area. After CNA a wiped Resident #12's perineal area, CNA A with the same gloves, touched Resident # 12's pillow and placed it at the Resident # 12's foot of bed. Resident #12 was repositioned to the left side, CNA A wiped Resident #12's bottom and removed the patient's briefs. CNA A removed her gloves, sanitized her hands, and donned another pair of gloves. Resident #12's pillow was placed back under her left arm.<BR/>2 Record review of Resident #67's facesheet (03/03/2023) revealed an admission date of 01/25/2023 and diagnoses of Disturbance, Neuromuscular Dysfunction of the Bladder, Benign Prostatic Hyperplasia with lower urinary tract symptoms, and Chronic Kidney Disease.<BR/>Record review of Resident #67's careplan revealed self-care performance deficit in activities of daily living tasks and required extensive assistance by staff. <BR/>Record review of Resident #67's MDS revealed he required extensive assistance with one person assist for toileting. Further review revealed Resident #67 had an indwelling catheter and frequently incontinent of bowel. <BR/>Record review of CNA A's last peri-care/incontinence care skill assessment (male and female) was on 12/22/2022. Further review revealed proficiency criteria included taking off the gloves, putting them in the trash bag and washing hands and putting on new gloves.<BR/>During an observation on 02/28/2023 at 09:15 a.m., CNA A Provided cath care for Resident #12. CNA A washed hands/gloved, anchor in place, wiped patients cath 3 to inches down, and around cath tubing, after, CNA A wiped head of penis and down and around and down, after, with same gloves CNA A left hip and blanket, to roll pt. to right side wiped bottom, touched clean brief, added brief, then removed gloves. <BR/>During an interview on 02/28/23 at 09:37 a.m., CNA A indicated she should've removed her gloves after cleaning Resident # 12's peri area, before touching Resident #12's pillow, and after wiping Resident #67's indwelling catheter and perineal area. Further interview with CNA A revealed she didn't pay attention to that because she's in a rush to care for other residents.<BR/>During an interview on 03/01/2023 at 4:10 p.m., the Administrator stated competency on incontinent care were done on hire and annually.<BR/>Record review of the facility's policy and procedure titled Stand Precautions (2001), read in part, Standard Precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .2. Gloves: d. Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #16) of 20 residents reviewed for medical records.<BR/>The facility failed to ensure facility nurses documented Resident #16's mechanically altered diet correctly on 06/08/2025's Weekly Swallowing/Nutritional Status. <BR/>This failure placed resident at risk for missed treatment and care which could result in decline in health and well-being.<BR/>Findings included:<BR/>Record review of Resident #16's face sheet, dated 06/13/2025, revealed the resident was a [AGE] year old male and originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit (complication of pulmonary aspiration or the inhalation of food, liquid, or vomit inti the lungs), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), dysphagia (difficulty swallowing), heart failure (the heart muscle does not pump blood as well as it should), and edema (swelling caused by fluid trapped in your tissues). <BR/>Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS was 0 out of 15 indicated the resident had severe cognitive impairment, and the resident required supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as resident completes activities) to eating and dependent (helper does all of the effort) to sit to stand and chair to bed transfer. Further record review of the MDS revealed the resident was receiving Mechanically altered diet. <BR/>Record review of Resident #16's comprehensive care plan, dated 04/12/2023, revealed The resident is able to feed self with setup, cuing direction. Does not like staff assistance and The resident has potential nutritional problem related to severe intellectual disabilities and history of dysphagia - Provide and serve diet as ordered of pureed diet and thin liquid for diet. <BR/>Record review of Resident #16's physician order, dated 05/28/2025, revealed Pureed diet and thin liquid diet.<BR/>Record review of Resident #16's Swallowing/Nutritional Status Weekly, dated 06/08/2025, revealed regarding to the question Has the resident required a mechanically altered diet in the past 7 days? (for example, pureed food, thickened liquids), the facility nurses answered No.<BR/>Observation on 06/10/2025 at 12:45 p.m. revealed Resident #16 received pureed diet with thin liquids per the physician order at the main dining room. <BR/>Interview on 06/13/2025 at 12:30 p.m. with ADON-B stated Resident #16's Weekly Swallowing/Nutritional Status on 06/08/2025 was inaccurate because Resident #16 was receiving pureed and thin liquid diet as ordered; therefore, the answered should have been Yes. ADON-B said she did not know what reason facility nurses documented inaccurately, but the resident's medical document should be accurate because inaccurate medical record might cause incorrect care to the resident, and the facility did not have policy regarding accurate clinical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately inform the resident and notify, consistent with his or her authority, the residents' representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status and or a need to alter treatment significantly, for 1 of 3 residents (Resident #1) reviewed for being informed of their health status.<BR/>The facility failed toensure they reported to Resident #1's Representative on 08/14/2024 of Resident #1's change of condition (episodic high blood pressure) to include new orders for anti-high blood pressure and anti-nausea / vomit medication. <BR/>This failure could place residents at risk for harm by not reporting a residents health status and the opportunity for consent of care . <BR/>The Findings included:<BR/>A record review of Resident #1's admission record dated 09/11/2024 revealed an admission date of 03/20/2024 with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), schizoaffective disorder, bipolar type (a mental disorder characterized by symptoms of both schizophrenia (psychosis) and mood disorder - either bipolar disorder or depression). Further review revealed Resident #1's (family member) was identified as Resident #1's Medical and Financial Power of Attorney, Responsible Party, and Emergency Contact. <BR/>A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a medically complex [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Further review revealed Resident #1's family was documented as participating in the MDS Assessment and Goal Setting. <BR/>A record review of Resident #1's nursing progress notes revealed LVN A documented on 08/14/2024 a change of condition with high blood pressure, vomiting, and low oxygen levels. LVN A reported the change of condition to the on-call Nurse Practitioner who gave new orders for oxygen, anti-high blood pressure medication, and anti-nausea medication:<BR/>Type: <BR/>Nurse's Note <BR/>Effective Date: <BR/>8/14/2024 22:12:00<BR/>Department: <BR/>Nursing<BR/>Position: <BR/>LVN/CHR<BR/>Created By: <BR/>(LVN A)<BR/>Created Date : <BR/>8/14/2024 22:19:32<BR/> Note Text: <BR/>resident was [being] changed when she threw up. She started shivering and vitals were taken. O2=84, HR=112, BR=198/98 and RR=22. O2 given. TeamHealth was notified and gave an order for 2L of O2 and 4Mg of Zofran. O2 came up to 95 and BP down to 178/88 and HR of 102. Message was left for TeamHealth informing them of improved O2 and high BP and HR.<BR/>A record review of Resident #1's August 2024 medication administration record and August 2024 physician's orders revealed LVN A documented on 08/14/2024, the Nurse Practitioners new order for hydralazine 10mg for high blood pressure, ondansetron 4mg for nausea and vomiting, and oxygen via a nasal canula at 2 liters for blood oxygen to be kept above 92%. <BR/>During an interview on 09/11/2024 at 15:55 AM, LVN A stated on 08/14/2024 he worked the 02:00 PM to 10:00 PM shift assigned to Resident #1's care. LVN A stated after dinner, Resident #1 had an episode of confusion, altered mental status, shortness of breath, high blood pressure, and vomitting. LVN A stated he reported the change of condition to the on-call nurse practitioner and received new orders for Resident #1 to receive an anti-high blood pressure medication, anti-nausea medication, and some oxygen to keep her oxygen level above 92%. LVN A stated he documented the new orders and assessments but did not consider reporting the change of condition and / or the new medication treatments to Resident #1's (family) representative. LVN A stated he understood Resident #1 and her representatives were not provided an opportunity to participate in their plan of care to include a report of their change of health status. <BR/>During a joint interview on 09/11/2024 at 10:00 AM, with the Administrator, the DON, and the ADON, the ADON stated Resident #1 was discharged from the facility on 08/17/2024 due to increased vomiting and high blood pressure. The ADON stated Resident #1 was treated at the hospital for a week. During Resident #1's hospitalization, the ADON stated she had been contacted by Resident #1's POA and the POA was given a report to Resident #1's health condition prior to hospitalization. The ADON stated she became aware that Resident #1's representative had not received a change of condition report on 08/14/2024 and when Resident #1's representative visited Resident #1 on 08/17/2024, the day Resident #1 was transferred to the hospital, Resident #1's representative was unaware of Resident #1's declined health status. The ADON stated she had reported the finding to the DON and the A dministrator. The administrator stated she began an investigation and reported an allegation of neglect to the state agency and coordinated with the DON for a root cause analysis and development of a plan of correction. The administrator stated the facility developed re-enforced trainings for all the nursing and CNA staff to cover change of conditions protocols to include notifications for residents and their representatives any new orders and or treatments in their care. The administrator stated she and her team identified LVN A as not having reported to Resident #1's representative the change of condition, new orders, and interventions to address Resident #1 new episodes of SOB, high blood pressure, and nausea. LVN A has since received further training and supervision from the DON and the ADON. The facility surveilled other residents for similar deficiencies and had not identified anyone else. <BR/>During an interview on 9/11/2024 at 11:50 AM, Resident #1's representative stated Resident #1 had her own cell phone and had a practice of calling family frequently at least every 2 days, if not daily, when on 8/16/2024, the family recognized Resident #1 had not called anyone. Resident #1's representative visited Resident #1 on the morning of 08/17/2024 and discovered she had not been well. Resident #1's representative received a report Resident #1 had not been eating, had been throwing up, and had high blood pressure. Resident #1's representative requested for the facility to transfer Resident #1 to the hospital for evaluation. Resident #1 was transferred out to the hospital that afternoon. Resident #1's representative stated she had not received any communication her loved one was ill until she learned herself by visiting Resident #1 on 08/17/2024 and was denied any earlier intervention and or participation in Resident #1's plan of care. <BR/>A record review of the facility's 2021 Change in a Resident's Condition or Status policy revealed, Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: . 4. <BR/>Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . <BR/>b. <BR/>there is a significant change in the resident's physical, mental, or psychosocial status. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #16) of 20 residents reviewed for medical records.<BR/>The facility failed to ensure facility nurses documented Resident #16's mechanically altered diet correctly on 06/08/2025's Weekly Swallowing/Nutritional Status. <BR/>This failure placed resident at risk for missed treatment and care which could result in decline in health and well-being.<BR/>Findings included:<BR/>Record review of Resident #16's face sheet, dated 06/13/2025, revealed the resident was a [AGE] year old male and originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit (complication of pulmonary aspiration or the inhalation of food, liquid, or vomit inti the lungs), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), dysphagia (difficulty swallowing), heart failure (the heart muscle does not pump blood as well as it should), and edema (swelling caused by fluid trapped in your tissues). <BR/>Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS was 0 out of 15 indicated the resident had severe cognitive impairment, and the resident required supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as resident completes activities) to eating and dependent (helper does all of the effort) to sit to stand and chair to bed transfer. Further record review of the MDS revealed the resident was receiving Mechanically altered diet. <BR/>Record review of Resident #16's comprehensive care plan, dated 04/12/2023, revealed The resident is able to feed self with setup, cuing direction. Does not like staff assistance and The resident has potential nutritional problem related to severe intellectual disabilities and history of dysphagia - Provide and serve diet as ordered of pureed diet and thin liquid for diet. <BR/>Record review of Resident #16's physician order, dated 05/28/2025, revealed Pureed diet and thin liquid diet.<BR/>Record review of Resident #16's Swallowing/Nutritional Status Weekly, dated 06/08/2025, revealed regarding to the question Has the resident required a mechanically altered diet in the past 7 days? (for example, pureed food, thickened liquids), the facility nurses answered No.<BR/>Observation on 06/10/2025 at 12:45 p.m. revealed Resident #16 received pureed diet with thin liquids per the physician order at the main dining room. <BR/>Interview on 06/13/2025 at 12:30 p.m. with ADON-B stated Resident #16's Weekly Swallowing/Nutritional Status on 06/08/2025 was inaccurate because Resident #16 was receiving pureed and thin liquid diet as ordered; therefore, the answered should have been Yes. ADON-B said she did not know what reason facility nurses documented inaccurately, but the resident's medical document should be accurate because inaccurate medical record might cause incorrect care to the resident, and the facility did not have policy regarding accurate clinical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately inform the resident and notify, consistent with his or her authority, the residents' representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status and or a need to alter treatment significantly, for 1 of 3 residents (Resident #1) reviewed for being informed of their health status.<BR/>The facility failed toensure they reported to Resident #1's Representative on 08/14/2024 of Resident #1's change of condition (episodic high blood pressure) to include new orders for anti-high blood pressure and anti-nausea / vomit medication. <BR/>This failure could place residents at risk for harm by not reporting a residents health status and the opportunity for consent of care . <BR/>The Findings included:<BR/>A record review of Resident #1's admission record dated 09/11/2024 revealed an admission date of 03/20/2024 with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), schizoaffective disorder, bipolar type (a mental disorder characterized by symptoms of both schizophrenia (psychosis) and mood disorder - either bipolar disorder or depression). Further review revealed Resident #1's (family member) was identified as Resident #1's Medical and Financial Power of Attorney, Responsible Party, and Emergency Contact. <BR/>A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a medically complex [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Further review revealed Resident #1's family was documented as participating in the MDS Assessment and Goal Setting. <BR/>A record review of Resident #1's nursing progress notes revealed LVN A documented on 08/14/2024 a change of condition with high blood pressure, vomiting, and low oxygen levels. LVN A reported the change of condition to the on-call Nurse Practitioner who gave new orders for oxygen, anti-high blood pressure medication, and anti-nausea medication:<BR/>Type: <BR/>Nurse's Note <BR/>Effective Date: <BR/>8/14/2024 22:12:00<BR/>Department: <BR/>Nursing<BR/>Position: <BR/>LVN/CHR<BR/>Created By: <BR/>(LVN A)<BR/>Created Date : <BR/>8/14/2024 22:19:32<BR/> Note Text: <BR/>resident was [being] changed when she threw up. She started shivering and vitals were taken. O2=84, HR=112, BR=198/98 and RR=22. O2 given. TeamHealth was notified and gave an order for 2L of O2 and 4Mg of Zofran. O2 came up to 95 and BP down to 178/88 and HR of 102. Message was left for TeamHealth informing them of improved O2 and high BP and HR.<BR/>A record review of Resident #1's August 2024 medication administration record and August 2024 physician's orders revealed LVN A documented on 08/14/2024, the Nurse Practitioners new order for hydralazine 10mg for high blood pressure, ondansetron 4mg for nausea and vomiting, and oxygen via a nasal canula at 2 liters for blood oxygen to be kept above 92%. <BR/>During an interview on 09/11/2024 at 15:55 AM, LVN A stated on 08/14/2024 he worked the 02:00 PM to 10:00 PM shift assigned to Resident #1's care. LVN A stated after dinner, Resident #1 had an episode of confusion, altered mental status, shortness of breath, high blood pressure, and vomitting. LVN A stated he reported the change of condition to the on-call nurse practitioner and received new orders for Resident #1 to receive an anti-high blood pressure medication, anti-nausea medication, and some oxygen to keep her oxygen level above 92%. LVN A stated he documented the new orders and assessments but did not consider reporting the change of condition and / or the new medication treatments to Resident #1's (family) representative. LVN A stated he understood Resident #1 and her representatives were not provided an opportunity to participate in their plan of care to include a report of their change of health status. <BR/>During a joint interview on 09/11/2024 at 10:00 AM, with the Administrator, the DON, and the ADON, the ADON stated Resident #1 was discharged from the facility on 08/17/2024 due to increased vomiting and high blood pressure. The ADON stated Resident #1 was treated at the hospital for a week. During Resident #1's hospitalization, the ADON stated she had been contacted by Resident #1's POA and the POA was given a report to Resident #1's health condition prior to hospitalization. The ADON stated she became aware that Resident #1's representative had not received a change of condition report on 08/14/2024 and when Resident #1's representative visited Resident #1 on 08/17/2024, the day Resident #1 was transferred to the hospital, Resident #1's representative was unaware of Resident #1's declined health status. The ADON stated she had reported the finding to the DON and the A dministrator. The administrator stated she began an investigation and reported an allegation of neglect to the state agency and coordinated with the DON for a root cause analysis and development of a plan of correction. The administrator stated the facility developed re-enforced trainings for all the nursing and CNA staff to cover change of conditions protocols to include notifications for residents and their representatives any new orders and or treatments in their care. The administrator stated she and her team identified LVN A as not having reported to Resident #1's representative the change of condition, new orders, and interventions to address Resident #1 new episodes of SOB, high blood pressure, and nausea. LVN A has since received further training and supervision from the DON and the ADON. The facility surveilled other residents for similar deficiencies and had not identified anyone else. <BR/>During an interview on 9/11/2024 at 11:50 AM, Resident #1's representative stated Resident #1 had her own cell phone and had a practice of calling family frequently at least every 2 days, if not daily, when on 8/16/2024, the family recognized Resident #1 had not called anyone. Resident #1's representative visited Resident #1 on the morning of 08/17/2024 and discovered she had not been well. Resident #1's representative received a report Resident #1 had not been eating, had been throwing up, and had high blood pressure. Resident #1's representative requested for the facility to transfer Resident #1 to the hospital for evaluation. Resident #1 was transferred out to the hospital that afternoon. Resident #1's representative stated she had not received any communication her loved one was ill until she learned herself by visiting Resident #1 on 08/17/2024 and was denied any earlier intervention and or participation in Resident #1's plan of care. <BR/>A record review of the facility's 2021 Change in a Resident's Condition or Status policy revealed, Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: . 4. <BR/>Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . <BR/>b. <BR/>there is a significant change in the resident's physical, mental, or psychosocial status. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 3 (Resident #3, #6, and #8) of 54 residents who resided on A and B hall reviewed for call lights. In that:<BR/>Resident #3 had no access to his call light which had been clipped to the privacy curtain at the foot of his bed.<BR/>Resident # 6 had no access to her call light which was on the floor under the roommate's bed and on the floor next to her bed.<BR/>Resident #8 had no access to her call light which was on the floor under the foot of her bed.<BR/>This deficient practice could place residents not being able to use call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>Record review of Resident's #3's face sheet, revealed he was a [AGE] year-old male, admitted on [DATE]. He had diagnoses that included: anxiety disorder and Epilepsy (a brain disorder that causes seizures).<BR/>Record review of Resident #3's quarterly MDS dated [DATE], revealed a BIMS score of 13 indicating intact cognition. The MDS reflected Resident #3 needed supervision with transfers and partial assistance with toileting and dressing. <BR/>Record review of Resident #3's care plan, revised 8/22/2023 with a target date of 06/05/2024, revealed Resident #3 was a high fall risk related to a history of seizures and poor safety awareness. An intervention, dated 8/29/2023, stated be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Record review of Resident #3's Fall Risk Evaluation, dated 04/06/2024, indicated resident was a high fall risk and stated Resident #3 had 1-2 falls in the past 3 months. The Fall Risk Evaluation instructions revealed that a score of 10 or greater was considered a High Risk for falls. Resident # 3's score was 19.<BR/>Observation and interview on 04/15/2024 at 3:15 p.m., Resident #3 was lying in bed with the call light attached to the privacy curtain behind the foot of the bed. Resident #3 stated his call light should have been on his bed where he can reach it. He stated he did not place the call light on the privacy curtain and stated that he used his call light to reach staff if he needed assistance with anything.<BR/>Record review of Resident #6's face sheet revealed she was a [AGE] year-old female, admitted on [DATE]. She had diagnoses that included: Anxiety Disorder, Seizures (a sudden, uncontrolled electrical disturbance in the brain which can causes changes in behavior, movements, or feelings) and schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and characterized by symptoms such as delusions and hallucinations).<BR/>Record review of Resident #6's quarterly MDS, dated [DATE], revealed a BIMS score of 12 indicating mild cognitive impairment. The MDS indicated Resident #6 required moderate to maximum assistance with dressing and bed mobility and was dependent for assistance with transfers. <BR/>Record review of Resident #6's care plan, revised 11/24/2023 with a target date of 05/21/2024, revealed resident was a high fall risk related to weakness, confusion, and poor impulse control. An intervention, dated 12/14/2022, stated be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Record review of Resident #6's Fall Risk Evaluation, dated 03/06/2024, indicated Resident #6 was a high fall risk. The Fall Risk Evaluation instructions revealed that a score of 10 or greater was considered a High Risk for falls. Resident # 6's score was 14.<BR/>Observation and interview on 04/15/2024 at 12:45 p.m., Resident #6 was lying in bed with her call light underneath her roommate's bed. Resident #6 stated she did not realize her call light was not on her bed. She stated she did not place it on the floor, and she stated staff usually place her call light within reach. Resident #6 stated she used the call light to call for help.<BR/>Observation and interview on 4/15/2024 at 3:35 p.m., Resident #6 was lying in bed with her call light on the floor by the left side of her bed. Resident #6 stated she did not realize her call light was on the floor. She stated she did not place it on the floor, and she stated staff usually place her call light within reach. Resident #6 stated she used the call light to call for help.<BR/>Observation on 04/15/2024 at 3:38 p.m., Resident #6 heard from the doorway of her room yelling help, I need help. Upon entering resident room with RN MDS, resident stated I need my call light.<BR/>During an interview, 04/15/2024 at 3:42pm, RN MDS said Resident #6's call light was on the floor beside the bed. RN MDS stated call lights should be within a resident's reach and stated staff are responsible for making sure the call lights are within reach. RN MDS stated it is important to keep the call lights within reach and that it could be detrimental for a resident to not have the call light in reach.<BR/>Record review of Resident #8's face sheet revealed she was a [AGE] year-old female, admitted on [DATE]. Resident #8's diagnoses included: Alzheimer's Disease (a progressive disease that affects memory and other important mental functions).<BR/>Record review of Resident #8's quarterly MDS, dated [DATE], revealed she had short term and long-term memory deficits and a severe impairment for cognitive decision-making skills. The MDS revealed Resident #8 is dependent on staff for all ADL's. <BR/>Record review of Resident #8's care plan, revised 08/27/2023 and target date 04/23/2024, revealed resident was a high fall risk related to confusion, incontinence, poor communication/comprehension, vision/hearing problems, unsteady trunk control, cognitive impairment, and history of falls. An intervention, dated 08/27/2023, stated be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Record review of Resident #8's Fall Risk Evaluation, dated 02/06/2024, revealed resident was a high fall risk. The Fall Risk Evaluation instructions revealed that a score of 10 or greater was considered a High Risk for falls. Resident # 8's score was 24.<BR/>Observation on 04/15/2024 at 3:40 p.m., revealed Resident #8 lying in bed with her call light on the floor under the foot of her bed.<BR/>During an interview on 04/15/2024 at 3:42 p.m., RN MDS said Resident #8's call light was on the floor under the resident's bed. <BR/>During an interview on 04/15/2024 at 4:50 p.m., CNA A stated resident call lights should be within reach when a resident is in their bed. He stated the CNA's, nurses and any staff who enter the room are responsible for making sure the call lights are in reach. CNA A stated it was important to keep the call lights in reach because a resident could fall or become soiled if they laid there too long. CNA A revealed he had received training in facility orientation he attended when hired two weeks ago. <BR/>During an interview on 04/16/2024 at 2:20 p.m., the DON stated call lights should be in reach of a resident and it was the responsibility of all staff to make sure they were in reach. She stated it was important to keep the call lights in reach of a resident because they could fall or lots of things could happen. The DON stated staff were trained on call light placement during in-services and we check them daily and talk to staff if we find one not close to a resident. <BR/>Record review of facility policy, Strategies for Reducing the Risk of Falls, revised 04/2022, stated call light within reach was a strategy to an environmental risk factor.<BR/>Record review of facility policy, Falls Prevention-Potential Interventions, revised 04/2022, stated call light as an intervention with a description of placed within reach at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 1 of 1 residents (Residents #89) reviewed for transfers, in that:<BR/>The facility did not provide Resident #89 with a written bed-hold policy when the resident was transferred out to the hospital. <BR/>This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred and at risk for of being improperly discharged and placed in unsafe conditions.<BR/>The findings were:<BR/>Record review of Resident #89's face sheet, undated, revealed an [AGE] year-old-female was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include respiratory failure, COPD (lung disease), heart failure, hypertension (high blood pressure), and diabetes (high blood sugar). <BR/>Record review of Resident #89's Comprehensive Minimum Data Set, dated [DATE], revealed: Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. <BR/>Record Review of Resident #89's census from the EMR revealed that on 03/11/24 billing was stopped. The discharge MDS dated [DATE] revealed Resident #89 was discharged to short-term general hospital with return anticipated . Resident #89 returned to facility on 03/12/24. <BR/>Record review of Resident #89's admission record indicated that she received the bed-hold policy [NAME] admission indicating that the facility procedure was upon transfer or discharge, a signed bed hold agreement was required on all residents who discharged to the community and wished to return to the same bed when admitted . <BR/>During an interview on 04/26/24 09:45 AM with the Admin Coor., he stated Resident #89 did not sign a bed hold when she went out to the hospital. He stated the facility did not do bed holds when residents were transferred out to the hospital. He stated the facility would hold the resident's bed because the facility wanted them to return to the facility. <BR/>During an interview on 04/26/24 at 09:50 AM with the ADM, she stated they do not give residents or family members a bed hold when the resident was discharged to the hospital. She stated they hold the bed until the resident returns. She stated the purpose of the bed hold was in the event a resident wanted to hold the bed to ensure they have the same room. She stated they have no system in place to ensure bed hold are given to residents when they are discharged from the facility and plan to return. She stated if the facility was at full capacity and a resident was private pay and went out to the hospital, they would notify the responsible party by phone and give them the option to pay for a bed hold. She stated residents applied income paid to the facility was what they consider payment for bed holds. She stated the BOM and admission Coor. were responsible for obtaining a resident bed hold when they find out a resident went out to hospital. <BR/>During an interview on 04/26/24 at 10:09 AM with BOM, she stated bed holds were used to guarantee the resident will be readmitted to same room. The BOM stated she had been trained on bed hold policy. She stated there would be no negative outcome of not giving a resident a bed hold, because they hold the residents bed until they return. She stated the facility had never given any bed holds since she had been here for the past 6 years.<BR/>Record review of the facility policy titled Bed Hold (undated) revealed: <BR/>I. Bed Hold Policy is governed by the Texas Administrative Code 40 TAC &sect;19.503 and all other State and Federal requirements for participation of a Texas Skilled Nursing Facility.<BR/>II. Signed bed hold agreements are required on all Residents who discharge the Community and wish to return to the same bed when readmitted .<BR/>This signed agreement should be obtained at the time of discharge.<BR/>If the Resident or Resident's Representative is unable to come to the Community location to sign, a verbal agreement can be obtained and is required to be documented.<BR/>Contact for, and documentation of, the verbal bed hold agreement will be completed by the Business Office Manager, or their appointed representative, during routine business hours of 8am - 5pm, Monday through Friday.<BR/>Contact for, and documentation of, the verbal bed hold agreement for after-hours discharge is completed by the nurse on duty, or their appointed representative, in the form of a clinical note in the electronic medical record system, detailing the date, time and name of the person verbally approving the bed hold.<BR/>After hours is generally considered nights and weekends but is expected to cover holidays and anytime other than the routine business hours stated above.<BR/>The bed hold agreement must be scanned, emailed, or faxed to be signed by the Resident or Resident Representative. The signed agreement must be returned within five (5) Business Days of discharge, but no later than the 2nd business day following the end of the month.<BR/>The bed hold agreement will be provided to the Resident and/or Resident Representative (RR) by the Business Office Manager, or appointed representative.<BR/>In the event of an after- hours discharge, the Business Office Manager, or appointed representative will provide the agreement to the Resident and/or RR the next business day.<BR/>Without a proper signature on the bed hold form by the 2nd business day of the following month,<BR/>the Resident will be discharged from the Community back to the date the Resident transferred out of the Community .<BR/>Bed hold Authorization & Agreement Forms must be filled out and signed by the Resident or<BR/>Resident Representative and designated to either execute the bed hold or not .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure when the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, a final summary of the resident's status to include items in paragraph, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative; reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter) for 1 of 3 (Resident #77) resident reviewed for discharge in that: <BR/>Resident #77 was discharged on 1/25/2024 and a discharge summary was not completed. <BR/>This could affect all residents and could result in residents' information not being accurate.<BR/>The Findings:<BR/>Record review of Resident #77's admission Record revealed she was admitted on [DATE] and her diagnoses were Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs.), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), adult failure to thrive, osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), )and osteopathic (degenerative joint disease. The record revealed Resident #77 was discharged on 1/25/2024. <BR/>Record review of Resident #77's chart revealed she did not have a discharge MDS. <BR/>Record review of Resident #77's chart revealed there was not a discharge summary report.<BR/>Record review of Resident #77's care plan dated 3/11/2023 revealed resident wishes to remain in long term care, pre-discharge care plan. <BR/>Record review of Resident #77's progress note dated 1/25/2024 reflected Resident #77 went to hospital due to critical labs and never returned. <BR/>Interview on 4/26/24 at 11:48 AM the DON stated she would look for Resident #77's discharge summary report. No evidence was provided before exit . <BR/>Record review of Policy Transfer or Discharge, Facility-Initiated, dated October 2022, revealed Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Documentation of Facility-Initiated Transfer or Discharge, 1. When a resident is transferred or discharged from the facility, the following information is documented in the medical record: f. A summary of the resident's overall medical, physical, and mental condition; g. Disposition of personal effects; and h. Disposition of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident, who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 20 residents reviewed for respiratory care. (Resident #240)<BR/>The facility did not ensure Resident #240 had orders for the administration of oxygen. <BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. <BR/>Findings included:<BR/>Record review Resident #240's face sheet dated 04/24/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), atrial fibrillation (irregular heart beat), COPD (lung disease) and falls. <BR/>Record review of Resident #240's EMR reflected he did not have a complete MDS assessment.<BR/>Record review of care plan dated 04/22/24 reflected Resident #240 had cardiac disease with intervention to administer oxygen as ordered per physician. Resident #240 had altered respiratory status/difficulty breathing with interventions oxygen settings: O2 via (specify: nasal prongs/mask) at (specify) L (specify freq.) Humidified (specify). <BR/>During observations Resident #240 had oxygen in progress as follows:<BR/>04/23/24 at 10:15 AM O2 on via oxygen concentrator at 4lpm via nasal cannula<BR/>04/24/24 at 09:00 AM O2 on via oxygen concentrator at 4lpm via nasal cannula<BR/>04/25/24 at 10:00 AM O2 on via oxygen concentrator at 4lpm via nasal cannula<BR/>During an interview on 04/23/24 at 10:15 AM with Resident #240, he stated he was admitted with oxygen and wears it all the time. He stated he was not sure how many liters it was to be set on.<BR/>Record review of Resident #240's physician's order listing report dated 04/23/24 reflected no order of oxygen. <BR/>During an interview on 04/25/24 at 02:00 PM with the DON, she stated any resident using oxygen must have a physician order. She stated all nursing staff had been trained to obtain orders and put them in the EMR. She stated the nurses was responsible for physician orders and she was responsible for monitoring orders. She stated nurses can place oxygen in emergency situations using nursing judgement but would need to get a physician order once the resident was stable. She stated Resident #240 did not have any orders for oxygen. She stated she was not sure why it was missed. She stated the oxygen orders should have been entered on day of admission. She stated the potential negative outcome could be a resident hyperventilated or had breathing difficulties. <BR/>During an interview on 04/25/24 at 04:00 PM with the ADM, she stated residents on oxygen does require an order. She stated the charge nurse, admission nurse and DON was responsible for obtaining the order. She stated staff had been trained on obtaining orders. She stated she was not sure why it was missed. She stated they review all new admissions during stand-up morning meeting to go over all orders and concerns. She stated the potential negative outcome could be a resident not getting what they need as for as oxygen was concerned. <BR/>Record review facility policy title Oxygen administration dated October 2010 reflected the following:<BR/>Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration.<BR/>Preparation<BR/>1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents (Resident #5 and #6) reviewed for pharmacy services.<BR/>1. The facility failed to ensure Resident #5's pain medications were acquired and dispensed per physician's orders.<BR/>2. The facility failed to ensure Resident #6's pain medications were acquired and dispensed per physician's orders.<BR/>This failure could place residents at risk of not receiving their prescribed medications and a decreased quality of life. <BR/>The findings included:<BR/>Record review of the facility provider investigation report written by the facility administrator, dated 3/6/25, reflected: A drug diversion has been identified. Review of the facility provider investigation report revealed a medication audit identified Resident #5 and Resident #6 had narcotic medications missing. The report further revealed the residents were assessed for pain with no deviation from baseline noted, no missing doses were noted, and back up medication was used from the facility emergency kit. The facility identified 6 nursing staff responsible for medications administered to Resident #5 and Resident #6 (RN D, RN G, LVN H, LVN K, LVN L and LVN M). <BR/>1. Record review of Resident #5's face sheet dated 3/9/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included osteomyelitis (infection of the bone usually caused by bacteria that can cause pain, selling and redness throughout the affected area), peripheral vascular disease (condition in which the blood vessels become narrowed or blocked and affects the blood flow to the legs, feed and sometimes arms), diabetes with neuropathy (condition where high blood sugar levels cause nerve damage), pain in right foot, and chronic ulcer (a long-lasting open wound or sore that does not heal within a typical timeframe due to underlying health conditions, such as diabetes) of the right foot.<BR/>Record review of Resident #5's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively intact for daily decision-making skills, experienced pain occasionally, and received opioid medications.<BR/>Record review of Resident #5's comprehensive care plan with revision dated 1/30/25 revealed the resident had acute/chronic pain related to surgical incision/wound with interventions that included to administer analgesics as ordered, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. <BR/>Record review of Resident #5's MAR (Medication Administration Record) for February 2025 included the following:<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, Give 1 tablet by mouth every 4 hours as needed for pain with start date 11/4/24 and no stop date. Further review of the MAR revealed the resident received one dose on 2/25/25 at 7:16 p.m. <BR/>- Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen), Give 2 tablets by mouth every 6 hours as needed for Pain until Hydrocodone comes in, with start date 11/4/24 and no stop date. Further review of the MAR revealed did not receive any does of the Tylenol Extra Strength for the month of February.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALERT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with order date 2/5/25 and no stop date. Further review of the MAR revealed the resident scored a 0, indicating no pain recorded for every shift, except 2/24/25 with a score of 4 recorded on the evening shift, and 2/26/25-2/27/25 with a score of 3 recorded on the day shift.<BR/>Record review of Resident #5's MAR for March 2025 included the following:<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth every 4 hours as needed for pain with start date 11/4/24 and no end date. Further review of the MAR revealed the resident did not receive any doses of the HYDROcodone-Acetaminophen.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALERT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no stop date. Further review of the MAR revealed the resident rated 0 for pain level during all three shifts for the month.<BR/>-Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen), Give 2 tablet by mouth every 6 hours as needed for Pain until Hydrocodone comes in, with start date 11/4/24 and no end date. Further review of the MAR revealed the resident received the Tylenol Extra Strength on 3/5/25 at 12:00 a.m., and again on 3/6/25 at 12:27p.m.<BR/>2. Record review of Resident #6's face sheet dated 3/9/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (symptoms associated with a decline in memory, reasoning and other cognitive abilities severe enough to interfere with daily life), bipolar disorder (mental health condition characterized by extreme mood swings), primary osteoarthritis of knee (degenerative joint disease that affects the same joints on both sides of the body), and age-related osteoporosis (condition characterized by a gradual decrease in bone mineral density and mas leading to weakened bones that are more susceptible to fractures) without current pathological fracture.<BR/>Record review of Resident #6's most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and did not receive antipsychotic or opioid medications.<BR/>Record review of Resident #6's comprehensive care plan with revision date 11/18/24 revealed the resident had osteoporosis with a history of fractures and interventions that included to give analgesics as needed for pain and medications as ordered.<BR/>Record review of Resident #6's MAR for February 2025 included the following:<BR/>- Tramadol HCL Oral Tablet 50 mg, Give 1 tablet by mouth every 6 hours as needed for pain, with start date 11/7/24 and no end date<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-300 MG, Give 1 tablet by mouth every 6 hours as needed for pain with start dated 11/7/24 and discontinue date 2/14/25. Further review of the MAR revealed the resident was not given any HYDROcodone-Acetaminophen during that timeframe.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALEFT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUMENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no end date. Further review of the MAR revealed the resident rated a pain level of 6 on 2/19/25 during the day shift and was administered Tramadol 50 mg used as needed for pain.<BR/>Record review of Resident #6's MAR for March 2025 included the following:<BR/>- Tramadol HCL Oral Tablet 50 mg, Give 1 tablet by mouth every 6 hours as needed for pain, with start date 11/7/24 and no end date. Further review of the MAR revealed the resident did not receive any doses of Tramadol up until the investigation on 3/9/25.<BR/>- MONITOR FOR PAIN EVERY SHIFT, USE 0-10 SCALE (A) FOR ALEFT RESIDENTS USE PAIN AD (B) FOR CONFUSED RESIDENTS DOCUMENT WHICH PAIN SCALE USED TO ASSESS RESIDENTS PAIN RATING, every shift with start date 2/5/25 and no end date. Further review of the MAR revealed the resident rated a pain level of 0 from 3/1/25 up until the investigation on 3/9/25.<BR/>During an interview on 3/8/25 at 8:26 a.m., RN I stated the process for avoiding a drug diversion required for nursing staff to count the narcotics in the medication cart with the next shift to ensure the medications were accounted for. RN I further stated, if there was a discrepancy with the narcotic count, the incoming nurse would not accept the keys to the medication cart and report to the DON for an investigation. RN I stated, a (narcotic) count is done every time (at shift change).<BR/>During an interview on 3/8/25 at 9:05 a.m., Med Aide J stated, the process for avoiding a drug diversion required for the nursing staff to count the narcotics in the medication cart with the next shift to ensure the medications were accounted for. Med Aide J stated, I would never accept the keys (to the medication cart) from somebody who did not count (narcotics) with me, you never know what they did. Not acceptable. Med Aide J stated she was not allowed to given pain medications when needed because only a nurse can make the assessment but was allowed to administer scheduled pain medications.<BR/>During an interview on 3/8/25 at 9:31 a.m., the DON stated, our policy, when narcotics are delivered, two nurses must sign for it (the narcotic delivery). The DON further stated, the delivery sheet/manifest (a detailed list of the items delivered) had to be signed by two nurses and then the delivery sheet/manifest would be filed in the medical records box after the medications were received. The DON acknowledged the facility identified a drug diversion on 3/5/25 in which Resident #5's and Resident #6's pain medications for HYDROcodone-Acetaminophen were missing from the medication cart. The DON acknowledged the facility did not have a process for checking to ensure the delivery sheet/manifest had two nurse signatures. <BR/>During an interview on 3/8/25 at 1:06 p.m., RN G stated the facility policy, when receiving medication deliveries, including narcotics, was for two nurses to sign the delivery sheet/manifest, place the narcotic log associated with the medication prescribed to the resident in the narcotic log, and place the medications in the medication cart. RN G further stated the delivery sheet/manifest was filed in a folder that used to be at the nurse's station. RN G stated the file for the delivery sheet/manifest had been gone for a while and (the delivery sheet/manifest) have been going to the shredder. I can't say if that was a good idea. RN G stated, the DON had only been employed since last year, so it's not like everybody has been doing that (checking for the delivery sheet/manifest), we used to file all that stuff, but then they (the file) disappeared. <BR/>During a telephone interview on 3/8/25 at 1:45 p.m., LVN F stated protocol for accepting a medication delivery, including narcotics would be to sign for the delivery on the pharmacy delivery driver's phone and then she would sign the delivery sheet/manifest. LVN F stated, the delivery sheet/manifest were supposed to be filed and it was a reference to show the medications were delivered. LVN F stated, the narcotic log once completed or the delivery sheet/manifest were never placed in the shredder, that is not protocol. <BR/>During an interview on 3/8/25 at 2:00 p.m., LVN H stated, once the pharmacy delivered medications, including narcotics, the receiving nurse signed electronically for the delivery on the pharmacy delivery driver's phone, and then the delivery sheet/manifest was supposed to be signed by two nurses confirming the order of medication was received. LVN H stated, the delivery sheet/manifest was filed in a binder that was at the nurse's station. LVN H stated, we have always had that binder, it has never gone away. LVN H stated, then the narcotic log was supposed to be signed by two nurses and placed in the narcotic log and the medication was stored in the locked box in the medication cart. LVN H stated it was not acceptable for one person to sign the narcotic sheet because a second person was needed to witness the medication was received. LVN H stated, once the narcotic log was zeroed out (completed) and the narcotic log was marked zero, I would take the narcotic log and place it in the medical records box and then throw the empty med card/blister pack away but tear the resident's information and put in the shredder and the empty blister pack was thrown in the trash. LVN H further stated, I would say the packing slips (delivery sheet/manifest) need to be saved, but the pharmacy has proof when we signed their phone that the product was delivered.<BR/>During an interview on 3/8/25 at 3:44 p.m., the ADON stated it was facility protocol, when the pharmacy delivered medications, including narcotics, the delivery sheet/manifest was supposed to be signed by one nurse for regular medications and two nurses for the narcotics. The ADON stated, once the delivery sheet/manifest was signed by two nurses, it was supposed to be delivered to the ADON to audit for signatures. The ADON stated, we do know we lost medications. I think part of the failure of the process was when the nurses stopped being accountable for the packing slips. But when you are no longer held accountable for what you receive that could be a very big problem. If the resident did not receive their medications when they needed them because they were unavailable their pain could not have been controlled and that is a serious problem.<BR/>During a telephone interview on 3/9/25 at 4:12 p.m., RN D stated, protocol for receiving medications, including narcotics were for the nurse receiving the medications to electronically sign for them on the pharmacy driver's phone. RN D stated, then the medication packets were opened, check what was delivered and then double check the delivery with a second nurse. RN D stated the count sheets (narcotic logs) were supposed to be signed by two nurses and placed in the narcotic log with the medication cart and place the narcotics in the lock box inside the medication cart. RN D stated she typically took the delivery sheet/manifest and placed it in the shred box. RN D stated, I was never told what to do with it (the delivery sheet/manifest) so I just put it in the shred box, whether it was a narcotic or regular medication. I've never worked like that before, so it was pretty much I didn't know what to do with it, had never been told what to do with it and just put it in the shredder box. Once the count sheets are zeroed out, we wrap the empty blister pack with the zeroed-out count sheet and put it back in the cart. <BR/>Record review of the facility policy and procedure titled Policies and Procedures for Pharmacy Services, undated revealed in part, .Delivery, Receipt and Storage of Medication .Upon delivery by the pharmacy, the facility nurse or designee will sign the electronic delivery receipt device and assume responsibility for the receipt, proper storage, and distribution of the medications .The facility staff should notify the pharmacy immediately of any discrepancy of the medications received (damage, erroneous, or missing items) .The pharmacy will send scheduled medications sign off of sheets for each scheduled medication. The scheduled medication inventory sheet should be completed for each dose administration. The scheduled medication inventory sheet should be archived upon completion of the medication supply .Drug Diversion .The facility will comply with all federal, state, and local laws as it pertains to controlled substances .The facility must have a system that records receipt, usage, and disposition of all controlled substances in sufficient detail that permits for an accurate reconciliation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #28) reviewed for medication administration.<BR/>Resident #28 was provided a medication, Midodrine, outside of physician parameters. <BR/>This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications. <BR/>The findings included:<BR/>Record review of Resident #28's face sheet, dated 4/25/2024, reflected a [AGE] year-old female resident with an initial admission date of 3/3/2017 and diagnosis including Huntington's disease (an inherited condition in which nerve cells in the brain break down over time). <BR/>A record review of resident #28's quarterly MDS assessment, dated 2/8/2024, revealed Resident #28 was assessed with a BIMS score of 2 out of a possible 15 which indicated severe cognitive impairment. <BR/>A record review of resident #28's Care Plan dated 3/1/2024, revealed the resident had hypotension with interventions including giving the resident their medications as ordered and monitoring vital signs. <BR/>A record review of Resident #28's Physician's orders, undated, revealed Resident #28 was prescribed Midodrine HCl Oral Tablet 5 MG for orthostatic hypotension (positional change in blood pressure) hold for SBP&gt;120, indicating the medication should not be provided to the resident if their systolic blood pressure (the top number, which measures the pressure in your arteries when your heart beats) is over 120. <BR/>A record review of Resident #28's April 2024 medication administration record dated 4/25/2024 revealed Resident #28 could have been administered Midodrine Hcl 63 times from 04/01/2024 to 04/25/2024 and was administered Midodrine HCl out of physician parameters as follows:<BR/>1. <BR/>On 4/6/2024, LVN F administered Midodrine to Resident #28 while her Systolic Blood Pressure was 124 at 7:00 PM.<BR/>2. <BR/>On 4/7/2024, LVN F administered Midodrine to Resident #28 while her Systolic Blood Pressure was 122 at 10:00 AM.<BR/>3. <BR/>On 4/9/2024, LVN F administered Midodrine to Resident #28 while her Systolic Blood Pressure was 128 at 2:00 PM.<BR/>4. <BR/>On 4/9/2024, LVN G administered Midodrine to Resident #28 while her Systolic Blood Pressure was at 7:00 PM.<BR/>5. <BR/>On 4/13/2024, LVN F administered Midodrine to Resident #28 while her Systolic Blood Pressure was 124 at 10:00 AM.<BR/>6. <BR/>On 4/13/2024, LVN F administered Midodrine to Resident #28 while her Systolic Blood Pressure was 126 at 7:00 PM. <BR/>7. <BR/>On 4/20/2024, LVN G administered Midodrine to Resident #28 while her Systolic Blood Pressure was 122 at 7:00 PM. <BR/>8. <BR/>On 4/21/2024, LVN H did not administer Midodrine to Resident #28 while her Systolic Blood Pressure was 105 at 2:00 PM. <BR/>During an interview on 04/25/2024 at 9:41 AM, LVN B stated staff who administer Midodrine or any medications with parameters such as Midodrine take the vitals immediately before administering the medication. LVN B also stated that if a resident was given medications out of parameters, the nurse would need to call the doctor immediately, and notify the DON and RP. <BR/>During an interview on 04/25/2024 at 10:45 AM the DON stated the expectation for nurses was to take the residents vitals when a medication had parameters that require knowing a vital sign. The DON stated if a nurse makes a medication error such as providing medications out of parameters, they should inform the DON, physician, and RP. The DON stated the risk of the resident receiving medications out of parameters included not properly managing the residents' conditions. <BR/>During an interview on 04/26/2024 at 12:35 PM the Administrator stated she was not a clinician and referred to the DON's supervision and stated the expectation would be for a nurse to notify the DON and physician of the medication error. <BR/>A record review of the facility's Policy Interpretation and Implementation, dated April 2019, revealed, Medications are administered in accordance with prescriber orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored properly in the medication cart for 1 (Station A) of 3 medication treatment carts observed for drug storage. <BR/>The facility failed to ensure 5 insulin pens were dated when opened. <BR/>This failure could result in harm due to resident received expired medications. <BR/>The findings were:<BR/>Record review Resident #4's face sheet dated 04/24/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (cognitive loss), diabetes (high blood sugar), and major depressive disorder (mental illness, feeling of sadness). <BR/>Record review of Resident #4's quarterly MDS assessment, dated 02/22/24 revealed a BIMS score of 12, which indicated cognition was moderately impaired. Section N - medications reflected Resident #4 had received insulin injections during the last 7 days. <BR/>Record review of Resident #4's care plan dated 03/07/24 reflected a focus area Resident #4 had diabetes with intervention for diabetes mediations as ordered by doctor. <BR/>Record review of Resident #4's physician order listing report dated 04/24/24 reflected an order for Basaglar Kwik pen solution pen-injection 100 unit/ml - inject 40 units subcutaneously in the evening for uncontrolled DM dated 2/27/24 and 40 units subcutaneously in the morning for uncontrolled DM dated 4/10/24. An order for NovoLog Flex Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale dated 01/25/24 . <BR/>Record review Resident #4's treatment administration record dated 04/24/24 reflected Resident #4 received Basaglar 40 units in the morning on 4/1/24 through 4/24/24 and Basaglar 40 units in the evening on 04/01/24 through 04/23/24. Resident #4 received Novolog per sliding scale on 04/01/24 through 04/24/24. <BR/>Observation on 04/24/24 at 09:30 AM during the medication cart inspection on Station A revealed Basaglar Kwik Pen and NovoLog Flex pen with Resident #4's name on the label and no open date on the pens. <BR/>Record review Resident #31s face sheet dated 04/24/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (cognitive loss), diabetes (high blood sugar), COPD (lung disease) and major depressive disorder (mental illness, feeling of sadness). <BR/>Record review of Resident #31's comprehensive MDS assessment, dated 02/08/24 revealed a BIMS score of 00, which indicated cognition was severely impaired. Section N - medications reflected Resident #31 had received insulin injections during the last 7 days. <BR/>Record review of Resident #31's care plan dated 03/01/24 reflected a focus area Resident #31 had diabetes with intervention for diabetes mediations as ordered by doctor. <BR/>Record review of Resident #31's physician order listing report dated 04/24/24 reflected an order for Humulin N Kwik Pen Subcutaneous Suspension Pen-injector 100 UNIT/ML (Insulin NPH (Human) (Isophane)) Inject 50 unit subcutaneously in the morning for uncontrolled DM dated 3/9/24 and 15 units subcutaneously in the evening for uncontrolled DM dated 03/25/24.<BR/>Record Review of Resident #31's treatment administration record dated 04/24/24 reflected Resident #31 received Humulin N 50 units in the morning on 04/01/24 through 04/24/24 and Humulin N 15 units in the evening on 04/01/24 through 04/23/24. <BR/>Observation on 04/24/24 at 09:30 AM during the medication cart inspection on Station A revealed Humulin N Kwik pen with Resident #31's name on the label and no open date on the pen. <BR/>Record review Resident #53's face sheet dated 04/24/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (cognitive loss), heart failure, diabetes (high blood sugar), hypertension (high blood pressure) and major depressive disorder (mental illness, feeling of sadness). <BR/>Record review of Resident #53's quarterly MDS assessment, dated 03/05/24 revealed a BIMS score of 14, which indicated cognition was intact. Section N - medications reflected Resident #4 had received insulin injections during the last 7 days. <BR/>Record review of Resident #53's care plan dated 03/05/24 reflected a focus area Resident #53 had diabetes with intervention for diabetes mediations as ordered by doctor. <BR/>Record review of Resident #53's physician order listing report dated 04/24/24 reflected an order for Lantus pen injector - inject 20 units subcutaneously at bedtime for diabetes dated 2/13/24 and Lantus pen injector - inject 50 units subcutaneously one time a day for diabetes dated 3/30/24 . <BR/>Record review of Resident #53's treatment administration record dated 04/24/24 reflected Resident #53 received Lantus 20 units at bedtime on 04/01/24 through 04/23/24 and Lantus 50 units in the morning on 04/01/24 through 04/24/24. <BR/>Observation on 04/24/24 at 09:30 AM during the medication cart inspection on Station A revealed Lantus pen injector with Resident #53's name on the label and no open date on the pen. <BR/>Record review Resident #82's face sheet dated 04/24/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure, heart failure, and Alzheimer's disease (cognitive loss). <BR/>Record review of Resident #82's quarterly MDS assessment, dated 03/08/24 revealed no BIMS score, but indicated cognition was severely impaired. Section N - medications reflected Resident #4 had received insulin injections during the last 7 days. <BR/>Record review of Resident #82's care plan dated 04/04/24 reflected a focus area Resident #4 had diabetes with intervention for diabetes mediations as ordered by doctor. <BR/>Record review of Resident #82's physician order listing report dated 04/24/24 reflected an order for insulin glargine subcutaneous solution 100unit/ml - inject 10 units subcutaneously at bedtime for diabetes dated 2/27/24 .<BR/>Record review of Resident #82 treatment administration record dated 04/24/24 reflected Resident #82 received insulin glargine 10 units at bedtime on 04/01/24 through 04/23/24.<BR/>Observation on 04/24/24 at 09:30 AM during the medication cart inspection on Station A revealed insulin glargine pen with Resident #82's name on the label and no open date on the pens. <BR/>During an interview on 04/24/24 at 09:50 AM with the ADON, he stated all insulin pens should be dated when opened. He stated it was the nurse's responsibility to date the pen when opened. He stated he did not know why the pens were not dated. He stated the potential negative outcome could be given a resident insulin past the expiration date. He stated he was trained to date insulin pens on the day it was opened. <BR/>During an interview on 04/25/24 at 02:00 PM with the DON, she stated all insulin pens should have a date on them when opened. She stated all staff have been trained to date multiuse pens when opened. She stated the nurses, ADON and DON were responsible to monitoring the medication carts and medication dates. She stated the potential negative outcome could be administering old or expired medications. <BR/>During an interview on 04/25/24 at 04:15 PM with the ADM , she stated insulin pens should be dated when opened. She stated all nurses had been trained. She stated the nurse, medication aide, ADON and DON were responsible for making sure medications were dated. She stated the potential negative outcome could be giving a resident a medication that was expired or past date it can be given. <BR/>Record review of facility policy titled Administering Medications dated April 2019 reflected the following:<BR/>Policy Statement - medications are administered in a safe and timely manner, and as prescribed. <BR/>Policy Interpretation and Implementation<BR/>12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container .<BR/>Record review of facility policy titled Medication and Preparation Administration, undated reflected the following:<BR/>9.1 Prior to Medication Administration .<BR/>The following general recommendations should be utilized during preparation of medication: .<BR/>Facility staff should plan an opened-on date on the medication label for medications with limited expiration date upon opening .

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable disease and infections for 2 of 2 (Residents #12 and #67) observed for care in that:<BR/>1. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #12.<BR/>2. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #67.<BR/>This failure can affect residents in the facility who received incontinent care and could result in spread of infections.<BR/>The findings were:<BR/>1. Record review of Resident #12's admission Record (03/03/2023) revealed an admission date of 01/17/2023 with diagnoses of Irritable bowel syndrome (disorder that affects the stomach and intestines, also called the gastrointestinal tract) with Diarrhea and Cerebral Infarction, unspecified.<BR/>Record review of Resident #12's careplan (01/17/2023) revealed activities of daily care deficit due to immobility and required one person assist for toileting. <BR/>Record review of Resident #12's MDS (01/31/2023) revealed she was always incontinent and was total dependent with toileting. Further record review revealed she required one person assistance.<BR/>During observation on 02/28/2023 beginning at 08:53 a.m., CNA A provided incontinent care for Resident # 12. Further observation revealed Resident #12 had a bowel movement. CNA A washed her hands and donned a pair of gloves. CNA A wipe Resident #12's perineal area. After CNA a wiped Resident #12's perineal area, CNA A with the same gloves, touched Resident # 12's pillow and placed it at the Resident # 12's foot of bed. Resident #12 was repositioned to the left side, CNA A wiped Resident #12's bottom and removed the patient's briefs. CNA A removed her gloves, sanitized her hands, and donned another pair of gloves. Resident #12's pillow was placed back under her left arm.<BR/>2 Record review of Resident #67's facesheet (03/03/2023) revealed an admission date of 01/25/2023 and diagnoses of Disturbance, Neuromuscular Dysfunction of the Bladder, Benign Prostatic Hyperplasia with lower urinary tract symptoms, and Chronic Kidney Disease.<BR/>Record review of Resident #67's careplan revealed self-care performance deficit in activities of daily living tasks and required extensive assistance by staff. <BR/>Record review of Resident #67's MDS revealed he required extensive assistance with one person assist for toileting. Further review revealed Resident #67 had an indwelling catheter and frequently incontinent of bowel. <BR/>Record review of CNA A's last peri-care/incontinence care skill assessment (male and female) was on 12/22/2022. Further review revealed proficiency criteria included taking off the gloves, putting them in the trash bag and washing hands and putting on new gloves.<BR/>During an observation on 02/28/2023 at 09:15 a.m., CNA A Provided cath care for Resident #12. CNA A washed hands/gloved, anchor in place, wiped patients cath 3 to inches down, and around cath tubing, after, CNA A wiped head of penis and down and around and down, after, with same gloves CNA A left hip and blanket, to roll pt. to right side wiped bottom, touched clean brief, added brief, then removed gloves. <BR/>During an interview on 02/28/23 at 09:37 a.m., CNA A indicated she should've removed her gloves after cleaning Resident # 12's peri area, before touching Resident #12's pillow, and after wiping Resident #67's indwelling catheter and perineal area. Further interview with CNA A revealed she didn't pay attention to that because she's in a rush to care for other residents.<BR/>During an interview on 03/01/2023 at 4:10 p.m., the Administrator stated competency on incontinent care were done on hire and annually.<BR/>Record review of the facility's policy and procedure titled Stand Precautions (2001), read in part, Standard Precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .2. Gloves: d. Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #6) reviewed for injuries of unknown origin reporting, in that:<BR/>Resident #6 was assessed with a large bruise from her chest to her under arm and continued to her back, which was not investigated and not reported to the state agency and Resident #6's Guardian as an injury of unknown origin. <BR/>This failure could place Resident(s) at risk for harm by further exposure to injuries without proper investigation and reporting. <BR/>The findings included:<BR/>A record review of Resident #6's admission Record, dated 02/28/2023, revealed an admission date of 11/30/2018, with diagnoses which included Alzheimer's disease [causes the brain to shrink and brain cells to eventually die] and dementia [a range of conditions that affect the brain's ability to think, remember, and function normally]. Further review revealed Resident #6 was represented by a Guardian [Guardian Q]. <BR/>A record review of Resident #6 quarterly MDS, dated [DATE], revealed Resident #6 was an [AGE] year-old female who could usually understand some conversations, could usually make herself understood, given time; however, Resident #6 was assessed to have severe cognitive impairment with short- and long-term memory problems. <BR/>A record review of Resident #6's medical records revealed a Weekly Skin Observation Tool, dated 01/27/2023, Observations; does Resident have any observed skin issues? No. <BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, c/o [complaint of] pain to RT [right] shoulder. PRN [as needed] tramadol and muscle pain cream applied. Notified [Nurse Practitioner P] Xray ordered to RT. Shoulder claim #XXXXXXXX.<BR/>A record review of Resident #6's Weekly Skin Observation Tool, dated 01/30/2023, revealed, Observations; does Resident have any observed skin issues? Yes .site: right shoulder bruising .<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, [Resident #6 Family Member] on premises to visit [Resident #6] this nurse notified him of some bruising to RT [right] shoulder and c/o [complaint of] pain and Xray was ordered [Resident #6 Family Member] got upset and stated the reason why she is here is to protect her and her [Resident #6 Family Member] kept asking her what happened she said I don't know then [Resident #6 Family Member] asked who hurt you [?] and she responded no one hurt her she does not know what happened. Call placed to [Guardian Q] mailbox full.<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN R, Resident is day 2/3 bruise to R [right] axilla site [arm pit]. Site is c [with] swelling, warmth and discoloration. Localized inflammation to site. Noted to grimace upon assessment c [with] Tylenol regiment offered per this nurse and resident refusing x2 [twice] attempts. Allow this nurse to slightly prop arm on pillow. Resident observed to touch site often. Pleasantly confused to baseline. Receptive to staff assessment. Routine X-ray results in with right shoulder demonstrating no acute fracture. No joint discoloration. mild Bony demineralization. unremarkable soft tissues. there is severe AC joint [shoulder joint] and mild glenohumeral [the joint that connects the body to the arm] arthritis manifested by joint space narrowing, subchondral sclerosis, and degenerative spurring. will follow up with team health as indicated.<BR/>A record review of Resident #6's medical records revealed a Nurse Practitioner's Progress Note, dated 01/31/2023, authored by Nurse Practitioner P, revealed, Chief complaint / nature of presenting problem: follow up done on large bruising to chest and underarm area reported by nursing today. patient is unable to recall events. She can verbalize needs and report concerns to nurses. Patient is not currently on blood thinners. no falls reported. Have met with director of nursing / administrator to discuss further. Plan: hematoma / ecchymosis [bruising] to chest yellowish in color. Patient is unable to recall how she got it. No falls or trauma reported by nursing. Marking may be associated with gait belt for transfers as it goes around chest and underarms. Patient denied pain at this time. Will monitor for now.<BR/>During an interview and record review on 02/28/2022 at 01:25 PM Resident #6's Guardian, Guardian Q, stated she was not aware Resident #6 had an injury of unknow origin. Guardian Q stated she would have expected the facility to have reported any injury, especially a large bruise of unknown origin to her and possibly to the police. Guardian Q stated she could be contacted by cell phone, text message, and or her email. Guardian Q and surveyor confirmed contact information held by the facility as accurate. Guardian Q stated if by chance she missed a cell call she could have been contacted by email and or text message. <BR/>During an interview on 02/28/2023 at 02:15 PM LVN G stated she had assessed Resident #6 with a bruise to her right under arm and chest and reported the bruise to Nurse Practitioner P and RN F. LVN stated she wrote a progress note in Resident #6's medical record. LVN G stated the bruise was of unknown origin and Resident #6 could not state how she developed the bruise. LVN G stated she had not considered Resident #6's bruise a reportable event. LVN G stated she now understands, due to reflection of the incident, Resident #6's injury of unknown origin was a reportable event she should have reported to the Administrator. <BR/>During an interview on 03/02/2023 at 07:56 AM, Resident #6's Family Member stated they spoke with LVN G and stated, it's not right she [Resident #6] had a bruise. Resident #6's Family Member stated they had a concern, no one could explain how this happened [bruise]. Resident #6's Family Member stated Resident #6 claimed, I don't know how the bruise came to be. Resident #6's Family Member stated no one has reported to him the results of how this [bruise] happened. <BR/>During an interview on 03/03/2023 at 08:30 AM, the Administrator stated he did not believe Resident #6's injury of unknown origin was not a reportable incident due to Resident #6's own report that no one hurt her, even though the surveyor reminded the Administrator of a record review of Resident #6's diagnoses of Alzheimer's disease and dementia. <BR/>A record review of the facility's Recognizing Signs and Symptoms of Abuse / Neglect policy, dated April 2021, revealed, All types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse / neglect to their supervisor or to the director of nursing services immediately. Policy interpretation and implementation: The following are signs and symptoms of abuse / neglect there should be promptly reported. this listing is not all inclusive. other signs and symptoms are actual abuse /neglect may be apparent . signs of physical abuse: injuries that are non-accidental or unexplained . bruises, including those found in unusual locations such as the head neck lateral locations on the arms or posterior trunk and torso . signs of sexual abuse: bruises around the breast, general area or inner thighs .<BR/>A record review of the facility's Abuse, neglect, exploitation and misappropriation prevention program policy, dated April 2021, revealed, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Policy interpretation and implementation . the resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: staff; other residents . identify and investigate all possible incidents of abuse neglect, mistreatment for misappropriation of resident property .investigate and report any allegations within time frames required by federal requirement .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to thoroughly investigate all alleged violations of resident abuse, neglect, exploitation, or mistreatment for 1 of 6 (Resident #56) residents assessed for reporting allegations.<BR/>The facility failed to thoroughly investigate an incident in which a resident was found on the floor of their room with a skin tear to the right forearm and a hematoma to the top of the resident's scalp. <BR/>This deficient practice placed residents at risk of abuse, neglect, exploitation, or mistreatment.<BR/>The findings included: <BR/>Record review of Resident #56's Face Sheet, dated 4/26/2024, reflected an [AGE] year-old female resident with an initial admission date of 11/30/2020, with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and that the resident was discharged on 04/17/2024. <BR/>Record review of Resident #56's Quarterly MDS Assessment, dated 3/4/2024, reflected the resident had a BIMS of 00, reflecting the resident had severe cognitive impairment. The MDS Assessment further reflected that the resident had not had any falls since their prior assessment. <BR/>Record review of Resident #56's Comprehensive Person-Centered Care Plan, dated 4/26/2024, reflected, The resident is risk for falls d/t dementia .Unsteady gait leans forward when ambulating . with interventions including, attempt to keep in sight of staff, when agitated and attempting to rise without assistance:. <BR/>Record review of a Nurse's Note, dated 3/29/2024 and created by LVN B, reflected, Resident found sitting on the bedroom floor holding napkin to head. Resident confused, denies pain but unable to verbalize how she hit her head. Skin tear noted to R forearm upon assessment. VS baseline. Resident assisted to bed by staff. DON, [Hospice], RP notified. Per [Hospice Physician] ice forehead and monitor neuros. Dressing cover for skin tear to forearm.<BR/>Record review of the fall incident report regarding Resident #26, dated 3/29/2024, reflected an incident description of Resident found sitting on the bedroom floor holding napkins to head. Resident confused, denies pain, unable to describe how she hit her head. The incident report also reflected, under the subsection, Witness, reflected No Witnesses found. <BR/>Interview on 4/26/2024 at 9:41 AM, LVN B stated that Resident #56 fell and there were not any witnesses. LVN B stated hospice had just been in to visit the resident and the resident had been found on the ground. LVN B stated she and the hospice nurse assessed Resident #56 together, and that the resident was unable to tell them how she fell. LVN B stated she informed the DON, RP, and residents' physician. LVN B stated the resident had a skin tear and a hematoma to her head. <BR/>Interview on 4/26/2024 at 10:19 AM, the DON stated she believed Resident #56's fall was witnessed but was unable to inform the surveyor of who witnessed the fall.<BR/>Interview on 4/26/2024 at 11:15 AM, the DON stated she believed a housekeeper witnessed Resident #56's fall and was attempting to look for the witness statement.<BR/>Interview on 4/26/2024 at 12:16 PM, the DON stated that she had not been able to find the witness statement but was calling the CNA staff member she believed was the witness. After requesting the DON's investigation of the fall, the DON stated she did not have it but would write it. <BR/>Interview on 4/26/2024 at 12:23 PM, the Administrator stated that the provided incident report should be the complete investigation of the incident. <BR/>Interview on 4/26/2024 at 2:30 PM, the DON stated she investigated incidents such as falls at the facility. When asked for the investigation report, the DON stated she would write one. <BR/>Record review of hand typed document provided by the facility, untitled, dated 4/2/2024, reflected Resident #56 fell out of bed, witnessed by the Admissions Coordinator, who then reported the residents fall to LVN B.<BR/>Record review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, undated, reflected, Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #6) reviewed for injuries of unknown origin reporting, in that:<BR/>Resident #6 was assessed with a large bruise from her chest to her under arm and continued to her back, which was not investigated and not reported to the state agency and Resident #6's Guardian as an injury of unknown origin. <BR/>This failure could place Resident(s) at risk for harm by further exposure to injuries without proper investigation and reporting. <BR/>The findings included:<BR/>A record review of Resident #6's admission Record, dated 02/28/2023, revealed an admission date of 11/30/2018, with diagnoses which included Alzheimer's disease [causes the brain to shrink and brain cells to eventually die] and dementia [a range of conditions that affect the brain's ability to think, remember, and function normally]. Further review revealed Resident #6 was represented by a Guardian [Guardian Q]. <BR/>A record review of Resident #6 quarterly MDS, dated [DATE], revealed Resident #6 was an [AGE] year-old female who could usually understand some conversations, could usually make herself understood, given time; however, Resident #6 was assessed to have severe cognitive impairment with short- and long-term memory problems. <BR/>A record review of Resident #6's medical records revealed a Weekly Skin Observation Tool, dated 01/27/2023, Observations; does Resident have any observed skin issues? No. <BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, c/o [complaint of] pain to RT [right] shoulder. PRN [as needed] tramadol and muscle pain cream applied. Notified [Nurse Practitioner P] Xray ordered to RT. Shoulder claim #XXXXXXXX.<BR/>A record review of Resident #6's Weekly Skin Observation Tool, dated 01/30/2023, revealed, Observations; does Resident have any observed skin issues? Yes .site: right shoulder bruising .<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, [Resident #6 Family Member] on premises to visit [Resident #6] this nurse notified him of some bruising to RT [right] shoulder and c/o [complaint of] pain and Xray was ordered [Resident #6 Family Member] got upset and stated the reason why she is here is to protect her and her [Resident #6 Family Member] kept asking her what happened she said I don't know then [Resident #6 Family Member] asked who hurt you [?] and she responded no one hurt her she does not know what happened. Call placed to [Guardian Q] mailbox full.<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN R, Resident is day 2/3 bruise to R [right] axilla site [arm pit]. Site is c [with] swelling, warmth and discoloration. Localized inflammation to site. Noted to grimace upon assessment c [with] Tylenol regiment offered per this nurse and resident refusing x2 [twice] attempts. Allow this nurse to slightly prop arm on pillow. Resident observed to touch site often. Pleasantly confused to baseline. Receptive to staff assessment. Routine X-ray results in with right shoulder demonstrating no acute fracture. No joint discoloration. mild Bony demineralization. unremarkable soft tissues. there is severe AC joint [shoulder joint] and mild glenohumeral [the joint that connects the body to the arm] arthritis manifested by joint space narrowing, subchondral sclerosis, and degenerative spurring. will follow up with team health as indicated.<BR/>A record review of Resident #6's medical records revealed a Nurse Practitioner's Progress Note, dated 01/31/2023, authored by Nurse Practitioner P, revealed, Chief complaint / nature of presenting problem: follow up done on large bruising to chest and underarm area reported by nursing today. patient is unable to recall events. She can verbalize needs and report concerns to nurses. Patient is not currently on blood thinners. no falls reported. Have met with director of nursing / administrator to discuss further. Plan: hematoma / ecchymosis [bruising] to chest yellowish in color. Patient is unable to recall how she got it. No falls or trauma reported by nursing. Marking may be associated with gait belt for transfers as it goes around chest and underarms. Patient denied pain at this time. Will monitor for now.<BR/>During an interview and record review on 02/28/2022 at 01:25 PM Resident #6's Guardian, Guardian Q, stated she was not aware Resident #6 had an injury of unknow origin. Guardian Q stated she would have expected the facility to have reported any injury, especially a large bruise of unknown origin to her and possibly to the police. Guardian Q stated she could be contacted by cell phone, text message, and or her email. Guardian Q and surveyor confirmed contact information held by the facility as accurate. Guardian Q stated if by chance she missed a cell call she could have been contacted by email and or text message. <BR/>During an interview on 02/28/2023 at 02:15 PM LVN G stated she had assessed Resident #6 with a bruise to her right under arm and chest and reported the bruise to Nurse Practitioner P and RN F. LVN stated she wrote a progress note in Resident #6's medical record. LVN G stated the bruise was of unknown origin and Resident #6 could not state how she developed the bruise. LVN G stated she had not considered Resident #6's bruise a reportable event. LVN G stated she now understands, due to reflection of the incident, Resident #6's injury of unknown origin was a reportable event she should have reported to the Administrator. <BR/>During an interview on 03/02/2023 at 07:56 AM, Resident #6's Family Member stated they spoke with LVN G and stated, it's not right she [Resident #6] had a bruise. Resident #6's Family Member stated they had a concern, no one could explain how this happened [bruise]. Resident #6's Family Member stated Resident #6 claimed, I don't know how the bruise came to be. Resident #6's Family Member stated no one has reported to him the results of how this [bruise] happened. <BR/>During an interview on 03/03/2023 at 08:30 AM, the Administrator stated he did not believe Resident #6's injury of unknown origin was not a reportable incident due to Resident #6's own report that no one hurt her, even though the surveyor reminded the Administrator of a record review of Resident #6's diagnoses of Alzheimer's disease and dementia. <BR/>A record review of the facility's Recognizing Signs and Symptoms of Abuse / Neglect policy, dated April 2021, revealed, All types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse / neglect to their supervisor or to the director of nursing services immediately. Policy interpretation and implementation: The following are signs and symptoms of abuse / neglect there should be promptly reported. this listing is not all inclusive. other signs and symptoms are actual abuse /neglect may be apparent . signs of physical abuse: injuries that are non-accidental or unexplained . bruises, including those found in unusual locations such as the head neck lateral locations on the arms or posterior trunk and torso . signs of sexual abuse: bruises around the breast, general area or inner thighs .<BR/>A record review of the facility's Abuse, neglect, exploitation and misappropriation prevention program policy, dated April 2021, revealed, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Policy interpretation and implementation . the resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: staff; other residents . identify and investigate all possible incidents of abuse neglect, mistreatment for misappropriation of resident property .investigate and report any allegations within time frames required by federal requirement .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the rights of residents to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents, for 1 of 5 residents reviewed (Resident #17) for accommodation of orthotic support devices, in that:<BR/>The facility failed to report to Resident #17's physician's the inability to fulfill Resident #17's order for a back brace, ordered by a neurologist [a medical doctor who specializes in diagnosing and treating diseases of the brain, spinal cord, and nerves]. Resident #17 had a compression fracture of vertebra and kyphosis. Resident #17had spinal surgery and an order for a back brace from November 2022 that she did not receive. Resident revealed she was in [NAME] pain.<BR/>This failure could place residents at risk for denial of their rights to have reasonable accommodations. <BR/>The findings included:<BR/>A record review of Resident #17's admission record, dated 03/01/2023, revealed an admission date of 10/07/2022, with diagnoses which included wedge compression fracture of T11-T12 vertebra [thoracic area of the spine], age-related osteoporosis [a silent disease that weakens your bones and makes them break easily], spinal stenosis [can cause pressure on your spinal cord or the nerves that go from your spinal cord to your muscles], lumbar region with neurogenic claudication [spinal nerves get compressed in the lower spine, causing intermittent leg pain], and kyphosis [a spinal disorder in which an excessive curve of the spine results in an abnormal rounding of the upper back]. <BR/>A record review of Resident #17's care plan dated 03/01/2023, revealed, The Resident has osteoporosis . the Resident has pain related to vertebrae compression fractures and muscle pain .interventions; . monitor/document report as needed signs and symptoms or complications related to osteoporosis: acute fracture, compression fractures, loss of height, kyphosis, pian, especially back pain.<BR/>A record review of Resident #17's quarterly MDS, dated [DATE], revealed Resident #17 was an [AGE] year-old female with needs for assistance with activities of daily life complicated by back pain, spine curvature, and porous bones. Resident #17's assessment revealed a BIMS of 14 out of 15 which indicated no mental cognition impairment. Resident #17 could be understood and could understand others.<BR/>A record review of Resident #17's medical records revealed a progress note, dated 10/7/2023, authored by Resident #17's neurosurgeon, Medical Doctor L, . this is an [AGE] year-old female with osteoporosis and T12, L2 compression fractures with ongoing axial low back pain issues status post kyphoplasty [after a surgery to fix broken vertebrae caused by compression fractures, which can cause pain and deformity] at T12 and L2, 3 weeks ago. Patient no longer has the back brace. We will refer her to orthotics clinic for a TLSO [NAME] extension brace [a unique tool for limiting motion of the spine and reducing pressure on its tissues]. Brace should be worn at all times. <BR/>A record review of Resident #17's medical records revealed an Encounter Summary, dated 10/12/2022, encounter type, after this visit, October 7th 2022 .reason for referral . orthotics, diagnosis, compression fracture of T12 vertebrae . comments: needs new TLSO [NAME] extension brace for T12 compression fracture with worsening kyphosis status post kyphoplasty . electronically signed by [Medical Doctor L].<BR/>During an observation and interview on 02/28/2023 at 02:00 PM, Resident #17 presented in her wheelchair self-ambulating to the dining room. Resident #17 was asked the question, are your needs being met here at the facility?, Resident #17 replied her needs were not being met. Resident #17 stated she had a painful curved spine, had recent spine surgery, and had a need for a back brace, which the neurosurgeon [Medical Doctor L] ordered for her. Resident #17 stated she had a back brace prior to her admission to the facility but somehow it has gone missing. Resident #17 stated she had been to the neurosurgeon [Medical Doctor L] in November [2022] and was prescribed a new back brace but has not received the brace. Resident #17 stated she has complained and asked for a status on the back brace often and has been told the hold-up is insurance paperwork. Resident #17 stated she has no money to pay for the back brace and the facility has reported to her they are attempting to have the neurosurgeon doctor's office fill out paperwork to have Medicaid pay for the brace. Resident stated she has been waiting for the brace since November of 2022. She stated she had had chronic pain and wishes to have the back brace, so my spine will not get worse. Resident #1 stated she has been strong and has not asked for much pain medication and stated she manages her pain by finding a comfortable position while sitting and or laying and only moves when she needs to due to the pain. Resident #17 stated the situation made her feel, angry and neglected.<BR/>During an interview on 02/28/2023 at 10:00 AM, LVN E stated Resident #17 needed a back brace. LVN E stated Resident #17 has seen the neurosurgeon [Medical Doctor L] and has been fitted for the [TLSO] back brace, however the brace will not be supplied by the shop until the neurosurgeon's office has had the doctor sign and return 2 documents. LVN E stated she, the ADON, and the DON, have been working with the doctor's office since December [2022] and have not been able to have the doctor's office return the 2 documents needed to pay for the brace. LVN E stated Resident #17's attending physician at the facility is Medical Doctor N and is seen by Medical Doctor N's Nurse Practitioner O. LVN E stated she had not given Medical Director N nor Nurse Practitioner O a report about Resident #17 needed a back brace and did not have one. LVN E stated they know [Medical Director N nor Nurse Practitioner O] because they can read the notes and the Resident [#17] can tell them.<BR/>A record review of Resident #17's medical record revealed a progress note authored by LVN E, dated 01/31/2021, detailing the most recent attempted call to neurosurgeon Medical Doctor L. The note revealed, Call placed to [name] orthotics clinic to follow up on [Resident #17's] TLSO Brace. Spoke to [M orthotics clinic personnel] who stated they have now sent SWO and title 19 forms to [Medical Doctor L's] office three times, since my last call. Forms have not been returned and the orthotics has called and emailed [Medical Doctor L] regarding the forms several times. Last attempt was 01/27/2023. Writer called [Medical Doctor L's] office to follow-up on forms. Message left for Dr. that Resident [#17] does not have brace and cannot attend his desired follow-up with brace due to forms not being faxed back to orthotics clinic. Expecting return phone call from [Medical Doctor L]. will continue to follow up.<BR/>During an interview on 02/28/2023 at 10:20 AM, ADON D stated she was aware of Resident #17's need of a back brace and stated she and her staff have been attempting to have the appropriate paperwork supplied to the orthotics shop for payment of Resident #17 back brace. ADON D stated the facility and Resident #17 were waiting for the doctor's office [Medical Doctor L] to fill out the paper-work for Resident #17. ADON D stated she had not given Medical Director N nor Nurse Practitioner O a report about Resident #17 needed a back brace and did not have one. ADON D stated she believed everyone knew about Resident #17 back brace situation. ADON D stated there were many progress notes in Resident #17's chart. <BR/>During an interview on 03/01/2023 at 11:10 AM, the SW stated she was aware Resident #17 needed a back brace but was not able to receive the back brace for unknown reasons. The SW stated she was not asked to intervene and advocate for Resident #17 by anyone at the facility. The SW stated she understood it was being resolved by the nursing staff. The surveyor asked the SW what could she have done if someone had asked her to intervene and advocate for Resident #17? The SW stated, Maybe, I would have called the doctor or doctors.<BR/>During an interview on 03/01/2023 at 04:48 PM the Medical Director stated he was the medical Director for the facility and Resident #17. Medical Director stated Medical Doctor N was a peer and attended to Resident #17. The Medical Director stated no one has reported to him Resident #17 needed a back brace. The Medical Director stated Resident #17 had a kyphosis diagnosis and understood she was being seen by a neurosurgeon but did not know about the neurosurgeon's order for a back brace and the lack of the brace for Resident #17. The Medical Director stated he could not state what effect the lack of the brace could have on Resident #17 and Resident #17 should be re-assessed by the neurosurgeon due to the prolonged time Resident #17 has been without the brace. When asked if the facility had given the Medical Director a report what could you have done? The Medical Director replied, well, there are many interventions .but I could have intervened by calling the neurosurgeon [Medical Doctor L] .a physician-to-physician call surveyor asked, an intervention. The Medical Doctor replied, Yes. <BR/>During an interview on 03/01/2023 at 05:48 PM Nurse Practitioner O stated no one has reported to him, nor Medical Doctor N, Resident #17 needed a back brace. NP O stated Resident #17 had a kyphosis diagnosis and understood she was being seen by a neurosurgeon but did not know about the neurosurgeon's order for a back brace and the lack of the brace for Resident #17. Nurse Practitioner O could not state what effect the lack of the brace could have on Resident #17 and Resident #17 should be re-assessed due to the prolonged time Resident #17 has been without the brace. Nurse Practitioner O stated he would give Medical Doctor N a report. <BR/>During an interview on 03/02/2023 at 10:05 AM the DON stated she was aware and very involved in the situation of Resident #17's back brace. The DON stated she and her staff have been trying to work with Medical Doctor L's office to secure the 2 documents needed to secure Resident #17 back brace and have had no success with Medical Doctor L's office. The DON stated, we have done all we could, they have not returned the documents needed. When asked if the Medical Director, Resident #17's attending Medical Doctor N, or Nurse Practitioner O have been given a report the DON stated, yes they know, when asked for documentation to support the medical doctors knew; the DON stated there was not any documentation other than the progress notes which detail all the requests for the brace and/or paper-work needed from the doctor's office [Medical Doctor L's office]. When the DON was asked who was responsible for the failure to secure Resident #17's back brace; the DON replied, the doctor's office [Medical Doctor L's office] who would not supply the signed forms needed by the orthotics clinic. When the DON was asked how this failure could affect Resident #17; the DON stated the surveyor could ask the doctor. An accommodation of needs policy regarding Resident #17's back brace orthotics equipment was requested from the DON; the DON replied she did not believe there would be a specific policy for the situation due to the facility was not responsible to pay for items such as back braces.<BR/>A record review of the facility's personal property policy did not adequately address the facility's response to Resident #17's reasonable accommodation of need for a back brace.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #2) reviewed for accidents and supervision.<BR/>1. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing on the evening of 09/24/2024. <BR/>The noncompliance was identified as PNC . The IJ began on 9/24/2024 and ended on 9/25/2024. The facility had corrected the noncompliance before the survey began.<BR/>2. CNA A transferred Resident #2 from the bed to the resident's wheelchair without using a lift on 08/15/2024. It caused Resident #2's toenail to catch on the floor, injuring her nailbed and removing her whole toenail on her left great toe.<BR/>The noncompliance was identified as PNC. The noncompliance began on 08/15/2024 and ended on 08/16/2024. The facility had corrected the noncompliance before the survey began<BR/>This deficient practice could place residents at-risk of harm, serious injury, or death. <BR/>The findings included:<BR/>1. Record review of Resident #1's admission record, 03/07/2025, reflected that Resident #1 was a [AGE] year-old male initially admitted on [DATE], with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and type 2 diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy). <BR/>Record review of Resident #1's quarterly MDS assessment, dated 09/20/2024, reflected that Resident #1 had a BIMS score of 2, indicating severely impaired cognition. The MDS assessment further reflected that wandering behavior was not exhibited by Resident #1. <BR/>Record review of Resident #1's Wandering Assessment with a completion date of 09/06/2024 reflected him to be ambulatory without a history of wandering and a score of 9, indicating the resident was At Risk to Wander. <BR/>Record review of Resident #1's wandering risk scale assessment dated [DATE] reflected that the resident had no history of wandering. <BR/>Record review of Resident #1's nursing note, dated 9/24/2024 at 6:25 PM, reflected, Resident observed by this writer walking with walker toward Exit. Name called multiple time. Resident keep walking [sic]. CNA came out of room right beside exit door at same time resident attempted to push door open. This writer was headed that way. This writer asked CNA to ask resident if he was in pain - Resident did say yes. At [6:05 PM] Pain medication given per PRN order. Resident was redirected away from exit. Went walking down the hall. <BR/>Record review of Facility Provider Investigation Report, undated, reflected that on 09/24/2024 around 6:45 PM, Resident #1 was found approximately .2 miles from the facility in a parking lot down the street by the Admissions Coordinator, who put the resident in his vehicle after completing a quick assessment for injuries and brought him back to the facility. The Provider Investigation Report further reflected that through investigation, it was determined that Resident #1 had likely exited through the front door after being let out by an unknown visitor to the facility.<BR/>Interview on 03/04/2025 at 1:45 PM, Admissions Coordinator stated he was on his way home from working at the facility when he saw the resident on the corner of an intersection approximately .2 miles from the front door of the facility. <BR/>Interview on 03/04/2025 at 2:15 PM, LVN C stated that Resident #1 was attempting to leave through a fire door on A Hall, and after providing him pain medication and dinner it seemed as though he had calmed down and was not wandering anymore. LVN C stated she did the assessment after the resident came back after the elopement event and had worked with him prior to the event. LVN C stated she did not see him ever attempt elopement before and that the resident did not wander any more than the average resident prior to the event. <BR/>Interview on 03/04/2025 at 2:36 PM, the DON stated Resident #1 was not an elopement risk prior to this incident. The DON stated in-servicing had been completed after the incident on elopement.<BR/>Interview on 03/04/2025 at 2:40 PM, the Regional Corporate Nurse stated that there had not been an elopement at the facility since the incident.<BR/>Interview on 03/04/2025 at 3:00 PM, the ADM stated he was not working at the facility at the time of the incident, and that he began as Administrator of the facility in December of 2024. <BR/>The Administrator was notified on 03/05/2024 at 5:25 PM, a past non-compliance IJ situation had been identified due to the above failure.<BR/>The facility implemented the following interventions.<BR/>Record review of Resident #1's Care Plan, undated, reflected that the facility enhanced Resident #1's to include transferred to memory care unit 9/24/2024 d/t elopement from facility with interventions to include monitoring wandering patterns and document wandering behavior and attempted diversional interventions in behavior log. <BR/>Further record review of the facilities provider investigation report reflected that after the incident, the facility reported the incident to the state, implemented frequent monitoring, updated the resident's care plan, and moved the resident to the secured unit in the building with family/RP consent due to wandering behaviors and elopement. <BR/>Record review of in-service training documentation, dated 09/25/2024, reflected that 100% of facility staff were in-serviced on elopement, wandering, and responding to alarming doors. All new hires are also in serviced as part of the new hire onboarding process. 10% of staff were interviewed on in-servicing on elopements. <BR/>Record review of facility Incidents and Accidents report, dated encompassing 03/04/2024 through 03/04/2025 reflected that no other resident had eloped apart from the incident on 09/24/2024. <BR/>Interview with DON on 03/04/2024 at 2:36 PM, stated everyone's wandering assessments were reviewed to ensure accuracy and stated they have a receptionist at the front door until 5:00 pm and at 5:00 pm the doors automatically lock and staff has to open it for anyone to get in or out and staff were educated on ensuring residents aren't following anyone out of the door. The DON stated that no other resident had eloped prior to or since the incident with Resident #1 on 09/24/2024. <BR/>Observation on 03/04/2024 at 2:45 PM near the entrance to the facility revealed a sign informing guests not to open the door for anyone outside of their party. <BR/>Interview on 03/05/2025 at 10:47 AM, RN D stated she is not familiar with the incident but was trained on elopement at the time of hire and has been in-serviced on wandering and elopement since the incident in September of 2024. RN D stated if she saw a resident exhibiting exit seeking behaviors, she would redirect the resident and inform her ADON and/or DON. <BR/>Interview on 03/05/2024 at 11:24 AM, LVN E stated she had been in-serviced on elopements and wandering after the incident with Resident #1 in September of 2024. LVN E stated that if a resident's wandering behaviors or exit seeking behaviors change from their baseline to inform the ADON or DON and begin more frequent visual checks on the resident.<BR/>Interview on 03/07/2025 at 10:44 AM, CNA F stated she had been trained on wandering and elopements, particularly after the incident with Resident #1 in September of 2024. CNA F stated that if she saw a resident attempting to leave the facility through any door she would redirect the resident and inform the charge nurse and/or ADON of the behavior of the resident. <BR/>Facility policy titled, Wandering and Elopements, dated revised March 2022, reflected, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The Facility Wandering and Elopements Policy then detailed the procedures for identifying residents at risk for elopement, locating a missing resident, and procedure for post-elopement. <BR/>The noncompliance was identified as PNC . The IJ began on 9/24/2024 and ended on 9/25/2024. The facility had corrected the noncompliance before the survey began<BR/>2. Record review of Resident #2's face sheet, dated 03/07/2025, reflected the resident was an [AGE] year-old female and originally admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (destroy memory and thinking skills), type 2 diabetes mellitus (not control blood sugar levels), and heart failure.<BR/>Record review of Resident #2's quarterly MDS, dated [DATE], reflected the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was dependent (helper does ALL the effort) sit to lying, bed-to-chair transfer, and tub/shower transfer, and that the resident was not physically able to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, toilet transfer, or walk 10 feet.<BR/>Record review of Resident #2's care plan, dated 03/07/2025, reflected Resident #2, requires substantial/dependent assistance by staff to move between surfaces. Assist x 2 with hoyer. with an initiated date of 08/12/2024. <BR/>Record review of the Facility Provider Investigation Report, dated 08/20/2024, reflected that at approximately 11:00 AM on 08/15/2024, CNA A transferred Resident #2 without a hoyer lift, by himself, by holding the resident under her arms and moving her. During this transfer, Resident #2 sustained an injury to her left foot. <BR/>Record review of Resident #2's progress note on 08/15/2024 at 11:29 AM reflected, Acetaminophen tablet 500MG given for pain, pain due to left big toe injury results pending further review of progress note reflects that on 08/15/2024 at 1:30 PM an assessment was completed and Resident #2's left big toenail was lifted and bleeding, and there was redness to her hips and ribs.<BR/>Record review of Resident #2's incident report, dated 8/15/2024 at 1:30 PM reflected that the resident had bleeding to left great toe, which was injured during a transfer, and PRN pain medication was provided.<BR/>Record review of the facility in-service training report, dated 08/16/2025, reflected the facility provided in-services to all nursing and maintenance staff regarding Transfer Status to include how to find each residents inidvidual transfer status and how to appropriately transfer residents. <BR/>Interview on 03/05/2025 at 10:47 AM, RN D stated she was trained on transfer status and is familiar with different residents need for different transfer status, to include rechecking transfer status for change in condition. RN D stated staff are frequently observed for competencies on transferring residents appropriately. <BR/>Interview on 03/05/2024 at 11:24 AM, LVN E stated she had been in-serviced on transfer status and ensuring residents are appropriately transferred based on their plan of care. <BR/>Interview on 03/07/2025 at 10:44 AM, CNA F stated she had been trained on transfer status and how to find what type of transfer a resident needs. CNA F was able to show the surveyors how to find out a residents transfer status in the EHR of the resident and was able to describe the procedure of different types of transfers to include hoyer transfers. <BR/>Record review of staff competencies reviewed on transfer status after the incident reflected no concerns with competencies. <BR/>Record review of the CNA A's employee profile reflected the facility terminated CNA A's employment on 08/15/2024. <BR/>Record review of Podiatry Visit Notes, dated 08/16/2024, reflected that the podiatrist saw Resident #2 the day after the incident occurred and removed her left big toenail, which was no longer connected to the toe. <BR/>Observation of transfer on 03/05/2025 at 10:30 AM reflected no concerns for the hoyer transfer of Resident #7 observed. Hoyer transfer was observed with 2 staff members operating the hoyer lift and no injuries to the resident as a result. <BR/>Record review of Resident #7's Care Plan reflected that Resident #7 needed to be assisted with transfers with 2 staff members using a hoyer lift. <BR/>Interview on 03/05/2025 at 3:00 PM, the ADM stated he was not working at the facility at the time of the incident, and that he began as Administrator of the facility in December of 2024. <BR/>Interview on 03/05/2025 at 5:00 PM, with the DON and RNC, the DON stated CNA A had not reported the injury to the nurse, and the family had informed the nurse of the injury when they noticed it within minutes of the injury occurring. The DON stated he believes CNA A did not realize there was an injury but did not know why he would have the resident sit on the edge of the bed to dress her. The DON stated Resident #2 saw podiatry the next morning with no concerns. The DON stated the expectation is that staff transfer residents as is appropriate and on the resident's plan of care. The DON stated the risk to residents could include injury for not being appropriately transferred . <BR/>The noncompliance was identified as PNC. The noncompliance began on 08/15/2024 and ended on 08/16/2024. The facility had corrected the noncompliance before the survey began

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 secured courtyards (B wing courtyard) reviewed, in that: <BR/>The facility failed to ensure that the B wing courtyard back door/fence was secured to prevent the public from coming into the facility and to prevent the residents from eloping. <BR/>The non compliance was identified as past noncompliance. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began.<BR/>This deficient practice could place residents, staff, and the public at risk of exposure to potentially dangerous materials.<BR/>The findings were: <BR/>Record review of Resident #1's admission record, dated [DATE], reflected a male with an admission date of [DATE], and diagnoses which included paranoid schizophrenia (a mental illness characterized by delusions and hallucinations), unspecified dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), major depressive disorder, generalized anxiety disorder, and alcohol dependence. <BR/>Record review of Resident #1's MDS, dated [DATE], reflected Resident #12 had a BIMS of 5/15, indicating severe cognitive impairment. Resident #1's MDS revealed that he had physical and verbal behaviorial symptoms towards others that could put himself and others at risk for physical injury. His MDS further revealed that wandering behavior had not been exhibited. <BR/>Record review of Resident #1's comprehensive person-centered care plan, reflected Resident #1 had a focus, initiated [DATE], of The Resident is an elopement risk/wanderer. Resident paces & wanders aimlessly at times, at other times he talks of leaving with interventions of Document wandering behavior and attempted diversional interventions and Identify pattern of wandering Intervene as appropriate. Another focus, initiated [DATE], revealed The resident has a potential behavior problem r/t dementia and schizophrenia, noted to be impatient and distrustful of others, can become physically aggressive and attempt to strike at others, noted to attempt to strike staff with a fork and also make aggressive gestures to staff, refuses care and medications at times<BR/>Record review of Resident #1's nursing progress notes reflected a note on [DATE] authored by LVN F at 4:31 PM that reflected resident push open door to secure unit and ran straight to back exit door causing alarm to go off this nurse and 2 other staff pulled him back from door before he could exit he was hitting and kicking staff as we were trying to get him off unit . we finally got him back to B wing call was placed to [NP] ordered Haldol 1mg IM STAT. medication ordered from pharmacy. Which included an intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from the situation and take to alternate location as needed and Refer to [psych care] for evaluation and treatment. <BR/>Record review of the investigation summary of this incident revealed that On [DATE] review of cameras reveal at approximately 8:45pm, [Resident #1] exited the lobby into the B wing courtyard. [Resident #1] does not live in the secured unit. A portion of the fence gate was found broken and the magnetic lock had been damaged (this courtyard is not part of the secured unit and the magnetic lock is not required).<BR/>During an interview on [DATE] at 10:47 AM, the Account Manager revealed that the B wing courtyard back door had to be pushed a certain way for it to be locked correctly (amount of time the back door was like this was not quantified). The account manager further revealed that the apartment complex behind the facility have had homeless people present sometimes and could be a danger to the facility. The Account Manager revealed that Resident #1 would tell her that he was going to leave and was exit seeking. <BR/>During an interview on [DATE] at 1:42 PM, LVN B revealed that the back gate in the B wing courtyard should be secured and equipped with a loud alarm. LVN B revealed that if the back gate was broken, then the public could come into the facility. About a year ago, there was a homeless person found in the dumpster, in the back of the building, and there had been instances where homeless people would try to come into the facility through the front door. They would be stopped to protect the residents. <BR/>During an interview on [DATE] at 2:55 PM, the Maintenance Director revealed that he checked the fence every day and it was working. He suggested to management, prior to this incident, that Resident #1 should be in memory care because he always studied the exits and tried to follow people out. However, he could not be in memory care due to being aggressive. The Maintenance Director further revealed the door was old and Resident #1 ended up being able to have enough strength to break the magnetic lock and eloped. <BR/>During a combined interview with the Administrator and the DON on [DATE] at 4:15 PM, it was revealed that more staff were hired to have increased monitoring of the residents to keep the residents safe. They were still evaluating and finding what can be improved for the facility. It was revealed that inrterventions for elopement are individualized for each resident in order to prevent further elopement incidents and staff had been trained on elopement/wandering procedures.<BR/>Observation from [DATE] through [DATE] revealed that the exit doors of the secured units were secured and functioning. Observation also revealed that the entire back fence was secured and locks were functioning properly, including the B wing fence being fixed. <BR/>Record Review of the Facility Assessment updated 1. 2023, revealed the facility had 3 secured courtyards for resident and family use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to provide basic life support, including CPR to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 1 residents reviewed for CPR, in that;<BR/>The facility failed to ensure Resident #1 received life saving measures including CPR (Cardiopulmonary Resuscitation) when he was found unresponsive on [DATE]. <BR/>The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. <BR/>This failure could place residents at risk of not receiving life safe measures including CPR and could lead to death. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated [DATE] revealed an admission date of [DATE] with diagnoses which included: severe-protein-calorie malnutrition, vascular dementia, and type 1 diabetes. <BR/>Record review of Resident #1's physician orders revealed an order for Code status: DNR dated [DATE] placed into the electronic medical record by LVN A. The physician order was not signed by the NP or physician. <BR/>Record review of Resident #1's baseline care plan dated [DATE] revealed Do Not Resuscitate Status with interventions which included: In the event of cardiac or respiratory arrest, do not perform cardio-pulmonary resuscitation (CPR) and Please ensure that I (Resident #1) have a completed signed Texas Out of Hospital Do Not Resuscitate form filed on my chart along with a signed facility physician order form.<BR/>Record review of Resident #1's progress note dated [DATE] revealed: Resident #1 was found unresponsive. LVN B documented Resident #1 was not breathing, had no pulse and no vitals were able to be obtained. She also documented she listened to the heart and no heartbeat was heard, pupils were fixed and dilated, and Resident #1 had expired (died). <BR/>Record review of a facility document, titled Skilled Status Bulletin (admission demographics) (undated) for Resident #1 revealed there was no documentation of code status. <BR/>Record review of Resident #1's electronic medical record revealed there was no signed out of hospital DNR form. <BR/>Record review of the facilities self-report document (undated) revealed the Administrator self-reported to HHSC that on [DATE] he was made aware Resident #1 expired (died) and CPR was not administered. The self-report indicated the facility records indicated Resident #1 was DNR status, but the family stated they wanted the resident full code. <BR/>During an interview on [DATE] at 3:22 p.m. the Administrator stated the facility did not have a signed out of hospital DNR form for Resident #1. <BR/>During an interview on [DATE] at 4:11 p.m. LVN A stated he was the admission nurse for Resident #1. LVN A stated he received a verbal report from staff at a local hospital prior to Resident #1's admission on [DATE]. He stated he completed an assessment of Resident #1 and reviewed orders with the NP that he placed in the electronic medical record. LVN A stated the nurse at the local hospital told him in the verbal report that Resident #1 was DNR. LVN A stated all paperwork including the DNR status was completed prior to admission. He stated he reviewed the paperwork but did not look for an out of hospital DNR. He stated the facility usually did not have access to DNR paperwork until the family brought it to the facility. He stated he assumed the family had already brought the paperwork in before Resident #1's admission. LVN A stated he went off the report from the local hospital and did not verify. He stated he did not know at the time who was responsible for verifying the code status. He stated he called the NP when Resident #1 was admitted . He stated he gave the NP Resident #1's diagnoses and code status based on what he knew and hospital records. LVN A stated he did not talk to the family. LVN A stated he now knew he should have verified by looking for the out of hospital DNR documentation. He stated he had received training on advanced directives and code status after the incident. He stated he was trained to look in the electronic medical record for the out of hospital DNR documentation or to look in the code book binder for the document. <BR/>During an interview on [DATE] at 4:24 p.m., Resident #1's RP stated Resident #1 was on hospice and a DNR status in the hospital. She stated while he was in the hospital, Resident #1 woke up and stated he wanted to live. The RP stated while he was still in the hospital, she revoked hospice and revoked the DNR status. The RP stated Resident #1 was supposed to have been full code in the nursing facility. The RP stated after a staff member (unknown) called her and said he passed away, the RP asked if they had tried to resuscitate Resident #1. The RP stated the staff stated he was DNR. The RP stated she asked to see the DNR paperwork, and the facility had not been able to provide it. The RP stated she did not sign any documents for the facility. <BR/>During an interview on [DATE] at 4:56 p.m., the Admissions Coordinator stated his job responsibilities included reviewing a hospital patient to see if they were an appropriate resident for the facility. He stated he reviewed hospital documentation and talked to the family. The Admissions Coordinator stated his understanding of Resident #1's code status was the family wanted to pursue skilled nursing services at the facility and he would be full code status. He stated the family had declined a DNR status. The Admissions Coordinator stated he did not communicate directly with the Admissions nurse at the facility or to staff taking care of the resident. He stated he uploaded admission documents in the computer, but code status was not an item listed on the admission paperwork. The Admissions Coordinator stated his job duties did not included obtaining out of hospital DNRs. The Admissions Coordinator stated the facility nurses should look for the out of hospital DNR documentation if they cared about their license. He stated sometimes the family would have a change of heart about the DNR status. He stated the staff should verify with family the correct DNR status. The Admissions Coordinator stated the SW usually verified with family the DNR status within 48 hours of admission, even if there was an out of hospital DNR on file. He stated without an out of hospital DNR signed the patient (resident) would automatically be a full code status. The Admissions Coordinator stated it was important for staff to verify out of hospital DNR documents were in place so that the facility was honoring the wishes of the family and the resident. <BR/>During an interview on [DATE] at 5:18 p.m. the SW stated Resident #1 was admitted on Saturday ([DATE]). She stated he was not listed as a pending admission on Friday. The SW stated by the time she got to the facility on Monday ([DATE]) he had already passed away. The SW stated she reviewed some of Resident #1's documentation from the hospital. She stated there was conflicting information documented in the hospital records. She stated she had not had the opportunity to speak with the family. She stated she did not see an out of hospital DNR in the paperwork. She stated for that reason Resident #1 should have been full code status. She stated she would expect nursing staff to perform CPR and other life saving measures for any change of condition that required life saving measures. She stated an accurate code status was important to ensure the facility was honoring the persons wishes. The SW stated since the incident she had audited the residents' medical records for DNR accuracy. She stated she spoke with families and updated a few records. She stated she had also participated in in-service training provided by the facility. <BR/>During an interview on [DATE] at 11:02 a.m., LVN B stated she worked night shift on [DATE]-[DATE]. She stated Resident #1 had been up watching TV for a portion of the night. She stated he did not have any noticeable change of condition. She stated she rounded and checked on him multiple times during the night. LVN B stated at approximately 5:00 a.m. Resident #1 was sleeping and did not appear to be in any distress. She stated at approximately 5:20 a.m. she returned to Resident #1's room and saw the resident lying there with his eyes open. She stated she called his name a couple of times, and he did not respond. LVN B stated she performed a sternal rub (elicits pain by firmly rubbing the chest) and got no response. She stated she checked Resident #1's pulse on his wrist and neck and listened with a stethoscope to his chest. She stated Resident #1 did not have a heartbeat or breath sounds. She stated at that point she knew Resident #1 had expired. She stated she did not attempt CPR because on the computer (electronic medical record) it indicated Resident #1 was a DNR status. LVN B stated a DNR status was documented on Resident #1 face sheet, profile, and physician orders. LVN B stated she had been trained to look for an out of hospital DNR, but it all happened so fast that she looked at the computer. LVN B stated she first became aware Resident #1 did not have a signed DNR when family came in and asked what Resident #1's code status was. She stated she told them he was a DNR, and the family said he was supposed to have been full code. LVN B stated at that point she started looking for the DNR documentation and did not see one. <BR/>During an interview on [DATE] at 11:55 a.m., the DON stated on [DATE] at 5:15 a.m., LVN B called her and said Resident #1 had passed (expired). The DON stated she asked LVN B what Resident #1's code status was since he was a new admission. The DON stated LVN B stated Resident #1 was a DNR. The DON stated LVN B stated she saw the actual out of hospital DNR form in the computer. The DON stated LVN B also confirmed Resident #1 had a physician's order for a DNR status which was put in the electronic medical record by LVN A and was signed by the NP. The DON stated when she arrived at the facility on [DATE] after speaking with the family she reviewed Resident #1's medical record. She stated she could not find the out of hospital DNR document. The DON stated at that point the facility self-reported the incident to HHSC. The DON stated staff had been trained to take report from the hospital, go through paperwork and see what there and then go from there for code status. The DON stated during the week, the facility management checked code status but Resident #1 came in on the weekend. The DON stated Resident #1's hospital record said the family did not want CPR in the hospital. She stated to ensure an appropriate DNR status at the facility, they needed an out of hospital DNR signed by the resident or family and the physician. The DON stated the SW was responsible for an out of hospital DNR during the week. The DON stated LVN A, the admitting nurse was responsible for ensuring the resident had a signed out of hospital DNR for Resident #1. The DON stated LVN A stated he called the NP and got an order for DNR status. The DON stated she had questions. She did not know how LVN A got an order without a signed out of hospital DNR. The DON stated the care plan should reflect accurate code status. The DON stated to correct the situation the facility identified how they were going to verify DNR status and had put policies in place. She stated the Weekend Supervisor will now be responsible for checking/verifying code status and are required to facetime management with the document to verify. The DON stated she had 18 licensed nurses on staff. She stated 14 of them had completed in-service training on the policy, how to identify code status and abuse/neglect. She stated the remaining 4 staff would have to complete in-service training before they could work again. The DON stated the SW and Admissions Coordinator had also been educated on the process and had completed the training. She stated the facility completed a full sweep audit of all medical records for out of hospital documentation which was completed on [DATE]. The DON stated the facility also held a QAPI meeting with the Medical Director on [DATE].<BR/>During an interview on [DATE] at 12:18 p.m., the NP stated she did receive a call from a staff member about Resident #1's admission. She stated she did not remember the date or time of the call. The NP stated she reviewed with the staff why the resident came to the facility. She stated she did not give an order for code status. The NP stated residents come from the hospital as full code status unless they had a out of hospital DNR. The NP stated the physician group typically reviewed with the resident code status in person. The NP stated she had not signed any orders for Resident #1. <BR/>During an interview on [DATE] at 12:34 p.m., the Administrator stated on Monday, [DATE] the facility had the processes in place to verify code status but those process did not occur for Resident #1. The Administrator stated on [DATE] at approximately 5:20-5:30 a.m. he received a call from LVN B notifying him that Resident #1 had passed (expired) and there was a DNR (document). The Administrator stated when he arrived at the facility the SW informed him she could not locate the DNR (document). He stated he also looked and could not find one. He stated he took the following steps after learning there was no DNR document for Resident #1: the Administrator stated he discussed with the DON and called in a self-report to HHSC. He stated the facility immediately conducted a full audit of out of hospital DNR's in the code binders and verified the DNR's were in place. He stated they also reviewed the care plans for the residents. The Administrator stated he started in-servicing nursing on code status. He stated to ensure competency he gave the in-service again a day later and added a post test to ensure competency. The Administrator stated he notified Resident #1's physician and the Medical Director. The Administrator stated they held a QAPI meeting with the Medical Director in which corporate regional staff also attended. The Administrator stated multiple people in management were part of the corrective action to ensure nothing got missed. He stated the Admissions Coordinator, the SW, LVN A and LVN B had also received 1 on 1 training in addition to the in-service. <BR/>RR of a facility document titled Incident Investigation and Follow up- Code Status dated [DATE] revealed: <BR/>-Resident affected: All residents with a code status that do not reflect the resident or responsible parties wishes have the potential to be affected. <BR/>-The failure is as follows: The facility allegedly failed to follow policy by having a resident's code status that did not reflect the resident or responsible parties wishes. <BR/>-In-servicing/education provided in response: 1. Facility policy on code status. Inservice's began on [DATE] and were completed with current nursing staff on [DATE]. All employees currently on shift will pass a post-test of 5 questions pertaining to the policy to demonstrate competency/understanding and a required grade of 100%. If they fail, they will be immediately re-educated and required to retake the post-test to achieve 100%. All other nursing staff not currently on shift will be in-serviced before taking any assignment in the facility. The nurse educations will be in-serviced by the DON on the code status policy and then the DON/RN and both ADON and Treatment Nurse will educate the nursing staff on the code status policy. All new hires that are nurses will receive training on the same topics during new employee orientation and prior to providing resident care. <BR/>-A QAPI meeting was held on [DATE] to review the allegations surrounding the alleged incident and the plan moving forward related to the Incident Investigation and Follow-up. <BR/>-The Medical Director was notified of alleged incident on [DATE]. <BR/>Monitoring:<BR/>-All new admits will have admissions orders reviewed with a specific focus on code status to ensure appropriate wishes have been honored. If the new admits are undecided, they will be educated that until a decision has been made to be an OOH DNR and a fully executed OOH DNR is obtained, they understand they will remain as a full code. <BR/>Preventing Reoccurrence:<BR/>-The DON, ADON, MDS nurse, Treatment Nurse or Weekend RN Supervisor will review the 24-hour report promulgated by PCC daily to review new admissions to ensure the code status of new admits are entered into PCC correct, reflect the resident or RP's wishes and if a DNR have a proper executed OOH DNR uploaded to PCC (Point Click Care). <BR/>Record review of an Ad Hoc QAPI Code Status document dated [DATE] revealed:<BR/>Problem: Resident #1 who was a full code was found unresponsive without a palpable pulse and nursing staff failed to perform CPR. <BR/>Interventions: <BR/>-Resident Code Status book and facility electronic medical records were reviewed and updated as needed to ensure all code status were properly identified and honored. <BR/>-Facility nursing staff were in-serviced regarding code status, resident rights, and where the Advanced Directive books were located. Nurses also in-serviced how to look at the order for a DNR, how to look under the document tab for the OOH DNR. <BR/>-RN Supervisor or designee on weekend to check and implement all DNR status.<BR/>-Code status will be reviewed and updated as needed every Monday<BR/>-Pending physician signature, telephone order may be obtained for code status<BR/>-Went over the facility policy regarding Advanced Directives and DNR policy with our Medical Director<BR/>-Had an Ad Hoc QAPI meeting regarding Code Status with Medical Director, DON, Administrator, and members of Regional Support Team<BR/>Implementation of Changes: Audit of all code status to ensure residents code status have the proper paperwork in place with DNR (written order, paperwork, on PCC in the resident's profile under code status, DNR in pace).<BR/>Monitoring: <BR/>-Monitor all new admissions advanced directives every Monday and as needed<BR/>-Weekend admission advanced directives will be reviewed by RN supervisor or designee<BR/>-Code status books will be reviewed and updated at nurse's station. <BR/>This document was signed by the Administrator, DON, Medical Director, Regional Director of Operations, and additional regional staff on [DATE]. <BR/>Record review of Code Status Binders on all 3 hallways revealed all out of hospital DNR documents had appropriate signatures of resident/family and physician. <BR/>Record review of an in-service training, titled Resident Rights dated [DATE] with attached Resident Rights policy and Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy revealed 19 licensed staff had signed the training document included the admission Coordinator, LVN A and LVN B. <BR/>Record review of an in-service training, titled Code Status dated [DATE] revealed 22 licensed staff including the DON had received training which included a review of the Full Code status policy, DNR policy and Advanced Directives and Advance Care Planning Procedures policy. <BR/>Record review of 1:1 in-service training record revealed LVN A, LVN B and the admission Coordinator completed training on abuse/neglect prevention policy, resident rights and DNR/Full Code given by the DON on [DATE].<BR/>During interviews on [DATE] licensed staff including 2 RN's and 5 LVN's verified they had received in-service training in out of hospital DNR's, code status, and abuse/neglect.<BR/>During an interview on [DATE] the Medical Director stated he had been notified of the incident involving Resident #1. He stated he attended a QA meeting held by the facility. He stated during the QA meeting along with the Administrator, DON and Regional Director. The Medical Director stated he recommended amending the policy and addressing full code status since the facility did not have a policy for full code. <BR/>Record review of a facility policy titled, Full Code Status (undated) revealed: 1. Upon admission of a new resident, the admitting nurse will determine the resident's code status. If the resident chooses full code, the nurse enters a full code order into PCC. <BR/>Record review of a facility policy titled DNR Policy (undated) revealed: The resident has the right to make the decision about completion of the DNR. A DNR signed by the resident that has two valid witnesses to the signature and is dated is a valid legal document. Physician signature is only required for acknowledgment purposes and is not an approval for the DNR. <BR/>Record review of a facility policy titled Advanced Directives and Advance Care Planning Procedure (undated) revealed: Prior to admission: 1. Assessment of the individual prior to admission to the nursing facility to determine if the individual has already completed c. out of hospital Do Not Resuscitate (OOH DNR). 2. If the above documents have already been completed, they will be copied and forwarded to b. Charge nurse for placement on resident's medical chart. Upon admission: 1. The admission charge nurse will obtain an order for code status. In the absence of an OOH DNR, the nurse will obtain a telephone order for Full Code Status .If OOH DNR is present, charge nurse will obtain a telephone order for Do Not Resuscitate .<BR/>On [DATE] at 4:07 p.m. the Administrator, DON, and corporate staff were informed of the IJ. The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure residents had the right to and the facility had made prompt to resolve grievances the residents may have had, in accordance with identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; for 2 of 5 residents(Resident #6 and Resident #17) reviewed for grievances, in that:<BR/>1. <BR/>Resident #6 family made a grievance in reference to the bruise to Resident #6's chest, under arm, and back, were not consistent with her planned quality of care; for which the facility did not initiate a grievance process.<BR/>2. <BR/> Resident #17 made a grievance regarding her need for a back brace; for which the facility did not initiate a grievance process.<BR/>These failures could place residents at risk for a diminished quality of life by their grievances not being processed. <BR/>The findings included: <BR/>1.<BR/>A record review of Resident #6's admission Record, dated 02/28/2023, revealed an admission date of 11/30/2018, with diagnoses which included Alzheimer's disease [causes the brain to shrink and brain cells to eventually die] and dementia [a range of conditions that affect the brain's ability to think, remember, and function normally]. Further review revealed Resident #6 was represented by a Guardian [Guardian Q]. <BR/>A record review of Resident #6 quarterly MDS, dated [DATE], revealed Resident #6 was an [AGE] year-old female who could usually understand some conversations, could usually make herself understood, given time; however, Resident #6 was assessed to have severe cognitive impairment with short- and long-term memory problem. <BR/>A record review of Resident #6's medical records revealed a Weekly Skin Observation Tool, dated 01/27/2023, Observations; does Resident have any observed skin issues? No. <BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, c/o [complaint of] pain to RT [right] shoulder. PRN [as needed] tramadol and muscle pain cream applied. Notified [Nurse Practitioner P] Xray ordered to RT. Shoulder claim #XXXXXXXX.<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, [Resident #6 Family Member] on premises to visit [Resident #6] this nurse notified him of some bruising to RT [right] shoulder and c/o [complaint of] pain and Xray was ordered [Resident #6 Family Member] got upset and stated the reason why she is here is to protect her and her [Resident #6 Family Member] kept asking her what happened she said I don't know then [Resident #6 Family Member] asked who hurt you [?] and she responded no one hurt her she does not know what happened. Call placed to [Guardian] mailbox full.<BR/>During an interview on 02/28/2023 at 02:15 PM LVN G stated she had assessed Resident #6 with a bruise to her right under arm and chest and reported the bruise to [Resident #6 Family Member] when they visited. LVN stated she wrote a progress note in Resident #6's medical record. LVN G stated the bruise was of unknown origin and [Resident #6 Family Member] became upset when they were told about the injury. LVN G stated she had reported the bruise to the next on-coming nurse and reported the bruise to [Nurse Practitioner P] but had not reported [Resident #6 Family Member]'s complaint as a grievance. LVN G stated she had not considered [Resident #6 Family Member] being upset as a grievance. LVN G stated she had been trained to assist residents and families to provide the grievance forms and to assist with reporting grievances to the facility's Administrator. LVN G stated she was not aware where grievance forms are kept and after a search of the nurses' station could not produce a grievance form. LVN G stated she can now understand she could have further assisted [Resident #6 Family Member] by asking [ADON D] for a grievance form. <BR/>During an interview on 03/02/2023 at 07:56 AM, Resident #6's Family Member stated they spoke with LVN G and stated, it's not right she [Resident #6] had a bruise. Resident #6's Family Member stated they had a concern, no one could explain how this happened [bruise]. Resident #6's Family Member stated Resident #6 claimed, I don't know how the bruise came to be. Resident #6's Family Member stated no one has reported to him the results of how this [bruise] happened. Resident #6's Family Member stated he had no education on the facility's grievance policy, had not been offered a grievance form, and or been supported to file a grievance on behalf of Resident #6. <BR/>2.<BR/>A record review of Resident #17's admission record, dated 03/01/2023, revealed an admission date of 10/07/2022, with diagnoses which included wedge compression fracture of T11-T12 vertebra [thoracic area of the spine], age-related osteoporosis [a silent disease that weakens your bones and makes them break easily], spinal stenosis [can cause pressure on your spinal cord or the nerves that go from your spinal cord to your muscles], lumbar region with neurogenic claudication [spinal nerves get compressed in the lower spine, causing intermittent leg pain], and kyphosis [a spinal disorder in which an excessive curve of the spine results in an abnormal rounding of the upper back]. <BR/>A record review of Resident #17's care plan dated 03/01/2023, revealed, The Resident has osteoporosis . the Resident has pain related to vertebrae compression fractures and muscle pain .interventions . monitor/document report as needed signs and symptoms or complications related to osteoporosis: acute fracture, compression fractures, loss of height, kyphosis, pian, especially back pain.<BR/>A record review of Resident #17's quarterly MDS, dated [DATE], revealed Resident #17 was an [AGE] year-old female with needs for assistance with activities of daily life complicated by back pain, spine curvature, and porous bones. Resident #17's assessment revealed a BIMS of 14 out of 15 which indicated no mental cognition impairment. Resident #17 could be understood and could understand others.<BR/>A record review of Resident #17's medical records revealed a progress note, dated 10/7/2023, authored by Resident #17's neurosurgeon, Medical Doctor L, . this is an [AGE] year-old female with osteoporosis and T12, L2 compression fractures with ongoing axial low back pain issues status post kyphoplasty [after a surgery to fix broken vertebrae caused by compression fractures, which can cause pain and deformity] at T12 and L2, 3 weeks ago. Patient no longer has the back brace. We will refer her to orthotics clinic for a TLSO [NAME] extension brace [a unique tool for limiting motion of the spine and reducing pressure on its tissues]. Brace should be worn at all times. <BR/>A record review of Resident #17's medical records revealed an Encounter Summary, dated 10/12/2022, encounter type, after this visit, October 7th 2022 .reason for referral . orthotics, diagnosis, compression fracture of T12 vertebrae . comments: needs new TLSO [NAME] extension brace for T12 compression fracture with worsening kyphosis status post kyphoplasty . electronically signed by [Medical Doctor L].<BR/>During an observation and interview on 02/28/2023 beginning at 02:00 PM, Resident #17 presented in her wheelchair self-ambulating to the dining room. Resident #17 was asked the question, are your needs being met here at the facility?, Resident #17 replied her needs were not being met. Resident #17 stated she had a painful curved spine, had recent spine surgery, and had a need for a back brace, which the neurosurgeon [Medical Doctor L] ordered for her. Resident #17 stated she had a back brace prior to her admission to the facility but somehow it has gone missing. Resident #17 stated she had been to the neurosurgeon [Medical Doctor L] in November [2022] and was prescribed a new back brace but has not received the brace. Resident #17 stated she has complained and asked for a status on the back brace often and has been told the hold-up is insurance paperwork. Resident #17 stated she has no money to pay for the back brace and the facility has reported to her they are attempting to have the neurosurgeon doctor's office fill out paperwork to have Medicaid pay for the brace. Resident stated she has been waiting for the brace since November of 2022. She stated she had had chronic pain and wishes to have the back brace, so my spine will not get worse. Resident #1 stated she has been strong and has not asked for much pain medication and stated she manages her pain by finding a comfortable position while sitting and or laying and only moves when she needs to due to the pain. Resident #17 stated she has asked for the status of her receiving the back brace from many staff members without resolve. Resident #17 stated she had not been offered a grievance form, stated she had not specifically requested a grievance form but had continued to complain and ask about the status of her back brace. Resident #17 stated the situation made her feel, angry and neglected.<BR/>During an interview on 02/28/2023 at 10:00 AM, LVN E stated Resident #17 needed a back brace. LVN E stated Resident #17 has seen the neurosurgeon [Medical Doctor L] and has been fitted for the [TLSO] back brace, however the brace will not be supplied by the shop until the neurosurgeon's office has had the doctor sign and return 2 documents. LVN E stated she, the ADON, and the DON, have been working with the doctor's office since December [2022] and have not been able to have the doctor's office return the 2 documents needed to pay for the brace. LVN E stated Resident #17 was aware of the situation due to LVN E gives her a report when Resident #17 asks about her back brace. LVN E stated she had not generated a grievance for Resident #17 because Resident #17 was not complaining about her back brace but was asking about her back brace. LVN E stated she was actively attempting to secure Resident #17's back brace. LVN E could not give details to exact dates and times Resident #17 inquired about her back brace. <BR/>During an interview on 03/01/2023 at 04:10 PM ADON D stated the grievance forms were kept in a binder which was kept on a table by the facility's entrance. When asked if there were grievance forms in other places like the nurses' station ADON D stated she did not know but believed the forms were only kept in the binder by the facility's entrance. ADON D stated she had not generated a grievance form on behalf of Resident #17 since Resident #17 did not complain about her back brace but was only asking about her back brace and she and staff were actively attempting to secure the back brace. ADON D could not give details to exact dates and times Resident #17 inquired about her back brace.<BR/>During an observation and record review on 03/02/2023 beginning at 04:20 PM revealed a small 2 shelved rectangular table located by the facility's front entrance upon which a 1 white 3 ringed binder was shelved on the tables lower shelf. The binder was labeled concerns and compliments. Record review of the contents of the binder revealed blank grievance forms. <BR/>During an interview on 03/03/2023 at 08:30 AM, the Administrator stated the grievance forms were kept in a binder which was kept on a table by the facility's entrance. The Administrator stated grievances, on behalf of residents, can be made by anyone to include staff, residents' visitors and / or family members. The Administrator stated no one had reported a grievance to him regarding Resident #6's bruising but he was aware of Resident #17's inquiries for her back brace. The administrator stated the facility was actively working with the physicians' offices to secure the back brace and Resident #17 had made inquiries which were not complaints therefore no grievance reports were generated. The Administrator stated the monthly Resident council meeting is not only a forum for grievances but can also be a positive / compliment comments forum. The Administrator stated if grievances are made the staff are trained to provide the complainant a grievance form and the grievance would be directed to the appropriate department for investigation and resolution. <BR/>A facility grievance policy was requested and provided on 03/02/2023 but was not secured by the surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #6) reviewed for injuries of unknown origin reporting, in that:<BR/>Resident #6 was assessed with a large bruise from her chest to her under arm and continued to her back, which was not investigated and not reported to the state agency and Resident #6's Guardian as an injury of unknown origin. <BR/>This failure could place Resident(s) at risk for harm by further exposure to injuries without proper investigation and reporting. <BR/>The findings included:<BR/>A record review of Resident #6's admission Record, dated 02/28/2023, revealed an admission date of 11/30/2018, with diagnoses which included Alzheimer's disease [causes the brain to shrink and brain cells to eventually die] and dementia [a range of conditions that affect the brain's ability to think, remember, and function normally]. Further review revealed Resident #6 was represented by a Guardian [Guardian Q]. <BR/>A record review of Resident #6 quarterly MDS, dated [DATE], revealed Resident #6 was an [AGE] year-old female who could usually understand some conversations, could usually make herself understood, given time; however, Resident #6 was assessed to have severe cognitive impairment with short- and long-term memory problems. <BR/>A record review of Resident #6's medical records revealed a Weekly Skin Observation Tool, dated 01/27/2023, Observations; does Resident have any observed skin issues? No. <BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, c/o [complaint of] pain to RT [right] shoulder. PRN [as needed] tramadol and muscle pain cream applied. Notified [Nurse Practitioner P] Xray ordered to RT. Shoulder claim #XXXXXXXX.<BR/>A record review of Resident #6's Weekly Skin Observation Tool, dated 01/30/2023, revealed, Observations; does Resident have any observed skin issues? Yes .site: right shoulder bruising .<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN G, [Resident #6 Family Member] on premises to visit [Resident #6] this nurse notified him of some bruising to RT [right] shoulder and c/o [complaint of] pain and Xray was ordered [Resident #6 Family Member] got upset and stated the reason why she is here is to protect her and her [Resident #6 Family Member] kept asking her what happened she said I don't know then [Resident #6 Family Member] asked who hurt you [?] and she responded no one hurt her she does not know what happened. Call placed to [Guardian Q] mailbox full.<BR/>A record review of Resident #6's medical records revealed a Progress Note, dated 01/30/2023, authored by LVN R, Resident is day 2/3 bruise to R [right] axilla site [arm pit]. Site is c [with] swelling, warmth and discoloration. Localized inflammation to site. Noted to grimace upon assessment c [with] Tylenol regiment offered per this nurse and resident refusing x2 [twice] attempts. Allow this nurse to slightly prop arm on pillow. Resident observed to touch site often. Pleasantly confused to baseline. Receptive to staff assessment. Routine X-ray results in with right shoulder demonstrating no acute fracture. No joint discoloration. mild Bony demineralization. unremarkable soft tissues. there is severe AC joint [shoulder joint] and mild glenohumeral [the joint that connects the body to the arm] arthritis manifested by joint space narrowing, subchondral sclerosis, and degenerative spurring. will follow up with team health as indicated.<BR/>A record review of Resident #6's medical records revealed a Nurse Practitioner's Progress Note, dated 01/31/2023, authored by Nurse Practitioner P, revealed, Chief complaint / nature of presenting problem: follow up done on large bruising to chest and underarm area reported by nursing today. patient is unable to recall events. She can verbalize needs and report concerns to nurses. Patient is not currently on blood thinners. no falls reported. Have met with director of nursing / administrator to discuss further. Plan: hematoma / ecchymosis [bruising] to chest yellowish in color. Patient is unable to recall how she got it. No falls or trauma reported by nursing. Marking may be associated with gait belt for transfers as it goes around chest and underarms. Patient denied pain at this time. Will monitor for now.<BR/>During an interview and record review on 02/28/2022 at 01:25 PM Resident #6's Guardian, Guardian Q, stated she was not aware Resident #6 had an injury of unknow origin. Guardian Q stated she would have expected the facility to have reported any injury, especially a large bruise of unknown origin to her and possibly to the police. Guardian Q stated she could be contacted by cell phone, text message, and or her email. Guardian Q and surveyor confirmed contact information held by the facility as accurate. Guardian Q stated if by chance she missed a cell call she could have been contacted by email and or text message. <BR/>During an interview on 02/28/2023 at 02:15 PM LVN G stated she had assessed Resident #6 with a bruise to her right under arm and chest and reported the bruise to Nurse Practitioner P and RN F. LVN stated she wrote a progress note in Resident #6's medical record. LVN G stated the bruise was of unknown origin and Resident #6 could not state how she developed the bruise. LVN G stated she had not considered Resident #6's bruise a reportable event. LVN G stated she now understands, due to reflection of the incident, Resident #6's injury of unknown origin was a reportable event she should have reported to the Administrator. <BR/>During an interview on 03/02/2023 at 07:56 AM, Resident #6's Family Member stated they spoke with LVN G and stated, it's not right she [Resident #6] had a bruise. Resident #6's Family Member stated they had a concern, no one could explain how this happened [bruise]. Resident #6's Family Member stated Resident #6 claimed, I don't know how the bruise came to be. Resident #6's Family Member stated no one has reported to him the results of how this [bruise] happened. <BR/>During an interview on 03/03/2023 at 08:30 AM, the Administrator stated he did not believe Resident #6's injury of unknown origin was not a reportable incident due to Resident #6's own report that no one hurt her, even though the surveyor reminded the Administrator of a record review of Resident #6's diagnoses of Alzheimer's disease and dementia. <BR/>A record review of the facility's Recognizing Signs and Symptoms of Abuse / Neglect policy, dated April 2021, revealed, All types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse / neglect to their supervisor or to the director of nursing services immediately. Policy interpretation and implementation: The following are signs and symptoms of abuse / neglect there should be promptly reported. this listing is not all inclusive. other signs and symptoms are actual abuse /neglect may be apparent . signs of physical abuse: injuries that are non-accidental or unexplained . bruises, including those found in unusual locations such as the head neck lateral locations on the arms or posterior trunk and torso . signs of sexual abuse: bruises around the breast, general area or inner thighs .<BR/>A record review of the facility's Abuse, neglect, exploitation and misappropriation prevention program policy, dated April 2021, revealed, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Policy interpretation and implementation . the resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: staff; other residents . identify and investigate all possible incidents of abuse neglect, mistreatment for misappropriation of resident property .investigate and report any allegations within time frames required by federal requirement .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility must 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. The comprehensive care plan must 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 for 1 of 8 (#47) residents in the secured memory care unit in that:<BR/>Resident #47 did not have a care plan for care in the secure memory care unit.<BR/>This could affect residents in the secure unit and could result in residents not provided care while in the memory care unit. <BR/>The findings included:<BR/>Record review of Resident #47's admission Record dated March 2. 2023 revealed she was admitted to the facility on [DATE] with diagnoses of dementia, schizoaffective, adult failure to thrive, major depressive disorder, convulsions, diabetes and muscle wasting/atrophy with hospice services.<BR/>Record review of Resident #47's care plan dated completed date 2/25/2023 revealed Resident #47 had potential to be physically/verbally aggressive related to difficulty with adjustments to change of facility and when re-directed, previously threw a chair at a window, impaired cognition related to dementia, hallucinations/delusions; at risk for falls related to decreased cognition, medications and history of falls, and under hospice services (start date 8/18/2022). Resident #47 did not have a care plan for the memory care unit. <BR/>Record review of Resident #47 Quarterly MDS dated [DATE] revealed her BIMs score was 99, her cognition was severely impaired. <BR/>Record review of Resident #47's memory care unit continued stay review assessment dated [DATE] and completed on this date 3/1/23 after surveyor intervention. <BR/>Record review of Resident #47 consolidated physicians' orders for March 2023 revealed she lived in the secured memory care unit start date 10/12/2021.<BR/>Observation on 2/28/2023 at 9:35 AM revealed Resident #47 was in her room, in the secure unit. <BR/>Interview on 2/28/2023 at 9:38 AM with LVN B stated Resident #47 was an elopement risk and she had a history of COVID (residents with COVID-19 were moved to the secured memory care unit.<BR/>Interview on 3/02/23 at 3:14 PM with SW stated she was responsible for residents' memory care assessments, but not the initials. The SW stated she took over the memory care assessments around May 2022. The SW stated she should keep track of assessments in memory care, but she relied on the PCC alerts and those are not always accurate. The SW stated the memory care unit continued stay review assessment should be completed quarterly. The SW confirmed Resident #47 did not have memory care unit continued stay review assessments for 2022. <BR/>Interview on 3/02/2023 at 3:47 PM with RN MDS C stated she did not see Resident #47's secured memory care unit in her care plan. RN MDS stated she missed inputting Resident #47's memory care unit care and will fix. The RN MDS stated during morning meetings they review resident admissions, re-admission and any change of conditions to include in a resident's care plan. <BR/>Record review of the facility Care Plan Comprehensive Person -Centered policy dated 2001 revealed A comprehensive, person-centered cater plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the residents' goals and preferences, to wear and be able to use the prosthetic device for 1 of 5 (Resident #17) residents reviewed for orthotic devices, in that:<BR/>Resident #17 needed a back brace as ordered by her neurosurgeon, and the facility failed to escalate their efforts to secure the back brace for Resident # 17. <BR/>This failure could place residents at risk for health status decline without the support and therapeutic effects of prostheses devices. <BR/>The findings included:<BR/>A record review of Resident #17's admission record, dated 03/01/2023, revealed an admission date of 10/07/2022, with diagnoses which included wedge compression fracture of T11-T12 vertebra [thoracic area of the spine], age-related osteoporosis [a silent disease that weakens your bones and makes them break easily], spinal stenosis [can cause pressure on your spinal cord or the nerves that go from your spinal cord to your muscles], lumbar region with neurogenic claudication [spinal nerves get compressed in the lower spine, causing intermittent leg pain], and kyphosis [a spinal disorder in which an excessive curve of the spine results in an abnormal rounding of the upper back]. <BR/>A record review of Resident #17's care plan dated 03/01/2023, revealed, The Resident has osteoporosis . the Resident has pain related to vertebrae compression fractures and muscle pain .interventions; . monitor/document report as needed signs and symptoms or complications related to osteoporosis: acute fracture, compression fractures, loss of height, kyphosis, pian, especially back pain.<BR/>A record review of Resident #17's quarterly MDS , dated 12/14/2022, revealed Resident #17 was an [AGE] year-old female with needs for assistance with activities of daily life complicated by back pain, spine curvature, and porous bones. Resident #17's assessment revealed a BIMS of 14 out of 15 which indicated no mental cognition impairment. Resident #17 could be understood and could understand others.<BR/>A record review of Resident #17's medical records revealed a progress note , dated 10/7/2023, authored by Resident #17's neurosurgeon, Medical Doctor L, . this is an [AGE] year-old female with osteoporosis and T12, L2 compression fractures with ongoing axial low back pain issues status post kyphoplasty [after a surgery to fix broken vertebrae caused by compression fractures, which can cause pain and deformity] at T12 and L2, 3 weeks ago. Patient no longer has the back brace. We will refer her to orthotics clinic for a TLSO [NAME] extension brace [a unique tool for limiting motion of the spine and reducing pressure on its tissues]. Brace should be worn at all times. <BR/>A record review of Resident #17's medical records revealed an Encounter Summary [an office visit to the neurosurgeon], dated 10/12/2022, encounter type, after this visit, October 7th, 2022 .reason for referral . orthotics, diagnosis, compression fracture of T12 vertebrae . comments: needs new TLSO [NAME] extension brace for T12 compression fracture with worsening kyphosis status post kyphoplasty . electronically signed by [Medical Doctor L].<BR/>During an interview on 02/28/2023 at 10:00 AM, LVN E stated Resident #17 needed a back brace. LVN E stated Resident #17 has seen the neurosurgeon [Medical Doctor L] and has been fitted for the [TLSO] back brace, however the brace will not be supplied by the shop until the neurosurgeon's office has had the doctor sign and return 2 documents. LVN E stated she, the ADON, and the DON, have been working with the doctor's office since December [2022] and have not been able to have the doctor's office return the 2 documents needed to pay for the brace. LVN E stated Resident #17's attending physician at the facility is Medical Doctor N and is seen by Medical Doctor N's Nurse Practitioner O. LVN E stated she had not given Medical Director N nor Nurse Practitioner O a report about Resident #17 needed a back brace and did not have one. LVN E stated they know [Medical Director N nor Nurse Practitioner O] because they can read the notes and the Resident [#17] can tell them.<BR/>During an observation and interview on 02/28/2023 at 02:00 PM, Resident #17 presented in her wheelchair self-ambulating to the dining room. Resident #17 was asked the question, are your needs being met here at the facility?, Resident #17 replied her needs were not being met. Resident #17 stated she had a painful curved spine, had recent spine surgery, and had a need for a back brace, which the neurosurgeon [Medical Doctor L] ordered for her. Resident #17 stated she had a back brace prior to her admission to the facility but somehow it has gone missing. Resident #17 stated she had been to the neurosurgeon [Medical Doctor L] in November [2022] and was prescribed a new back brace but has not received the brace. Resident #17 stated she has complained and asked for a status on the back brace often and has been told the hold-up is insurance paperwork. Resident #17 stated she has no money to pay for the back brace and the facility has reported to her they are attempting to have the neurosurgeon doctor's office fill out paperwork to have Medicaid pay for the brace. Resident stated she has been waiting for the brace since November of 2022. She stated she had had chronic pain and wishes to have the back brace, so my spine will not get worse. Resident #1 stated she has been strong and has not asked for much pain medication and stated she manages her pain by finding a comfortable position while sitting and or laying and only moves when she needs to due to the pain. Resident #17 stated the situation made her feel, angry and neglected.<BR/>A record review of Resident #17's medical record revealed a progress note authored by LVN E, dated 01/31/2021 , detailing the most recent attempted call to neurosurgeon Medical Doctor L. The note revealed, Call placed to [name] orthotics clinic to follow up on [Resident #17's] TLSO Brace. Spoke to [M orthotics clinic personnel] who stated they have now sent SWO and title 19 forms to [Medical Doctor L's] office three times, since my last call. Forms have not been returned and the orthotics has called and emailed [Medical Doctor L] regarding the forms several times. Last attempt was 01/27/2023. Writer called [Medical Doctor L's] office to follow-up on forms. Message left for Dr. that Resident [#17] does not have brace and cannot attend his desired follow-up with brace due to forms not being faxed back to orthotics clinic. Expecting return phone call from [Medical Doctor L]. will continue to follow up.<BR/>During an interview on 02/28/2023 at 10:20 AM, ADON D stated she was aware of Resident #17's need of a back brace and stated she and her staff have been attempting to have the appropriate paperwork supplied to the orthotics shop for payment of Resident #17 back brace. ADON D stated the facility and Resident #17 were waiting for the doctor's office [Medical Doctor L] to fill out the paperwork for Resident #17. ADON D stated she had not given Medical Director N nor Nurse Practitioner O a report about Resident #17 needed a back brace and did not have one. ADON D stated she believed everyone knew about Resident #17 back brace situation. ADON D stated there were many progress notes in Resident #17's chart. <BR/>During an interview on 03/01/2023 at 11:10 AM, the SW stated she was aware Resident #17 needed a back brace but was not able to receive the back brace for unknown reasons. The SW stated she was not asked to intervene and advocate for Resident #17 by anyone at the facility. The SW stated she understood it was being resolved by the nursing staff. The surveyor asked the SW what could she have done if someone had asked her to intervene and advocate for Resident #17? The SW stated, Maybe, I would have called the doctor or doctors.<BR/>During an interview on 03/01/2023 at 04:48 PM the Medical Director stated he was the medical Director for the facility and Resident #17. Medical Director stated Medical Doctor N was a peer and attended to Resident #17. The Medical Director stated no one has reported to him Resident #17 needed a back brace. The Medical Director stated Resident #17 had a kyphosis diagnosis and understood she was being seen by a neurosurgeon but did not know about the neurosurgeon's order for a back brace and the lack of the brace for Resident #17. The Medical Director stated he could not state what effect the lack of the brace could have on Resident #17 and Resident #17 should be re-assessed by the neurosurgeon due to the prolonged time Resident #17 has been without the brace. When asked if the facility had given the Medical Director a report what could you have done? The Medical Director replied, well, there are many interventions .but I could have intervened by calling the neurosurgeon [Medical Doctor L] .a physician-to-physician call surveyor asked, an intervention. The Medical Doctor replied, Yes. <BR/>During an interview on 03/01/2023 at 05:48 PM Nurse Practitioner O stated no one has reported to him, nor Medical Doctor N, Resident #17 needed a back brace. NP O stated Resident #17 had a kyphosis diagnosis and understood she was being seen by a neurosurgeon but did not know about the neurosurgeon's order for a back brace and the lack of the brace for Resident #17. Nurse Practitioner O could not state what effect the lack of the brace could have on Resident #17 and Resident #17 should be re-assessed due to the prolonged time Resident #17 has been without the brace. Nurse Practitioner O stated he would give Medical Doctor N a report. <BR/>During an interview on 03/02/2023 at 10:05 AM the DON stated she was aware and very involved in the situation of Resident #17's back brace. The DON stated she and her staff have been trying to work with Medical Doctor L's office to secure the 2 documents needed to secure Resident #17 back brace and have had no success with Medical Doctor L's office. The DON stated, we have done all we could, they have not returned the documents needed. When asked if the Medical Director, Resident #17's attending Medical Doctor N, or Nurse Practitioner O have been given a report the DON stated, yes they know, when asked for documentation to support the medical doctors knew; the DON stated there was not any documentation other than the progress notes which detail all the requests for the brace and/or paper-work needed from the doctor's office [Medical Doctor L's office]. When the DON was asked who was responsible for the failure to secure Resident #17's back brace; the DON replied, the doctor's office [Medical Doctor L's office] who would not supply the signed forms needed by the orthotics clinic. When the DON was asked how this failure could affect Resident #17; the DON stated the surveyor could ask the doctor. An accommodation of needs policy regarding Resident #17's back brace orthotics equipment was requested from the DON; the DON replied she did not believe there would be a specific policy for the situation due to the facility was not responsible to pay for items such as back braces .<BR/>A record review of the facility's personal property policy did not adequately address the facility's response to Resident #17's reasonable accommodation of need for a back brace.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable disease and infections for 2 of 2 (Residents #12 and #67) observed for care in that:<BR/>1. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #12.<BR/>2. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #67.<BR/>This failure can affect residents in the facility who received incontinent care and could result in spread of infections.<BR/>The findings were:<BR/>1. Record review of Resident #12's admission Record (03/03/2023) revealed an admission date of 01/17/2023 with diagnoses of Irritable bowel syndrome (disorder that affects the stomach and intestines, also called the gastrointestinal tract) with Diarrhea and Cerebral Infarction, unspecified.<BR/>Record review of Resident #12's careplan (01/17/2023) revealed activities of daily care deficit due to immobility and required one person assist for toileting. <BR/>Record review of Resident #12's MDS (01/31/2023) revealed she was always incontinent and was total dependent with toileting. Further record review revealed she required one person assistance.<BR/>During observation on 02/28/2023 beginning at 08:53 a.m., CNA A provided incontinent care for Resident # 12. Further observation revealed Resident #12 had a bowel movement. CNA A washed her hands and donned a pair of gloves. CNA A wipe Resident #12's perineal area. After CNA a wiped Resident #12's perineal area, CNA A with the same gloves, touched Resident # 12's pillow and placed it at the Resident # 12's foot of bed. Resident #12 was repositioned to the left side, CNA A wiped Resident #12's bottom and removed the patient's briefs. CNA A removed her gloves, sanitized her hands, and donned another pair of gloves. Resident #12's pillow was placed back under her left arm.<BR/>2 Record review of Resident #67's facesheet (03/03/2023) revealed an admission date of 01/25/2023 and diagnoses of Disturbance, Neuromuscular Dysfunction of the Bladder, Benign Prostatic Hyperplasia with lower urinary tract symptoms, and Chronic Kidney Disease.<BR/>Record review of Resident #67's careplan revealed self-care performance deficit in activities of daily living tasks and required extensive assistance by staff. <BR/>Record review of Resident #67's MDS revealed he required extensive assistance with one person assist for toileting. Further review revealed Resident #67 had an indwelling catheter and frequently incontinent of bowel. <BR/>Record review of CNA A's last peri-care/incontinence care skill assessment (male and female) was on 12/22/2022. Further review revealed proficiency criteria included taking off the gloves, putting them in the trash bag and washing hands and putting on new gloves.<BR/>During an observation on 02/28/2023 at 09:15 a.m., CNA A Provided cath care for Resident #12. CNA A washed hands/gloved, anchor in place, wiped patients cath 3 to inches down, and around cath tubing, after, CNA A wiped head of penis and down and around and down, after, with same gloves CNA A left hip and blanket, to roll pt. to right side wiped bottom, touched clean brief, added brief, then removed gloves. <BR/>During an interview on 02/28/23 at 09:37 a.m., CNA A indicated she should've removed her gloves after cleaning Resident # 12's peri area, before touching Resident #12's pillow, and after wiping Resident #67's indwelling catheter and perineal area. Further interview with CNA A revealed she didn't pay attention to that because she's in a rush to care for other residents.<BR/>During an interview on 03/01/2023 at 4:10 p.m., the Administrator stated competency on incontinent care were done on hire and annually.<BR/>Record review of the facility's policy and procedure titled Stand Precautions (2001), read in part, Standard Precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .2. Gloves: d. Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 2 of 5 Residents (Resident #15 and Resident #18) reviewed for the ability to call for staff, in that:<BR/>Resident #15 and Resident #18 presented with their call light on the floor away from their reach. <BR/>This failure could place residents at risk for injury and diminished self-esteem, due to the inability to call for assistance. <BR/>The findings included:<BR/>A record review of Resident #15's admission record, dated 03/03/2023, revealed an admission date of 03/18/2022 with diagnoses which included Parkinson's disease [a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement], and severe intellectual disabilities.<BR/>A record review of Resident #15's care plan, dated 03/03/2023, revealed, The Resident has an activity of daily life self-care performance deficit related to severe intellectual disabilities. Needs extensive assistance for all activities of daily life. non-ambulatory [cannot walk or self-propel] .the resident has stiffness in bilateral upper lower extremities .the resident requires extensive total assistance by staff for toileting .the resident is at risk for falls related to intellectual disabilities, poor impulse control, decrease functional status, and leans . interventions . be sure the Resident's call light is within reach and encourage the resident to use it for assistance as needed. The Resident needs prompt response to all requests for assistance.<BR/>A record review of Resident #15's quarterly MDS, dated [DATE], revealed Resident #15 was a [AGE] year-old male with severe mental disabilities and needed assistance with all activities of daily life to include eating, drinking, and toileting.<BR/>During an observation and interview on 02/27/2023 beginning at 11:08 AM, revealed Resident #15 in his bedroom, dressed, and seated in his wheelchair. Resident #15 was seated by his bed facing the television and his call light was resting on the floor between the bed and the wall out of Resident #15's reach. During an interview with Resident #15 revealed Resident #15 communicated with body gestures. Resident #15 was asked where his call light was, Resident #15 replied with a shoulder shrug as if communicating I don't know. Surveyor identified to Resident #15 his call light was on the floor and asked Resident #15 if he could reach it, Resident #15 nodded his head from left to right to communicate a no response. <BR/>A record review of Resident #18's admission record revealed an admission date of 08/06/2013, with diagnoses which included dementia [a term for a range of conditions that affect the brain's ability to think, remember, and function normally], and schizoaffective disorder [a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms]. <BR/>A record review of Resident #18's care plan, dated 03/03/2023, revealed, The Resident is at risk for falls related to confusion, gate balance problems, incontinence, psychoactive drug use, unawareness of safety needs . interventions . be sure the residents call light is within reach and encourage the resident to use it for assistance as needed. The Resident needs prompt response to all requests for assistance.<BR/>A record review of Resident #18's quarterly MDS, dated [DATE], revealed Resident #18 was a [AGE] year-old female who was assessed with moderate intellectual impairment and required limited assistance with personal hygiene, and locomotion in and out of her room. <BR/>During an observation and interview on 02/27/2023 beginning at 11:12 AM, revealed Resident #18 in her bedroom, dressed, and laying in her bed. The call light presented behind the bed on the floor in between the bed and the wall, out of Resident #18's reach. During an interview Resident #18 was asked by surveyor can you call for help, Resident #18 stated yes by nodding her head in an up and down motion. When asked where her call light was? Resident #18 responded with a shoulder and outward hand gestures. When surveyor identified the call light as being behind the bed and on the floor; Resident #18 nodded her head in a left to right motion to answer the question, if she could reach the call light?<BR/>During an interview and observation on 02/27/2023 beginning at 11:27 AM, CNA H stated she was the CNA responsible for residents on A hall to include Residents #15 and #18. CNA H confirmed the observations of the call lights located on the floor and out of reach for residents #15 and #18. CNA stated she had placed the call lights on the residents within their reach and they must have thrown the call lights down. CNA H promptly repositioned the call lights off the floor and within reach of residents #15 and #18. CNA H stated residents #15 and #18 could use their call lights and should always have their call lights within their reach. CNA stated if residents are not able to call for assistance, they may suffer a fall or incontinence. <BR/>During an interview on 02/27/2023 at 11:30 AM, RN F stated she was the charge nurse for A hall to include CNA H and Residents #15 and #18. RN F stated she would provide reinforced delegation of duties for CNA H to include call lights should be attached to Residents' reachable area, such as their robes, clothes, and / or blankets and it is unacceptable for call lights to be out of Residents' reach. RN F stated residents could have a fall if denied the ability to call for assistance. <BR/>A call light policy was requested on 03/03/2023 and the policy was provided, and the surveyor failed to secure the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the rights of residents to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents, for 1 of 5 residents reviewed (Resident #17) for accommodation of orthotic support devices, in that:<BR/>The facility failed to report to Resident #17's physician's the inability to fulfill Resident #17's order for a back brace, ordered by a neurologist [a medical doctor who specializes in diagnosing and treating diseases of the brain, spinal cord, and nerves]. Resident #17 had a compression fracture of vertebra and kyphosis. Resident #17had spinal surgery and an order for a back brace from November 2022 that she did not receive. Resident revealed she was in [NAME] pain.<BR/>This failure could place residents at risk for denial of their rights to have reasonable accommodations. <BR/>The findings included:<BR/>A record review of Resident #17's admission record, dated 03/01/2023, revealed an admission date of 10/07/2022, with diagnoses which included wedge compression fracture of T11-T12 vertebra [thoracic area of the spine], age-related osteoporosis [a silent disease that weakens your bones and makes them break easily], spinal stenosis [can cause pressure on your spinal cord or the nerves that go from your spinal cord to your muscles], lumbar region with neurogenic claudication [spinal nerves get compressed in the lower spine, causing intermittent leg pain], and kyphosis [a spinal disorder in which an excessive curve of the spine results in an abnormal rounding of the upper back]. <BR/>A record review of Resident #17's care plan dated 03/01/2023, revealed, The Resident has osteoporosis . the Resident has pain related to vertebrae compression fractures and muscle pain .interventions; . monitor/document report as needed signs and symptoms or complications related to osteoporosis: acute fracture, compression fractures, loss of height, kyphosis, pian, especially back pain.<BR/>A record review of Resident #17's quarterly MDS, dated [DATE], revealed Resident #17 was an [AGE] year-old female with needs for assistance with activities of daily life complicated by back pain, spine curvature, and porous bones. Resident #17's assessment revealed a BIMS of 14 out of 15 which indicated no mental cognition impairment. Resident #17 could be understood and could understand others.<BR/>A record review of Resident #17's medical records revealed a progress note, dated 10/7/2023, authored by Resident #17's neurosurgeon, Medical Doctor L, . this is an [AGE] year-old female with osteoporosis and T12, L2 compression fractures with ongoing axial low back pain issues status post kyphoplasty [after a surgery to fix broken vertebrae caused by compression fractures, which can cause pain and deformity] at T12 and L2, 3 weeks ago. Patient no longer has the back brace. We will refer her to orthotics clinic for a TLSO [NAME] extension brace [a unique tool for limiting motion of the spine and reducing pressure on its tissues]. Brace should be worn at all times. <BR/>A record review of Resident #17's medical records revealed an Encounter Summary, dated 10/12/2022, encounter type, after this visit, October 7th 2022 .reason for referral . orthotics, diagnosis, compression fracture of T12 vertebrae . comments: needs new TLSO [NAME] extension brace for T12 compression fracture with worsening kyphosis status post kyphoplasty . electronically signed by [Medical Doctor L].<BR/>During an observation and interview on 02/28/2023 at 02:00 PM, Resident #17 presented in her wheelchair self-ambulating to the dining room. Resident #17 was asked the question, are your needs being met here at the facility?, Resident #17 replied her needs were not being met. Resident #17 stated she had a painful curved spine, had recent spine surgery, and had a need for a back brace, which the neurosurgeon [Medical Doctor L] ordered for her. Resident #17 stated she had a back brace prior to her admission to the facility but somehow it has gone missing. Resident #17 stated she had been to the neurosurgeon [Medical Doctor L] in November [2022] and was prescribed a new back brace but has not received the brace. Resident #17 stated she has complained and asked for a status on the back brace often and has been told the hold-up is insurance paperwork. Resident #17 stated she has no money to pay for the back brace and the facility has reported to her they are attempting to have the neurosurgeon doctor's office fill out paperwork to have Medicaid pay for the brace. Resident stated she has been waiting for the brace since November of 2022. She stated she had had chronic pain and wishes to have the back brace, so my spine will not get worse. Resident #1 stated she has been strong and has not asked for much pain medication and stated she manages her pain by finding a comfortable position while sitting and or laying and only moves when she needs to due to the pain. Resident #17 stated the situation made her feel, angry and neglected.<BR/>During an interview on 02/28/2023 at 10:00 AM, LVN E stated Resident #17 needed a back brace. LVN E stated Resident #17 has seen the neurosurgeon [Medical Doctor L] and has been fitted for the [TLSO] back brace, however the brace will not be supplied by the shop until the neurosurgeon's office has had the doctor sign and return 2 documents. LVN E stated she, the ADON, and the DON, have been working with the doctor's office since December [2022] and have not been able to have the doctor's office return the 2 documents needed to pay for the brace. LVN E stated Resident #17's attending physician at the facility is Medical Doctor N and is seen by Medical Doctor N's Nurse Practitioner O. LVN E stated she had not given Medical Director N nor Nurse Practitioner O a report about Resident #17 needed a back brace and did not have one. LVN E stated they know [Medical Director N nor Nurse Practitioner O] because they can read the notes and the Resident [#17] can tell them.<BR/>A record review of Resident #17's medical record revealed a progress note authored by LVN E, dated 01/31/2021, detailing the most recent attempted call to neurosurgeon Medical Doctor L. The note revealed, Call placed to [name] orthotics clinic to follow up on [Resident #17's] TLSO Brace. Spoke to [M orthotics clinic personnel] who stated they have now sent SWO and title 19 forms to [Medical Doctor L's] office three times, since my last call. Forms have not been returned and the orthotics has called and emailed [Medical Doctor L] regarding the forms several times. Last attempt was 01/27/2023. Writer called [Medical Doctor L's] office to follow-up on forms. Message left for Dr. that Resident [#17] does not have brace and cannot attend his desired follow-up with brace due to forms not being faxed back to orthotics clinic. Expecting return phone call from [Medical Doctor L]. will continue to follow up.<BR/>During an interview on 02/28/2023 at 10:20 AM, ADON D stated she was aware of Resident #17's need of a back brace and stated she and her staff have been attempting to have the appropriate paperwork supplied to the orthotics shop for payment of Resident #17 back brace. ADON D stated the facility and Resident #17 were waiting for the doctor's office [Medical Doctor L] to fill out the paper-work for Resident #17. ADON D stated she had not given Medical Director N nor Nurse Practitioner O a report about Resident #17 needed a back brace and did not have one. ADON D stated she believed everyone knew about Resident #17 back brace situation. ADON D stated there were many progress notes in Resident #17's chart. <BR/>During an interview on 03/01/2023 at 11:10 AM, the SW stated she was aware Resident #17 needed a back brace but was not able to receive the back brace for unknown reasons. The SW stated she was not asked to intervene and advocate for Resident #17 by anyone at the facility. The SW stated she understood it was being resolved by the nursing staff. The surveyor asked the SW what could she have done if someone had asked her to intervene and advocate for Resident #17? The SW stated, Maybe, I would have called the doctor or doctors.<BR/>During an interview on 03/01/2023 at 04:48 PM the Medical Director stated he was the medical Director for the facility and Resident #17. Medical Director stated Medical Doctor N was a peer and attended to Resident #17. The Medical Director stated no one has reported to him Resident #17 needed a back brace. The Medical Director stated Resident #17 had a kyphosis diagnosis and understood she was being seen by a neurosurgeon but did not know about the neurosurgeon's order for a back brace and the lack of the brace for Resident #17. The Medical Director stated he could not state what effect the lack of the brace could have on Resident #17 and Resident #17 should be re-assessed by the neurosurgeon due to the prolonged time Resident #17 has been without the brace. When asked if the facility had given the Medical Director a report what could you have done? The Medical Director replied, well, there are many interventions .but I could have intervened by calling the neurosurgeon [Medical Doctor L] .a physician-to-physician call surveyor asked, an intervention. The Medical Doctor replied, Yes. <BR/>During an interview on 03/01/2023 at 05:48 PM Nurse Practitioner O stated no one has reported to him, nor Medical Doctor N, Resident #17 needed a back brace. NP O stated Resident #17 had a kyphosis diagnosis and understood she was being seen by a neurosurgeon but did not know about the neurosurgeon's order for a back brace and the lack of the brace for Resident #17. Nurse Practitioner O could not state what effect the lack of the brace could have on Resident #17 and Resident #17 should be re-assessed due to the prolonged time Resident #17 has been without the brace. Nurse Practitioner O stated he would give Medical Doctor N a report. <BR/>During an interview on 03/02/2023 at 10:05 AM the DON stated she was aware and very involved in the situation of Resident #17's back brace. The DON stated she and her staff have been trying to work with Medical Doctor L's office to secure the 2 documents needed to secure Resident #17 back brace and have had no success with Medical Doctor L's office. The DON stated, we have done all we could, they have not returned the documents needed. When asked if the Medical Director, Resident #17's attending Medical Doctor N, or Nurse Practitioner O have been given a report the DON stated, yes they know, when asked for documentation to support the medical doctors knew; the DON stated there was not any documentation other than the progress notes which detail all the requests for the brace and/or paper-work needed from the doctor's office [Medical Doctor L's office]. When the DON was asked who was responsible for the failure to secure Resident #17's back brace; the DON replied, the doctor's office [Medical Doctor L's office] who would not supply the signed forms needed by the orthotics clinic. When the DON was asked how this failure could affect Resident #17; the DON stated the surveyor could ask the doctor. An accommodation of needs policy regarding Resident #17's back brace orthotics equipment was requested from the DON; the DON replied she did not believe there would be a specific policy for the situation due to the facility was not responsible to pay for items such as back braces.<BR/>A record review of the facility's personal property policy did not adequately address the facility's response to Resident #17's reasonable accommodation of need for a back brace.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, for 1 of 5 residents (Resident #238) reviewed for laboratory services, in that:<BR/>Resident #238 was ordered a urinalysis which was not sent to the laboratory for 7 days. <BR/>This failure placed residents at risk for health status decline related to denying the physician a prompt result from the ordered urinalysis. <BR/>The findings included:<BR/>A record review of Resident #238's admission Record, dated 2/28/2023, revealed an admission date of 02/16/2023 with diagnoses which included encephalopathy [a term for any disease of the brain that alters brain function or structure] and seizures [a seizure is a sudden, uncontrolled burst of electrical activity in the brain].<BR/>A record review of Resident #238's care plan, dated 03/01/2023, revealed, The Resident [Resident #238] uses mood stabilizers, anticonvulsive medications related to seizures .Interventions: . obtain and monitor lab diagnostic work as ordered. Report results to MD [medical doctor] and follow up as indicated.<BR/>A record review of Resident #238's admission MDS, dated [DATE], revealed Resident #238 was a [AGE] year-old female who was admitted from the hospital. Resident #238 was assessed as a 12 out of 15 for the Brief Mental Interview Status which indicated mild cognitive impairment and is occasionally incontinent of bladder. <BR/>A record review of Resident #238's physicians orders, dated 02/21/2023, revealed Doctor S ordered for Resident #17 a urinalysis, with a culture and sensitivity, to rule out urinary tract infection.<BR/>A record review of the facility's unit A 24hr reports for the dates 02/21/2023 through 02/28/2023 revealed on 02/2021 RN F documented [Resident #238] has new orders UA [urinalysis] , labs and LVN G documented UA to be obtained. Record review of the 24-hr. report dated 02/22/2023, revealed RN F documented, UA needed did not collect. Record review of the 24-hr. report dated 02/23/2023, revealed UA collected and RN F documented pending urine PU [pick-up]. Record review of the 24-hr. reports dated 02/24/2023 and 02/25/2023, revealed, pending UA results. Record review of the 24-hr. report dated 02/26/2023, revealed LVN U and LVN T documented Resident #238 *Needs UA*. Record review of the 24-hr. report dated 02/27/2023, revealed LVN U, RN F and LVN G documented Resident #238 *Needs UA*, unable to collect. <BR/>During an observation, interview, and record review on 02/28/2023 beginning at 10:02 AM, revealed the facility's contracted laboratory's representative was asking RN F for the sample to be sent to the laboratory. A record review of the sample and documentation paperwork revealed the sample was ordered on 02/21/2023. When RN F was asked why the sample was being sent out to the laboratory seven days later than ordered, RN F replied there were some difficulties collecting the urine sample and was collected twice and the current sample was collected yesterday [02/27/2023] and was the most recent. RN F stated the laboratory picked up samples from the facility three times a week Monday, Tuesdays, and Thursdays. RN F stated she, LVN U, and LVN G recognized the UA sample for Resident #238 collected on 02/23/2023 was not picked up from the facility on 02/23/2023 and by 02/24/2023 the nurses [LVN G, LVN T, LVN U, and RN F] gave report to each other to collect a new sample and send the new sample to the laboratory. RN F stated the sample was older than 48 hours and a new sample was required. RN F stated LVN G collected the new sample on the evening of 02/27/2023. RN F stated the facility recently upgraded their laboratory services plan to include the use of the laboratory contractor's website to enter laboratory orders for residents. RN F stated she recognized this morning [02/28/2021] no one had entered the urinary analysis order for Resident #238, and she entered the order into the system. RN F stated she had not reported to Doctor S his 02/21/2023 was not collected until 02/23/2023 and not picked up by the laboratory until 02/28/2023. RN F stated Resident #238 was fine, as evidenced by Resident #238's vital signs, and did not see any problem not reporting to Doctor S his 02/21/2023 was not collected until 02/23/2023 and not picked up by the laboratory until 02/28/2023.<BR/>During an observation, interview, and record review on 02/28/2023 beginning at 04:02, LVN G stated on 02/27/2023, she received report from RN F, the urine sample collected on 02/23/2023, for Resident #238, was not picked up by the laboratory and a new sample was needed. LVN G stated she collected a urine sample from Resident #238 on her shift on the evening of 02/27/2023. LVN G stated she had not reported to Doctor S the late collection of the UA. LVN G stated she had not considered she needed to report the late collection of the urine sample and believed RN F would have reported the late collection since RN F worked the day shift. <BR/>During an interview on 03/01/2023 at 10:00 AM the facility's Medical Director stated he was responsible for all residents in the facility to include Resident #238. The Medical Director stated a urinalysis ordered on 02/21/2023 and sent to the lab seven days later [02/28/2023] would have been too long. The Medical Director stated a regularly ordered urinalysis would be reasonable for the sample to be sent the next business day to include a couple of days. The Medical Director stated it would be reasonable for the laboratory to pick up samples from the facility three times a week. The Medical Director stated no one contacted him to report Resident #238's urine sample was not sent to the lab until seven days later. The Medical Director stated he could not give comment on what Doctor S would have done if he had been given a report of the difficulty collecting and sending the urine sample to the laboratory; but an option could have been to intervene with a plan of care dependent on the resident's assessment. <BR/>An unsuccessful interview was attempted with Doctor S on 03/01/2023 at 01:46 PM. <BR/>During an interview on 03/01/2023 at 4:05 PM, Resident #238 stated she was asked several times by nursing staff to alert them when she needed to urinate and was provided a hat to pee in when she needed to urinate. Resident stated this occurred last week and again this weekend. Resident #238 could not recall the exact dates and times. <BR/>During an interview on 03/02/2023 at 04:38 PM the DON stated she was not given a report of the 02/21/2023 UA order for Resident #238 which was sent to the lab om 02/28/2023. The DON stated the urine sample could have been picked up, by the laboratory, on 02/23/2023 when it was collected. The DON stated the order could have been put into the laboratory's web-based portal on the day the order was given [02/23/2023]. The DON could not comment on the details surrounding the incident, due to the nurses involved did not give her a report. The DON stated the nurses involved should have given Doctor S a report to the delay in sending the urine sample. A policy regarding reporting to a physician a delay in following laboratory orders was requested.<BR/>A record review of the facility's policy regarding reporting to a physician a delay in following laboratory orders was not reviewed due to the policy provided by the facility did not address the facility not sending Resident #238's urine sample to the laboratory until seven days later. The policy provided addressed medication orders; how to receive and record medication orders.

Based on interview and record review, the facility failed to ensure annual communications training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. <BR/>The facility failed to ensure communication training was provided CNA N and LVN O annually. <BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>Findings were:<BR/>Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received annual communication training. <BR/>Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual communication training. <BR/>Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. <BR/>Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. <BR/>A policy required annual training topics, including communication trainings, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review, the facility failed to ensure annual ethics training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. <BR/>The facility failed to ensure abuse, neglect and exploitation training was provided CNA N and LVN O annually. <BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>Findings were:<BR/>Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received ethics training. <BR/>Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual ethics training. <BR/>Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. <BR/>Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. <BR/>A policy required annual training topics, including ethics training, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review, the facility failed to ensure annual QAPI training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. <BR/>The facility failed to ensure QAPI training was provided CNA N and LVN O annually. <BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>Findings were:<BR/>Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received QAPI training. <BR/>Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual QAPI training. <BR/>Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. <BR/>Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. <BR/>A policy required annual training topics, including QAPI training, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review, the facility failed to ensure annual abuse, neglect and exploitation training and dementia training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. <BR/>The facility failed to ensure abuse, neglect and exploitation training and dementia training was provided CNA N and LVN O annually. <BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>Findings were:<BR/>Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received abuse, neglect and exploitation training or dementia training. <BR/>Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual abuse, neglect and exploitation training or dementia training. <BR/>Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. <BR/>Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. <BR/>A policy required annual training topics, including abuse, neglect and exploitation training and dementia training, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable disease and infections for 2 of 2 (Residents #12 and #67) observed for care in that:<BR/>1. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #12.<BR/>2. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #67.<BR/>This failure can affect residents in the facility who received incontinent care and could result in spread of infections.<BR/>The findings were:<BR/>1. Record review of Resident #12's admission Record (03/03/2023) revealed an admission date of 01/17/2023 with diagnoses of Irritable bowel syndrome (disorder that affects the stomach and intestines, also called the gastrointestinal tract) with Diarrhea and Cerebral Infarction, unspecified.<BR/>Record review of Resident #12's careplan (01/17/2023) revealed activities of daily care deficit due to immobility and required one person assist for toileting. <BR/>Record review of Resident #12's MDS (01/31/2023) revealed she was always incontinent and was total dependent with toileting. Further record review revealed she required one person assistance.<BR/>During observation on 02/28/2023 beginning at 08:53 a.m., CNA A provided incontinent care for Resident # 12. Further observation revealed Resident #12 had a bowel movement. CNA A washed her hands and donned a pair of gloves. CNA A wipe Resident #12's perineal area. After CNA a wiped Resident #12's perineal area, CNA A with the same gloves, touched Resident # 12's pillow and placed it at the Resident # 12's foot of bed. Resident #12 was repositioned to the left side, CNA A wiped Resident #12's bottom and removed the patient's briefs. CNA A removed her gloves, sanitized her hands, and donned another pair of gloves. Resident #12's pillow was placed back under her left arm.<BR/>2 Record review of Resident #67's facesheet (03/03/2023) revealed an admission date of 01/25/2023 and diagnoses of Disturbance, Neuromuscular Dysfunction of the Bladder, Benign Prostatic Hyperplasia with lower urinary tract symptoms, and Chronic Kidney Disease.<BR/>Record review of Resident #67's careplan revealed self-care performance deficit in activities of daily living tasks and required extensive assistance by staff. <BR/>Record review of Resident #67's MDS revealed he required extensive assistance with one person assist for toileting. Further review revealed Resident #67 had an indwelling catheter and frequently incontinent of bowel. <BR/>Record review of CNA A's last peri-care/incontinence care skill assessment (male and female) was on 12/22/2022. Further review revealed proficiency criteria included taking off the gloves, putting them in the trash bag and washing hands and putting on new gloves.<BR/>During an observation on 02/28/2023 at 09:15 a.m., CNA A Provided cath care for Resident #12. CNA A washed hands/gloved, anchor in place, wiped patients cath 3 to inches down, and around cath tubing, after, CNA A wiped head of penis and down and around and down, after, with same gloves CNA A left hip and blanket, to roll pt. to right side wiped bottom, touched clean brief, added brief, then removed gloves. <BR/>During an interview on 02/28/23 at 09:37 a.m., CNA A indicated she should've removed her gloves after cleaning Resident # 12's peri area, before touching Resident #12's pillow, and after wiping Resident #67's indwelling catheter and perineal area. Further interview with CNA A revealed she didn't pay attention to that because she's in a rush to care for other residents.<BR/>During an interview on 03/01/2023 at 4:10 p.m., the Administrator stated competency on incontinent care were done on hire and annually.<BR/>Record review of the facility's policy and procedure titled Stand Precautions (2001), read in part, Standard Precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .2. Gloves: d. Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care.

Based on observation, interview, and record review the facility failed to ensure 1 of 46 (Resident #67) sampled residents was treated with dignity during dining room observation.<BR/>CNA A prevented Resident #67 to move freely by locking his wheelchair after he was finished with his breakfast.<BR/>This failure could affect all residents in the facility and could result in residents not being treated with dignity.<BR/>The findings were:<BR/>Record review of Resident #67's admission Record (03/03/2023) revealed an admission date of 01/17/2023 with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction, Cerebral Infarction, unspecified, and Irritable Bowel Syndrome with Diarrhea. <BR/>Record review of Resident #67's care plan (02/14/2023) revealed he was at risk for falls due poor safety awareness and needed extensive assistance with activities of daily living with the assistance of two staff when combative. Further record review revealed Resident #67 propels short distances with his wheelchair. <BR/>Record review of Resident #67's MDS (02/21/2023) revealed a Brief Interview for Mental Status (BIMS) score of 99 (resident was unable to complete the interview). Further review revealed Resident #67 had no potential for indicators of psychosis and exhibited no physical or verbal behavioral symptoms towards others. <BR/>During an observation on 02/27/23 12:16 p.m., Resident #67 was observed eating his meal. After Resident #67 had finished at 12:20 p.m., he started to reverse-propel himself away from the dining table. Further observation revealed CNA A pushed his wheelchair back under his dining table and proceeded to lock his wheel. CNA A was observed telling Resident #67 to stay there until she can help him get to his bed after she's done with her task. Resident #67 was observed in the same position until 12:40 p.m., when he was assisted out of the dining area. <BR/>During an interview on 02/28/23 at 09:37 a.m., CNA A stated I wanted to leave the patient in the dining room to monitor him until she can put him in bed because he was a fall risk. Further interview revealed CNA A didn't realized she wasn't supposed to lock Resident #67's wheelchair.<BR/>During an interview on 03/01/2023 at 04:10 p.m., the Administrator stated locking a resident's wheelchair was part of CNA training and depended on safety, transfer, or if a resident was standing. Further interview with the Administrator revealed it wouldn't be a practice for a CNA to lock their wheelchair after a resident was done eating (and wanting to leave the table) or locking the wheelchair until the CNA can put patient to bed. Further interview with the Administrator revealed patients were free to roam unless they were a danger to self or others.<BR/>Observation on 3/2/2023 at 12:15 p.m. revealed Resident #67 was able to release his wheelchair brakes on his own. <BR/>Record review of the agency's policy titled Resident Rights (2001), read in part, .Employees shall treat all residents with kindness, respect, and dignity .I. Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that accommodated the preferences for 2 of 13 residents reviewed for food preferences and the accommodation of resident's meal choices (Resident #'s 5 and 7).<BR/>The facility did not honor Resident #5's allergy to foods and continued to serve her foods she was allergic to.<BR/>The facility did not honor Resident #7's food preferences and continued to serve him foods he asked not to receive.<BR/>This failure could place residents who report likes/dislikes and allergies at risk for dissatisfaction, poor intake, weight loss, and/or allergic reaction.<BR/>Findings included:<BR/>Record review of Resident # 5's face sheet revealed she was a [AGE] year-old female, admitted [DATE]. Resident #5's diagnoses include: anxiety disorder and Hemiplegia (paralysis of one side of the body) and Hemiparesis (muscle weakness of one side of the body) following a Cerebral Infarction (a disruption in the brain's blood flow).<BR/>Record review of Resident # 5's admission MDS assessment, dated 04/08/2024, revealed a BIMS score of 15 indicating no cognitive impairment. <BR/>Record review of Resident #5's care plan, dated 04/16/2024 with a target date of 07/08/2024, stated resident is allergic to penicillin, chicken, chocolate, oats, spinach. Interventions dated 04/16/2024 included: Do not administer medications, offer food/drink or expose to allergens the resident is known to be allergic to. Have appropriate documentation of allergies/alerts on chart, per facility protocol. <BR/>Record review of Resident # 5's Resident Food Preference Form, dated 03/31/2024, listed food allergies as chicken, chocolate, oats and spinach. <BR/>Record review of Resident # 5's tray card served with her lunch and dinner meal tray, undated, revealed food allergies as chicken, chocolate, oats and spinach.<BR/>During an interview and observation on 04/15/2024 at 1:25 p.m., revealed Resident #5's tray card on the table listed food allergies that included chicken and chocolate. Resident #5 stated she is allergic to chocolate and chicken and had been served these items several times since admission on [DATE]. Resident #5 further stated eating these items gives her a stomachache.<BR/>Observation on 04/15/2024 at 5:00 p.m., revealed LVN A checking resident meal trays in A Hall dining room prior to passing the trays to the residents.<BR/>Observation on 04/15/2024 at 5:02 p.m., revealed Resident #5 received her meal tray with a chocolate milk shake on the tray. Resident #5 upon seeing the chocolate shake, said I cannot have the chocolate shake, I am allergic to it. <BR/>During an interview, 04/15/24 at 5:05 p.m., LVN A verified he did check Resident #5's tray card against the meal on her tray. He stated he must have missed it when asked about Resident #5's listed allergies. He stated he had received training on verifying trays with the tray card. Furthermore, he stated serving a resident a food item that they are allergic too could have resulted in the resident having an allergic reaction. <BR/>Record review of Resident #7's face sheet revealed he is a [AGE] year-old male, admitted [DATE]. Resident #7's diagnoses include: anxiety disorder, Depression and Dementia (a general term for impaired ability to remember, think, or make decisions). <BR/>Record review of Resident #7's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating no cognitive impairment. <BR/>Record review of Resident #7's care plan, revised 11/09/2023, revealed Resident #7's food preferences and dislikes were not included in the plan of care. <BR/>Record review of Resident #7's Resident Food Preference Form, dated 07/03/2023, revealed no dislikes listed under Section D. Dislikes.<BR/>Record review of Resident #7's tray card, undated, revealed a list of Dislikes/Intolerances to include: sweet potatoes/Yams; Zucchini.<BR/>Observation on 04/15/24 at 5:15 p.m., revealed RN A verifying trays in the memory care dining room before the trays were passed out to the residents.<BR/>Observation on 04/15/2024 at 5:21 p.m., revealed Resident #7's meal tray consisted of ham, candied yams and mixed vegetables including zucchini. <BR/>During an interview on 04/15/2024 at 5:22 p.m., Resident #7 stated he did not like yams or zucchini and planned to not eat those items.<BR/>During an interview on 04/15/2024 at 5:25 p.m., RN A verified she checked the tray card and the resident meal tray. RN A responded No, I must have missed it when asked if she observed Resident #7's dislikes listed on the tray card. RN A stated it was important to make sure each resident has the appropriate food and if the resident received food they do not like, they could not be eating a sufficient amount of food. <BR/>During an interview on 04/16/2024 at 1:20 p.m., the Dietary Manager stated resident food allergies and food preferences were obtained from the resident or their representative upon admission, quarterly and as needed. He stated he entered the information onto the resident meal tray card system and a tray card was provided at every meal. He stated three people were responsible for verifying the tray accuracy in the kitchen which included the cook, dietary aide, and dishwasher (whom he stated brought the trays out to the dining room). He stated a nurse then verified the accuracy of the trays in the dining room before being handed to a resident. Furthermore, he stated his staff had received training on verifying tray accuracy and the importance of the accuracy was to make sure a resident did not have an allergic reaction and enjoyed the food they were provided. When asked about Resident #5 and Resident #7's trays he stated, it must have been overlooked. <BR/>During an interview on 04/16/2024 at 2:20 p.m., the DON stated resident allergies and preferences were listed on the resident's tray cards. She stated dietary checks the trays before they are sent to the dining room and then a nurse checks the trays before being handed to a resident. She stated it was important to verify the accuracy of the meals to prevent a resident from having an allergic reaction and residents had the right to follow the resident's preferences. Furthermore, she stated staff had received training on verifying the accuracy of meal trays. <BR/>Record review of facility policy, Alternate Food Choices and Substitutions and Honoring Preferences, copyright 2018, stated the policy was the facility also supports resident choice and allowing residents to choose foods by honoring their food preferences. Steps listed in the procedure for the policy included: The Nutrition and Foodservice Manager or designee will obtain the resident's food preferences upon admission and record preferences in the tray card system. If a resident's preferences indicate they dislike the main meal, the alternate will be served unless the resident requests a substitution.

Based on interview and record review, the facility failed to ensure annual rights of the resident training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. <BR/>The facility failed to ensure resident rights training was provided CNA N and LVN O annually. <BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>Findings were:<BR/>Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received resident rights training. <BR/>Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual resident rights training. <BR/>Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. <BR/>Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. <BR/>A policy required annual training topics, including resident rights training, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review, the facility failed to ensure annual behavioral health training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. <BR/>The facility failed to ensure abuse, neglect and exploitation training was provided CNA N and LVN O annually. <BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>Findings were:<BR/>Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received behavioral health training. <BR/>Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual behavioral health training. <BR/>Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. <BR/>Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. <BR/>A policy required annual training topics, including behavioral health training, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 5 (CNA E) CNAs in that:<BR/>CNA E did not have a current EMR/NAR check. <BR/>This could place residents at risk of abuse, neglect, and exploitation. <BR/>The Findings:<BR/>Record review of the staff list dated 4/23/2024 revealed that CNA E was hired on 4/21/2024.<BR/>Record review of CNA E's personnel file revealed there was not a current EMR/NAR. CNA E's last EMR/NAR check was on 3/17/2023. <BR/>Interview on 4/26/2024 at 12:33 PM the Administrator stated she would search for the EMR/NAR for CNA E. The Administrator did not provide evidence before exit. ADM stated they did not have HR (Human Resources) staff in the building. ADM searched and provided the information for licensure. ADM stated she was not able find CAN E's EMR/NAR. <BR/>Record review of policy Abuse, Neglect and Exploitation Program, dated April 2021 revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident' s symptoms. 4.Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1 of 24 (Resident #66) residents was treated with dignity during dining room observation.<BR/>On 06/10/2025 at 12:45 pm, the Activity Director stood over Resident #66 when she fed her lunch.<BR/>This failure could affect all residents in the facility and could result in low self-esteem.<BR/>The findings included:<BR/>Record review of Resident #66's electronic face sheet dated 06/10/2025 revealed an original admission date of 03/09/2024 and readmission date of 02/05/2025. Resident #66 was a [AGE] year-old female and her diagnoses included: Alzheimer's disease (a brain disorder that destroys memory and thinking skills), dementia (loss of cognitive functioning that interferes with ADLs), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities), anxiety (a feeling of worry, nervousness, or unease), and dysphagia (swallowing disorder).<BR/>Record review of Resident #66's comprehensive care plan revised date 02/20/2025 reflected Problem, resident has an ADL self-care performance deficit r/t dementia. Interventions, EATING: Resident is now fed by staff. <BR/>Record review of Resident #66's quarterly MDS assessment dated [DATE] reflected Resident #66 could rarely/never understand and could rarely/never be understood. She was not a candidate for a BIMS which indicated she was severely cognitively impaired. She was dependent on staff for her ADLs.<BR/>During an observation on 06/10/2025 at 12:45 pm, Resident #66 was observed being fed by the Activity Director. The Activity Director stood over Resident #66 who was constantly trying to grab the food tray. <BR/>During an interview on 06/10/2025 at 12:50 pm, the Activity Director stated she realized after a few bites of food were given to Resident #66, she needed to sit down to feed the resident. The Activity Director stated the importance of sitting at the level of the resident and to look at Resident #66 was more dignified than to stand and look down at her. She stated she was trained to sit while she fed a resident.<BR/>During an interview on 06/11/2025 at 3:00 pm., the DON stated the Activity Director needed to sit while she fed Resident #66. She stated the Activity Director sitting was more dignified than standing over the resident. She stated staff that are trained to assist residents with eating are supposed to sit and be at eye level with the resident.<BR/>During an interview on 06/13/2025 at 08:27 am, ADON B stated everyone who assisted with feeding should be sitting to the resident at eye-to-eye level. She stated it was disrespectful or undignified to stand over someone.<BR/>Record review of the agency's policy titled Resident Rights, revised December 2016, reflected Team members shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. <BR/>1. The facility failed to ensure two trays of prepared and poured glasses of beverages in the refrigerator were dated.<BR/>2. The facility failed to ensure a try with six prepared bowls of cereal in the dry storage were dated.<BR/>These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. <BR/>The findings included: <BR/>During observation 06/10/2025 at 8:53 a.m. the initial tour of the kitchen revealed in the walk-in refrigerator two trays with beverages poured not dated, and in the dry storage a tray with 6 bowls of cereal not dated. <BR/>An interview with DM on 06/10/2025 at 10:27 a.m. revealed all open items being stored in the walk-in refrigerator and in the dry storage are to be labeled with the date prepared and date to use by. DM stated staff preparing to store open or prepared items in the walk-in refrigerator or dry storage are responsible to date items. DM stated by not dating the items the residents were at risk for food born illness. <BR/>An interview with [NAME] on 06/12/2025 at 10:34 a.m. revealed all open items being stored in the kitchen's walk-in refrigerator and in the dry storage were to be labeled with the date opened and the use by date. [NAME] stated all staff are responsible to label items. [NAME] stated if items were not labeled then it would be possible to use old or expired items causing food born illness. <BR/>Record review of the facility's policy named Food Storage dated 2018 revealed Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. and Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on interview and record review, the facility failed to ensure CNA received the required minimum 12 hours annual in-service 1 of 27 (CNA N) employees reviewed for training requirements was completed. <BR/>The facility failed to provide the required 12 hours of annual training to CNA N. <BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>Findings were:<BR/>Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. <BR/>Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. <BR/>Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. <BR/>A policy required annual training topics including required trainings for CNAs, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review, the facility failed to ensure annual infection control training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. <BR/>The facility failed to ensure infection control training was provided CNA N and LVN O annually. <BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>Findings were:<BR/>Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received infection control training. <BR/>Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual infection control training. <BR/>Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. <BR/>Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. <BR/>A policy required annual training topics, including infection control training, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that each resident receives an accurate assessment for 1 of 9 (#77) that were reviewed in that:<BR/>Resident #77 was discharged on 1/25/2024 and a discharge MDS was not completed. <BR/>This could affect all residents and could result in residents' information not being accurate.<BR/>The Findings:<BR/>Record review of Resident #77's admission Record revealed she was admitted on [DATE], [AGE] year old female, and her diagnoses were Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs.), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), adult failure to thrive, osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), )and osteoarthritis (degenerative joint disease. The record revealed Resident #77 was discharged on 1/25/2024. <BR/>Record review of Resident #77's chart revealed she did not have a discharge MDS. <BR/>Record review of Resident #77's care plan dated 3/11/2023 revealed the resident wished to remain in long term care, no discharge at this time. <BR/>Record review of Resident #77's progress note dated 1/25/2024 reflected Resident # 77 went to hospital due to critical labs and never returned. <BR/>Interview on 4/25/24 at 12:35 PM RN/MDS A stated she had completed Resident #77's last MDS assessments, and she missed the discharge MDS at the time of discharge on [DATE] . MDS stated should be done soon after resident was discharged and SNF knew they would not be back to facility. <BR/>Interview on 4/25/2204 at 2:40 PM LVN B stated Resident #77's had critical labs. She stated Resident #77 was refusing medications. So, Resident #77 was sent to hospital via physician.<BR/>Interview on 4/25/2024 at 3:43 PM MDS C stated she missed the discharge MDS and would mess up the MDS system and resident monitoring.<BR/>Record review of the Discharge Process policy, no date, revealed 5. communicate with staff about the residents' upcoming discharge date and time, d. The following people should be notified of planned discharge, vii MDS nurse.<BR/>Record review of MDS RAI 3.0 was documented 09. Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. o Must be completed within 14 days after the discharge date . o Must be submitted within 14 days after the MDS completion date.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 27 (Cook K, Dietary Aide L, CNA M, CNA N, and LVN O) employees reviewed for training requirements. <BR/>The facility failed to implement and maintain a training program that ensured [NAME] K, Dietary Aide L and CNA M received required trainings upon hire. <BR/>The facility failed to implement and maintain a training program that ensured CNA N and LVN O received required trainings annually. <BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>Findings were:<BR/>Record review of personnel record for [NAME] K revealed hire date of 03/25/2025. Review of training log provided by human resources revealed [NAME] K did not complete required trainings upon hire. <BR/>Record review of personnel record for Dietary Aide L revealed hire date of 04/07/2025. Review of training log provided by human resources revealed Dietary Aide L did not complete required trainings upon hire. <BR/>Record review of personnel record for CNA M revealed hire date of 05/12/2025. Review of training log provided by human resources revealed CNA M did not complete required trainings upon hire. <BR/>Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N completed the required annual trainings. <BR/>Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O completed the required annual trainings. <BR/>Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. <BR/>Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. <BR/>A policy indicating new hire training topics, time frame to complete initial trainings, required annual training topics, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.