DOWNTOWN HEALTH AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #2) of five residents reviewed for abuse. <BR/>The facility failed to prevent Resident #2 from being abused by Resident #1 on the secure unit, who had a history of being verbally and physically aggressive to other residents. Resident #1 physically attacked Resident #2 which resulted in him being sent to the hospital and sustained a serious injury to his right eye on 12/29/24. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/29/24 and ended on 12/29/24. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death. <BR/>Findings included: <BR/>1.<BR/>Record review of Resident #1's face sheet, dated 01/16/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses which included: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skill), unspecified, unsteadiness on feet, cognitive communication deficit, personal history of transient ischemic attack (a short period of symptoms similar to those of a stroke), and cerebral infarction (stroke) without residual deficits and personal history of traumatic brain injury (a head injury causing damage to the brain by external force or mechanism. It causes long term complications or death). <BR/>Record review of Resident #1's quarterly MDS assessment, dated /30/24, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Resident#1 coded behavior for wandered daily. <BR/>Record review of Resident #1's care plan, initiated 06/06/24 and revised 10/25/24, reflected: the resident was at risk for behaviors: [Resident#1] has a potential for maladaptive behaviors .Physical aggression toward others .Verbally aggressive. Interventions included intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Administer medication as ordered. Monitor/document for side effects and effectiveness.<BR/>Record review of Resident#1 progress notes dated 05/09/24 to 01/16/25 reflected, Resident#1 had a history of being physically and verbally aggressive towards staff and residents. Progress notes reflected the incident on 12/29/24 was the first time a resident needed to be sent out to the hospital. <BR/>On 07/04/24, LVN B reported: Resident verbally abusive with other residents calling them idiots and zombies <BR/>On 07/09/24, LVN A reported: Ambulating in hall and stopped to yell at another resident that was confused<BR/>On 7/12/24, LVN B reported: Resident yelling at other residents calling them idiots and stupid this nurse reminded resident that he needs to respect the other residents<BR/>On 07/19/24, LVN B reported Resident yelling at another resident calling him a retard zombie resident redirected, resident walked away.<BR/>On 08/12/24 LVN B reported Resident mocking other residents CNA explained to resident that he needed to stop that behavior . Resident yelling at resident from room [Resident#1] states I will kick his ass if he comes to my room .<BR/>On 08/14/24, SSD reported SSD submitted referral to [Psy MD] for psych consult.<BR/>On 08/20/24 LVN B reported On Gabapentin 300 for aggressive behavior, resident yelling at residents at dining room table.<BR/>On 09/02/24, LVN B reported Resident verbally abusive with other residents<BR/>On 09/04/24, SSD reported IDT team care plan carried out by [DON, DOR, ADON], . Family seeking possible admission to all male unit, wanting to stay localized, per family request . Referral sent to [Facility] per family request.<BR/>On 10/20/24, LVN A reported [Resident#1] was observed unbuttoning and unzipping his jeans. He pulled his penis out and urinated on the floor. When ask to stop and go to his room he started yelling at staff. He was informed by this nurse . rest room. he was informed besides exposing himself to non-employees that it created a danger to residents staff.<BR/>On 10/23/24, P Admin reported Resident observed displaying agitating and aggressive behavior towards staff and other residents.<BR/>On 12/26/24, reported by LVN A [Resident#1] behaviors is getting worse and he is getting more aggressive both physically and verbally.<BR/>Record review of Resident #1's progress notes and incident report in the EHR, dated 12/29/24 by LVN C , reflected: Nursing description: This nurse called to hallway when heard hollering and yelling, resident as on floor bleeding, when I approach him, he said he was ???? [sic]unable to comprehend, Full body assessment laceration on his head and eye area. Called 911 and police and advised admin and other in group text also called them, contacted [Family member], left message to call. Police came [PD #] to get report, and info. then EMS came and evaluated and took to [Hospital]. [Resident#1] stated he did nothing, the whole incident was witnessed by Housekeeping, had her write out a statement. Description of action taken: Immediately look to see where blood was coming from head and right eye.<BR/>Record review of LA A's handwritten statement dated 12/31/24 reflected: To whom it may concern [LA A] was present when [Resident#1] was yelling down the hall he assaulted me. As [LA A] was putting linens in the closet on the unit. [LA A] looked down the hall and saw [Resident#1] push [Resident#2] down causing him to bleed. [LA A] yelled out for the nurse and she assisted [Resident#2]. Resident 21 was transported to hospital.<BR/>Record review of police report, dated 12/29/24, reflected: injured persons report by [Resident#1] to [Resident#2].<BR/>Record review of Psy consults reflected:<BR/>Record review of Psy consult, dated 10/28/24 reflected, Resident#1 increase Gabapentin for aggressive behavior. Continue Lexapro for depression. 10 mg, &frac12; tablet PO QD. Increase Neurontin 300 mg PO BID. <BR/>Record review of Psy consult, dated 12/09/24 reflected Resident#1 started Depakote 250 mg, BID. <BR/>Record review of Resident#1 January MAR reflected Resident#1 had received medication as ordered:<BR/>Aricept Tablet 10 MG (Donepezil HCl) Give 1 tablet by mouth one time a day for Dementia.<BR/>Depakote Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for Seizures and Aggressive Behaviors related to other seizures. <BR/>Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for Aggressive behavior.<BR/>2.<BR/>Record review of Resident #2's face sheet, dated 01/17/25, reflected an [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, muscle weakness (generalized), cognitive communication deficit, personal history of transient ischemic attack (a short period of symptoms similar to those of a stroke), and cerebral infarction (stroke) without residual deficits. <BR/>Record review of Resident #2's quarterly MDS assessment, dated 12/30/24, reflected his BIMS score was 04, which indicated severe cognitive impairment. Resident#2 coded behavior for wandered daily. <BR/>Record review of Resident #2's care plan, revised 9/30/24, reflected Resident#2 had behavior problem r/t dementia. Physical aggression towards other. Interventions included: Administer medications as ordered. Monitor/document for side effects. <BR/>Record review of Resident#2's hospital records dated 12/29/24 reflected: Resident#2 had right forehead with small laceration, large medial lower lid laceration. Lower puncta was displaced for temporally, past the midpoint of cornea. Resident#2 had to have right lower eyelid canalicular repair, repair of laceration on 01/02/25.<BR/>Record review of Resident #2's December 2024 progress notes reflected:<BR/>On 12/29/24, LVN C reported [Resident #2] Full body assessment laceration on his head and eye area. Called 911 . PD Incident report [number].<BR/>On 12/30/24, LVN C reported [Resident#2] returned from [Hospital] Resident has sutures to right eye and head from his injuries on 12/29/24.<BR/>On 01/02/25 resident returned from surgery has instructions for eye care and next 2 appointments this month.<BR/>In an interview on 01/16/25 at 1:21 PM, LVN D stated she worked at the facility for almost 3 weeks. Resident #1 was on Q15 monitoring since the incident on 12/29/24 with Resident#2. LVN D did not see the incident on 12/29/24. LVN D stated she has not witnessed any behaviors since the incident. <BR/>In an interview on 01/16/25 at 1:25 PM, CNA E stated she has worked in the facility for 3 months and Resident #1 had been verbally and physically aggressive toward residents and staff. CNA E did not witness the incident on 12/29/24. Resident#1 has been verbally aggressive and physically aggressive towards staff and verbal aggressive to residents CNA E stated she would redirect residents and the nurse on duty documents the Q15 monitoring. CNA E stated in the secure unit staff had to pay attention and stay alert to care for the residents. <BR/>In an interview on 01/16/25 at 1:45 PM, LA A stated she heard two residents yelling at each other and saw Resident#1 push Resident#2. Resident#2 fell face first and it was a lot of blood. LA A stated she called for help and the nurse came and provided help. LA A stated she had not witnessed more behaviors recently. LA A stated she would yell for help for a nurse when residents were being verbally/physically aggressive to each other.<BR/>Attempted to call LVN C on 01/17/25 at 5:40 PM and voicemail box was full.<BR/>Attempted to call LVN B on 01/17/25 at 5:42 PM and left voicemail.<BR/>Attempted to call LVN A on 01/17/25 at 5:45 PM and left voicemail.<BR/>Record review of the facility's policy titled Abuse/Neglect, revised 03/2018, reflected in part the following: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, Definitions . Abuse is the willful infliction of injury . Willful, as used in this definition of abuse, means the individual must have acted deliberately . C. Prevention The facility will provide the residents, families, and staff an environment free from abuse and neglect.<BR/>The non-compliance was identified as past non-compliance (PNC). The IJ began on 12/29/24 and ended on 12/29/24. The facility had corrected the non-compliance before the state's investigation began. On 02/11/25 at 1:00 PM the Administrator, DON and Corporate Nurse were notified of the PNC IJ. <BR/>The facility took the following actions to correct the non-compliance prior to the survey:<BR/>Record review of incident/accident reports, from 12/19/24 to 02/11/25, reflected no other incidents involved Resident#1. <BR/>Record review of in-service dated 12/29/24, reflected behavior management by DON to all staff members. <BR/>Record review of Q15 monitoring dated 12/29/24 to 01/07/25, by LVN C and LVN D showed Resident#1 was checked on every 15 minutes and no behaviors were documented. <BR/>Record review of order recap report dated 01/30/25 reflected, Depakote oral tablet delayed release 500mg (Divalproex Sodium) Give 1 tablet by mouth two times a day for Seizures and Aggressive Behaviors related to other seizures was increased by PCP.<BR/>In an interview on 01/16/25 at 3:00 PM the Administrator and the DON stated the Administrator had worked in the facility since 12/29/24 and the DON had worked in the facility since 12/20/24. The and the DON stated Resident#1 had no aggressive behaviors since they started at the facility. The Administrator stated they were looking for placement for Resident#1. <BR/>In an interview on 01/17/25 at 5:15 PM the Corporate Nurse and Administrator stated the facility had been searching for placement for Resident#1 and he has been denied placement because of his behaviors. The Corporate Nurse stated Resident#1 has not had behaviors since his Depakote has been increased. The corporate Nurse and Administrator stated Resident#1 was no longer on Q15 and he had no behaviors since the incident on 12/29/24. The corporate Nurse and Administrator stated Resident#1 was to be redirected when he displayed aggressive behavior, Resident#1 medications had been adjusted and Resident#1 was on Q15 monitoring for 72 hours.<BR/>In an interview on 01/20/25 at 12:15 PM LVN D stated Resident#1 had not had any behaviors in the past month. Resident#2 was able to see out of his eye and has not wanted to come out of his room today.<BR/>An observation on 1/16/25 at 1:30 PM both Resident#1 and Resident#2 were in their rooms asleep. <BR/> Observation of the secure unit on 01/20/25 from 12:15 PM to 1:45 PM revealed:<BR/>An attempted interview and observation on 01/30/25 at 12:30 PM, Resident#1 did not recall any incidents with the other resident. Resident#1 ate lunch and talked about his college. <BR/>An observation on 01/30/25 at 1:15 PM revealed Resident#2 was in the bed asleep. <BR/>An interview on 01/30/25 at 4:00 PM the Administrator stated Resident#1 had no behaviors since the incident and the facility was looking for placement for him and he was not accepted. <BR/>In an observation on 02/11/25 in the secure unit from 5:30 AM to 9:00 AM revealed:<BR/>In an observation on 02/11/25 at 5:40 AM revealed Resident#1 was no longer in the facility.<BR/>In an observation on 02/11/25 at 6:30 AM revealed Resident#2 was awake in his wheelchair. <BR/>Attempted to interview Resident#2 on 02/11/25 at 7:00 AM and he did not respond back. <BR/>Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM with LA A, LVN C, LVN D, LVN F, CNA E (1st and 2nd shift) staff were able to provide competency regarding in-service over ANE and behavior management. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE and how to care for resident with physical and verbal aggressions. <BR/>An interview on 02/11/25 at 5:45 AM to 9:30 AM with LVN B (overnight shift) and SC G, AD H, DON And Administrator (1shift) staff were able to provide competency regarding in-service over ANE and behavior management. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE and how to care for resident with physical and verbal aggressions. <BR/>In an interview on 02/11/25 at 7:00 AM the Administrator stated Resident#1 was transported to the new facility on 02/10/25. <BR/>Record review of Resident#2 follow-up appointment on 01/14/25 reflected: right eyelid laceration was healing well, no drainage. Continue current care, no change in current therapies. Forehead laceration was healed and no further treatment needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 4 residents (Residents #1 and Resident #2) reviewed for abuse.<BR/>The facility failed to report a resident-to-resident altercation that occurred on 02/18/24 between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of being notified.<BR/>This failure could place residents at risk for abuse. <BR/>Findings include:<BR/>Resident #1<BR/>A record review of Resident #1's electronic face sheet, dated 02/21/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses which included dementia , abnormalities of gait (a change to your walking pattern) and mobility, and muscle weakness. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was able to complete a BIMS assessment and had a BIMS score of 0, which indicated his cognition was severely impaired. <BR/>A record review of Resident #1's Care Plan, revised 12/21/23, reflected Resident #1 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included Administer meds as ordered, Communicate with the resident/family/caregivers regarding residents capabilities and needs encourage therapeutic conversation as able. The Care Plan reflected Resident #1 had the potential to demonstrate physical behaviors. The interventions included . Communication provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately .Monitor/document/report to MD of danger to self and others . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. <BR/>Resident #2<BR/>A record review of Resident #2's electronic face sheet, dated 02/21/24, reflected Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective disorder bipolar type (experience psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - bipolar type (episodes of mania and sometimes depression)), psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), abnormalities of gait (a change to your walking pattern) and mobility, and altered mental status. <BR/>A record review of Resident #2's Optional State Assessment MDS, dated [DATE], reflected Resident #2 was able to complete a BIMS assessment and had a BIMS score of 3, which indicated his cognition was severely impaired. <BR/>A record review of Resident #2's Care Plan, revised 12/22/23, reflected Resident #2 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included . Communication: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV , radio, close door etc . The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. The Care Plan reflected Resident #2 had a potential to demonstrate physical/verbal behaviors due to poor impulse control and adjusting to facility. The interventions included Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . Notify the charge nurse of any physically abusive behaviors . Re-educate staff on redirection of aggressor, Relocate other residents as needed to prevent re-altercations.<BR/>A record review of the facility documents titled Even Nurses' Note- Behavior, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #1 had a resident-to-resident altercation in the dining room. The document indicated there were no injuries to Resident #1 when he was assessed, yet the document reflected LVN A notified the facility MD and Resident #1's family on 02/18/24 at 2:30 PM. <BR/>A record review of the facility documents titled Behavior Nurses Note 8 hr, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #2 had an argument with another resident and there were no changes to Resident #2 that required physician notification.<BR/>In an interview on 02/20/24 at 1:54 PM, LVN A stated she was PRN at the facility and worked on Sunday 02/18/24 in the MC unit. LVN A stated Resident #1 and Resident #2 got into an argument and fight. She stated she did not witness the incident. LVN A stated she was called to the dining room by a CNA (did not recall her name). She stated the CNA told her Resident #1 and Resident #2 were arguing and fighting and she had just broken them up. LVN A stated the CNA said the residents were fighting because one resident said the other stole from him. LVN A stated Resident #1 had a scratch above his eye and Resident #2 had no injuries. LVN A stated she assessed Resident #1's eye and contacted the MD and residents' family. LVN A stated the MD did not give her any new orders. She stated she notified the DON and the Administrator. LVN A stated the Administrator told her because she did not witness the incident, to hold off on doing the incident report, because she wanted to do an investigation. LVN A stated she did not complete the incident report and did not know if the Administrator completed the report. <BR/>In a phone interview on 02/21/24 at 10:28 AM, CNA B stated she worked in the MC unit on 02/18/24 from 6AM to 2PM. CNA B stated there was a verbal altercation between Resident #1 and Resident #2. She stated Resident #2 accused Resident #1 of stealing his truck, so they started arguing. CNA B stated she split the residents up and got them to calm down. She stated later when the residents were going outside to smoke, Resident #2 bumped Resident #1, but Resident #1 did not fall nor was he injured. CNA B stated she never witnessed a physical altercation between the residents on her shift. She stated she worked the following day on 02/19/24 and saw the scratch on Resident #1's eye. CNA B stated the scratch was not on Resident #1's eye on 02/18/24. CNA B stated she did not ask what happened to his eye nor did anyone tell her how he got the scratch. She stated she did not know if something happened after her shift ended at 2:00 PM . <BR/>An observation and interview on 02/21/24 at 11:03 AM revealed Resident #1 had a scratch approximately 1 inch in length, above his right eye. When Resident #1 was asked how he got the scratch on his eye, he appeared confused and said he did not know. Resident #1 was asked if he had gotten into any arguments or fights in the facility, he said no and he could not remember. <BR/>In an interview on 02/21/24 at 11:06 AM, Resident #2 stated he did not believe he hit anyone at the facility, but he sometimes could not remember things. He stated he did not get into any fights or arguments with other residents because he liked everyone at the facility. <BR/>In a phone interview on 02/21/24 at 12:16 PM, CNA C stated she worked on 02/18/24 and was scheduled for the 2-10 PM shift. CNA C stated she arrived to work late about 3/3:30 PM and things seemed crazy. She stated one of the residents told her Resident #1 and Resident #2 had a fight, but the resident often got confused so she did not know if it was true. CNA C stated she worked with CNA D and LVN A and neither of them mentioned there was an altercation between Resident #1 and Resident #2. CNA C stated she did see LVN A looking at Resident #1's eye and she took a picture of it. She stated she did see the scratch above Resident #1's eye. CNA C stated the scratch was not bleeding but it looked like a fresh scratch. CNA C stated she did not ask CNA D or LVN A how Resident #1 received the scratch .<BR/>In an interview on 02/21/24 at 12:26 PM, the Administrator stated LVN A called her on 02/18/24 and said she was called into the dining room by an aide because there was an argument between Resident #1 and Resident #2. The Administrator stated LVN A said the altercation happened during shift change and she did not witness the incident. The Administrator stated because LVN A did not witness the incident, she told her to hold off on completing an incident report because she wanted to investigate the situation. She stated she told her to make an event note in PCC. She stated she contacted CNA B, who was working 6-2PM. She stated CNA B told her she was in the dining room when Resident #1 and Resident #2 were arguing about a truck. She stated CNA B told her that nothing was physical, and they were only arguing, which she split them up. The Administrator stated LVN A and CNA B did not report to her that Resident #1 had a scratch above his eye. She stated she did not ask LVN A if she assessed the resident for any injuries. The Administrator stated she did observe the scratch above Resident #1's eye today. She stated she did not complete a report to the state because she was told it did not get physical and was only a verbal altercation. The Administrator stated she did investigate the situation by talking to all the staff who worked on Sunday and everyone she spoke to stated they did not witness anything physical. She stated she did not have any documentation of the investigation.<BR/>In a follow up interview on 02/21/24 at 1:23 PM, LVN A stated she did notify the Administrator that even though she did not witness the incident, she believed there was a physical altercation because Resident #1 had a scratch above his eye. She stated she did not know why the Administrator would say she did not notify her of the scratch above Resident #1's eye. She stated she told the Administrator she contacted the MD about the scratch on Resident #1's eye. LVN A stated she had the text message feed that she contacted the MD and would provide it.<BR/>A record review of LVN A's text feed reflected on Sunday (02/18/24) at 2:18 LVN A texted the MD and stated the following Good afternoon [Resident #1] and [Resident #2] got into a physical altercation. [Resident #2] being the aggressor. [Resident #1] has a laceration to his top left eye otherwise no c/o pain. The text revealed the MD responded Ok; does it need steri [stupa] . strips. LVN A responded to the MD with the following No Strips needed. They are both [are] up and ambulating throughout the unit. Will keep them separated and monitored. <BR/>In a phone interview on 02/21/24 at 1:54 PM, CNA D stated there was a physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch above his eye. CNA D stated she did not witness the incident. She stated she the worked 2-10 PM shift on 02/18/24. CNA D stated she heard screaming coming from the dining area and headed that way. She stated the altercation happened during the shift change, so everything was out of order. CNA D stated when she entered the dining room, CNA B and LVN A were in there and had broken them apart. CNA D stated Resident #1 had a scratch above his eye and the area looked a bit red. She stated she did see LVN A assessing and treating the scratch .<BR/>In a confidential interview, the facility staff member stated they were aware of the physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch on his eye because the facility had a group chat and LVN A notified everyone via the group chat. The facility staff member read the text message aloud, which said Resident #1 had a scratch above his eye. The facility staff member stated the Administrator was included on the facility's group chat. <BR/>A record review of the facility's policy titled Abuse/Neglect, dated 03/29/18, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse . E. Reporting: 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 . a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation . Resident to Resident: The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.

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 1 (medication cart) of 1 medication cart on the memory care unit reviewed for pharmacy services<BR/>The facility failed to ensure discontinued medication were removed from the medication cart. Resident #1's Diazepam that was DC on 12/30/24 was in the narcotic box on the secure unit medication cart.<BR/>This failure could place residents at risk of unnecessary medication error and/or lead to possible harm or drug diversion.<BR/>The findings included:<BR/>Interview on 5/13/25 at 9:50 PM LVN A stated when medications were wasted, they should be crushed and disposed of and two people, 2 nurses, were to sign off on the narcotics sheet and document medication was wasted. <BR/>Observation and record review on 05/13/25 at 11:00 PM revealed a secure unit narcotic sheet that was not filled out completely for Resident #1's Diazepam 5 mg tablet. Review of Resident#1's Diazepam 5mg narcotic sheet reflected the 10th pill was given with no date and no signature. Further review revealed the 9th pill was removed on 4/11 /25and on 5/4/25 the 8th pill was marked off as wasted. Observation of Resident #1's Diazepam 5 mg package reflected the medication was still in the bubble pack for the 8th tablet. Observation of the Diazepam bubble package revealed medication was filled on 11/12/24. Review of the Diazepam narcotic sheet revealed the Diazepam was put on the medication cart on 11/14/25. <BR/>Record review of Resident #1's order summary revealed to give 1 tablet Diazepam by mouth every 6 hours as needed and not to exceed 3 daily until 12/30/24 for anxiety.<BR/>Record review of Resident#1's November MAR reflected Diazepam was administered on 4/11/24.<BR/>Record review of Resident #1's March 2025 MAR reflected Diazepam was not a listed medication. <BR/>Interview on 05/13/25 at 11:00 PM LVN A stated Resident#1's Diazepam was DC and the DON was responsible for coming to pick up the DC medication from the medication cart. LVN A stated when medication was wasted two nursing staff would sign off on the medication. LVN A stated narcotics were crushed and put in water.<BR/>Interview on 05/14/25 at 12:15 PM the DON stated she had not been informed of staff taking narcotic medications for personal use off the medication cart. <BR/>Interview and observation on 5/14/25 at 1:43 PM the DON stated Resident #1's 5mg Diazepam was DC on 12/30/24. She stated that DC medication needed to be brought to her as soon as possible. The DON stated that nurses was responsible for taking DC medications off the medication cart. The DON stated the pharmacy comes every other month to destroy medications. The DON stated residents are at risk of being given medications that are no longer needed. The DON stated when medications are wasted two nursing staff members are supposed to sign off. Observed the CN leave out of the DON, and she went to pull the DC medication off the secure unit cart. The CN stated the nurse must have written the number backwards instead of 04/11/24 it should have been 11/04/24. <BR/>Record review of the facility policy titled, Medication Administration Procedures revealed, 3. Open the unit dose package only when you are administering medication directly to the resident.<BR/>Record review of the policy titled Controlled Medication Disposal, undated, revealed, 3. Schedule II, III, IV and V medications remaining in the facility after the resident has been discharged , or the order<BR/>discontinued, are disposed either in the facility by legally authorized personnel, Director of Nursing, and Consultant Pharmacist .<BR/>Record review of the facility policy titled, Discontinued Medications, undated, reflected : Policy .When medications are discontinued by physician order, . the medications are marked appropriately and destroyed .Procedure 1. If a physician discontinues a medication .the medication container is marked the date discontinuance is indicated along with the initials of the nurse. 2. Medications awaiting disposal are stored in a locked secure area designated for that purpose until disposed of medications are removed from the medication cart immediately upon receipt of an order to discontinue avoiding inadvertent administration. 3. Discontinued medications are destroyed in accordance with destruction policy and procedure .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. <BR/>1. The facility failed to address Resident #1's multiple refusals of care and services on the comprehensive care plan<BR/>This failure could place residents at risk of not receiving the necessary care and services. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an admission date of 07/11/24. Resident #1 had diagnoses of Multiple Sclerosis (chronic disease that affects the brain and spinal cord), Cognitive Communication Deficit (communication difficulty), and History of Transient Ischemic Attack (brief interruption of blood flow to the brain). The face sheet noted a discharge date of 09/17/24. <BR/>Record review of Resident #1's Admitting MDS Assessment, dated 07/17/24, reflected Resident #1 had a BIMS score of 11, which meant Resident #1 had a moderate level of cognition. The MDS noted the resident did not exhibit any behaviors. <BR/>Record review of Resident #1's care plan with an initial date of 07/12/24, reflected no interventions for Resident #1's multiple refusals of wound care, perineal care, medication administration, or showers. <BR/>Record review of the progress notes on Resident #1's electronic record, dated, 05/08/25, reflected the following:<BR/>07/19/24 15:36 (3:36 PM)- Resident #1 refused wound debridement after multiple attempts, application of Nystatin Powder (antifungal medication for skin infections), application of Hydrocortisone External Cream (medication used to treat skin conditions) for wound care<BR/>07/23/24 at 16:17 (4:17 PM)- Resident #1 refused the application of Nystatin Powder for wound care<BR/>07/24/24 at 12:20 PM- Resident #1 refused the application of Hydrocortisone External Cream<BR/>08/01/24 at 9:38 AM- Resident #1 refused Pro-Stat AWC (protein drink for wound healing) 3 times<BR/>08/02/24 at 8:31 AM- Resident #1 refused Pro-Stat AWC 3 times<BR/>08/09/24 21:47 (9:47 PM)- Resident #1 refused a blood sugar check<BR/>08/10/24 at 8:37 AM- Resident #1 refused the application of Nystatin Powder and Hydrocortisone External Cream for wound care, cleansing of wound, and dressing change<BR/>08/10/24 at 8:45 AM- Resident #1 refused a shower<BR/>08/10/24 at 13:21 (1:21 PM)- Resident #1 refused a blood sugar check<BR/>In an interview on 05/08/25 at 2:30 PM, the DON stated she did not work at the facility when Resident #1 was living there. She stated the refusals should have been addressed and interventions should have been in place to encourage Resident #1 not to refuse care. The DON stated the risk of refusals not addressed was a possible decline in health. <BR/>In an interview on 05/08/25 at 2:40 PM, the Administrator stated she was not working at the facility last year when Resident #1 lived there. She stated the refusals should have been addressed so staff would know how to best assist the resident. She stated the risk would have been Resident #1 not receiving the services she needed. <BR/>Record review of the facility's undated policy, titled, Comprehensive Care Planning, reflected the following:<BR/>The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -<BR/>o <BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and<BR/>o <BR/>the right to refuse treatment<BR/>Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.<BR/>The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.<BR/>In situations where a resident's choice to decline care or treatment (e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempts to find alternative means to address the identified risk/need should be documented in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of four residents reviewed for medications.<BR/>1. Resident #1's Lisinopril and Metoprolol (medications used to lower blood pressure) were not held per physician's order on 07/13/25, 07/21/25, 07/23/24, and 07/25/24 when the resident's blood pressure was below parameters. <BR/>These failures could place residents at risk of not receiving their medications as ordered or possible illness. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an admission date of 07/11/24. Resident #1 had a diagnoses of Multiple Sclerosis (chronic disease that affects the brain and spinal cord), Cognitive Communication Deficit (communication difficulty), Essential Hypertension (high blood pressure), and History of Transient Ischemic Attack (brief interruption of blood flow to the brain). The face sheet noted a discharge date of 09/17/24. <BR/>Record review of the active physician's order dated 07/11/24, reflected the following: <BR/>Lisinopril Tablet 2.5 MG give one tablet one time a day by mouth for hypertension hold for SBP &lt;110, DBP &lt;60, HR &lt;60<BR/>Metoprolol Succinate ER Oral Tablet 50 MG Give one tablet by mouth one time a day for HTN hold for SBP &lt;110, DBP &lt;60, HR &lt;60<BR/>Record review of Resident #1's Medication Administration Record dated July 2024 reflected that Lisinopril and Metoprolol were both given by RN A on 07/13/24 when Resident #1's SBP was 106, outside of the ordered perimeters. RN A also administered both medications outside of the ordered perimeters to Resident #1 on 07/21/24 when Resident #1's SBP was 104 and DBP was 59. Both medications on both days were marked as given. <BR/>Record review of Resident #1's July 2024 Medication Administation Record reflected on 07/23/24 and 07/25/24 LVN B administered both medications outside of the ordered perimeters when Resident #1's SBP was 98. Both medications on both days were marked as given. <BR/>Record review of the progress notes on Resident #1's electronic record reflected no documented adverse effects. <BR/>Record review of the Employee roster reflected RN A and LVN B no longer worked at the facility. <BR/>In an interview on 05/08/25 at 2:30 PM, the DON stated she was not working at the facility at the time Resident #1 lived there. She stated the two medications should have not been given outside of the perimeters. She stated all physician orders should be followed. The DON stated the risk of not following the physician orders and giving the medications outside of the perimeters was a sentinel event or hypotension (low blood pressure). <BR/>In an interview on 05/08/25 at 2:40 PM, the Administrator stated all physician orders should be followed and the risk of not following orders was adverse effects. <BR/>Record review of the facility's policy titled, Medication Administration Policies, dated 10/25/15, reflected the following: <BR/>13. <BR/>When ordered or indicated, Include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber.<BR/>20. The 10 rights of medication should always be adhered to<BR/>1. Right patient<BR/>2. Right medication<BR/>3. Right dose<BR/>4. Right route<BR/>5. Right time<BR/>6. Right patient education<BR/>7. Right documentation<BR/>8. Right to refuse<BR/>9. Right assessment<BR/>10. Right evaluation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #1) of two residents reviewed for nutrition.<BR/>The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 experiencing a 25.96% weight loss in 4 months. She had an active decline in her weight from 01/08/25 - 04/15/25.<BR/>This failure could place residents at risk for decreased nutritional status, decline in health, malnutrition, or hospitalization.<BR/>Findings included:<BR/>Review of Resident #1's admission record reflected she was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses including protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), diabetes mellitus (a group of metabolic diseases characterized by high blood sugar levels), dependence on renal dialysis (when a person's kidneys are no longer functioning properly and they rely on dialysis to filter their blood and remove waste products), end stage renal disease (a medical condition where the kidneys have permanently lost the ability to function adequately), and Parkinson's Disease (a progressive neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and slowness of movement) .<BR/>Review of Resident #1's quarterly MDS assessment, dated 03/30/25, reflected a BIMS score of 15, indicating no cognitive impairment. Section GG (Functional Abilities) reflected she required Setup or clean-up assistance with eating. Section K (Swallowing/Nutritional Status) reflected she was on Mechanically altered diet. Section K0300 (Weight Loss) reflected that she had weight loss, but she was not on physician- prescribed weight-loss program.<BR/>Review of Resident #1's quarterly care plan revised 03/30/25 reflected that Resident#1 has a diet order other than regular and was at risk for unplanned weight loss or gain. The interventions included: Determine food preferences and provide within dietary limitations. Encourage meal completion and document amount consumed. Monitor weight per facility protocol. Offer sub, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%. Praise resident for eating well. RD assess per facility protocol. Serve diet and snacks as ordered. Speech Therapy to eval and treat per Physicians orders as condition warrants. The resident has a no salt on tray diet.<BR/> Review of Resident #1's weights reflected an active decline in her weight from 01/08/25 - 4/15/25. Her weight on 01/08/25 reflected 195.00 pounds and a weight of 169.40 pounds on 04/15/25. <BR/>Review of Resident #1's Nutrition Assessment, dated 01/16/2025 and documented by the RD, reflected the following: Height:63.0, Weight: 195.0. Diet Renal Texture Order was Regular, and that Residents#1 Food Intake was 50-75%.<BR/>Review of Resident #1's Nutrition assessment dated [DATE] and documented by the RD, reflected the following: During that visit, the dietician noted Resident #1 had a significant weight loss of 9.7% (18.8 lbs.) over the past month. The only recommendation made at that time was for Resident #1's diet order be changed from a renal mechanical soft diet to a regular mechanical soft diet.<BR/>Review of Resident #1's meal intake documentation reflected that the resident refused 6 meal trays. She refused dinner on the following dates: 4/5/2025, 4/7/2025, 4/9/2025, 4/22/2025, 4/27/2025, and lunch on 5/1/2025.<BR/>Review of the list of residents on the red cup program (a program in which residents received a red cup at meals to alert staff that they were at risk for weight loss/malnutrition) did not include Resident #1.<BR/>During an interview on 05/04/25 at 11:45 AM with Resident #1 revealed that she goes to dialysis Monday Wednesday and Friday. She stated that she has lost weight in the last few months because she did not like the food, especially ground up meat or the mashed food. She stated that the alternative meal was a sandwich which she did not like because the meat was salty. She stated that she liked the chicken pot pie whenever they served it. <BR/>During an interview on 05/04/2025 at 12:07 PM with the DM revealed that the dietitian was responsible for monitoring residents weight loss, dietary recommendations, and also which residents needed to be on the Red Cup program . The program alerts staff to pay attention to the resident on the program monitor their intake. She stated that if a resident were placed on the red cup program the charge nurse would send a communication slip to dietary. She stated that since she started working at the facility in March no residents had been added to the red cup program. She stated that the dietitian monitors weight loss every other week.<BR/>During an observation on 05/04/2025 at 12:35pmResident#1 only ate her desert and stated that she did not like the ground chicken that was served at lunch. Resident#1 declined offer for alternative food from CNA A. <BR/>During an interview 05/04/25 at 12:45 PM with the Dietician , she stated she was aware of Resident #1's weight loss. She stated she had noted discrepancies with the facility's weights in the past, so she was not sure if Resident #1's weights were actually accurate. She stated she felt as though the facility should be monitoring and recording post-dialysis weights for consistency purposes. She stated she was not sure if she had made that recommendation to the facility, and she stated she did not review dialysis communication logs (which documented weights taken at the dialysis facility) when assessing residents for further recommendations. She stated Resident #1 could definitely be put on a supplement and/or increased weights for additional weight support. She stated she does not necessarily monitor the facility's Red Cup program; she was not sure who monitored this program. <BR/>During an interview on 05/04/25 at 1:25pm with the Director of Nursing (employed by the facility for approximately 4 months), she stated she was aware of Resident #1's weight loss, as she was the individual who entered weights into the electronic charting system. She stated although she knew of Resident #1's weight loss, she did not realize how significant the issue of severe weight loss could be until she completed her DON training this past week. She stated she felt as though Resident #1 should have weekly weights as well as supplements for appetite stimulation/extra nutrition. She also stated Resident #1 should have been placed on the facility's Red Cup program. The Director of Nursing stated she had left weight monitoring and intervention plans up to the dietician.<BR/>During an interview on 05/04/2025 at 2:00pm with a CNA A who was assigned to Resident #1's care, she stated she could tell that Resident #1 had lost weight because during ADL care, Resident #1 felt much lighter. CNA stated that the resident requires set up for meals but can feed herself. She also stated Resident#1 was not on the red cup program and that staff was required to pay extra attention to resident on the Red Cup program.<BR/>During an interview on 5/04/2025 at 3:21 with LVN B assigned residents care revealed that she did not work on the 300 hall usually and was not familiar with her weight loss or meal intake. She stated that the charge nurses monitored the dialysis communication sheets and reported any concerns to the MD and administration.<BR/>During an interview on 05/04/2025 at 2.06pm with the MD revealed that Resident #1 had abdominal surgery hemicolectomy where she had removed part of her colon . The MD stated that Resident#1's weight loss started after the abdominal surgery, and she has had a lot of Gastrointestinal issues. The MD stated that some of the weight loss was good because she was over 200 pounds so losing some weight was beneficial if the resident was still eating. He stated that the facility continued to monitor Resident#1's weight monthly. The MD stated that the resident had complained of acid reflux, and she was started on Protonix to help with reflux . He stated that the resident had also complained of the food, and the facility had tried to adjust her diet to what she could tolerate and was seen by speech therapy who recommended mechanical soft diet. The MD stated that because the resident was on dialysis the only supplement, she could take was Nepro however she has not shown signs of malnourishment and was taking renal vite tabs for dialysis supplement. <BR/>Review of the facility's Red Glass/Red Napkin and Fortified Food Program reflected :<BR/>These programs are a way for residents with unintended weight loss to receive increased nutrients as soon as the weight loss is identified, and for facility staff to be aware of residents increased nutritional needs and to provide encouragement to complete their meal.<BR/>Procedure:<BR/>1. <BR/>Nursing is to supply dietary on a weekly basis with an updated list of residents with unfavorable weight loss who may need additional supplements and additional encouragement to complete their meals. This list may be generated in the weekly weight meeting.<BR/>2. <BR/>Residents on enteral feedings with unfavorable weight changes will be re-evaluated for protein, calorie and vitamin/mineral needs with adjustments recommended as needed by the registered dietitian.<BR/>6. <BR/>Nutrition intervention may be needed for residents with weight loss. <BR/>If warranted, a red napkin or red glass will be used on the resident's meal tray to alert the dietary and nursing staff to pay close attention to the resident's food/fluid intake and to encourage the resident to eat and drink as much as possible. <BR/>Review of the Facility' Resident Weight policy reflected that the following assessments and Recognition:<BR/>Nursing Policy & Procedure Manual 2003 Revised: February 13, 2007<BR/>All residents will be weighed by the 10th of the month and their weights documented correctly. The appropriate actions regarding significant changes will be carried out.<BR/>Procedure:<BR/>1. Weights shall be obtained and documented at admission, readmission, and monthly unless ordered otherwise by the physician, or unless dictated more frequently by the resident's condition. Factors indicating the need for more frequent weights include significant weight loss, drastic decrease in food consumption, prolonged nausea, vomiting, or diarrhea, significant weight gain, swelling or edema, poor appetite during adjustment period to the facility, recent change from tube feeding to oral intake, or pressure ulcers that are not resolving as expected.<BR/>The Dietary Profile will be completed upon admission and quarterly thereafter by the dietary manager. The Nutrition Risk Assessment form will be completed by the Registered Dietitian upon admission, annually, and updated if the resident has a significant change. The RD and dietary manager will also chart in the dietary Progress Notes as needed regarding visits, nutritional issues, updates to food preferences, etc.<BR/>4. All residents must be weighed as indicated, unless otherwise ordered by the attending physician. Pre-medicate resident for pain or discomfort, as per physician's orders, as needed prior to weighting.<BR/>5. Monitor fluid intake and output because body weight may increase as a result of fluid retention.<BR/>6<BR/>7. Significant Weight Loss<BR/>The facility review resident weights after monthly weights are obtained, to determine residents with significant weight changes. A significant weight change will be defined as 5% or greater in one month, 7.5% or greater in three months, or 10% or greater in six months. The weight change will be recorded on the appropriate weight watcher's form along with interventions, and follow-up will also be recorded in the designated location. The physician and family will be notified. In addition, an acute care plan for weight loss will be initiated and the clinical record reviewed for possible need of a significant change of condition MDS assessment. Assess the resident for possible reason for weight loss to include:<BR/>9. All significant weight changes will be referred to the Regional Dietitian on the next visit. The Regional Dietitian will generate a copy of the facility weight report and can review the weight watchers' forms in PCC. The Regional Dietitian will complete an assessment on all significant weight losses. The Regional Dietitian will review all facility interventions, and will make appropriate recommendations, which will be approved by the physician, if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. <BR/>CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. <BR/>CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). <BR/>These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. <BR/>Findings include:<BR/> A record review of Resident #1's electronic face sheet, dated 02/09/23, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included muscle weakness, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one?sided weakness) following intracerebral hemorrhage (bleeding into the brain tissue) affecting right dominant side, muscle wasting and atrophy, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS of 15, which indicated the resident's cognition was intact. Resident #1's MDS revealed she required extensive assistance with two-persons physical assistance for the following ADLs: bed mobility, transfers, and toilet use. <BR/>A record review of Resident #1's Care Plan dated 10/13/22 revealed Resident #1 had an ADL self-care performance deficit related to weakness on right side upper and lower extremities with history of CVA impaired mobility for bed mobility, toilet use, transfers. The interventions included the following: Toilet Use: The resident requires Extensive Assist x2 providers; Transfer: Requires Extensive Assist x2 providers.<BR/>A record review of Resident #1's Progress Notes by LVN C, dated 01/15/23, revealed Resident was being transferred to bed by agency CNA when she became weak, and CNA lowered her slowly to the floor with no complications. Resident noted stable denied no pain or any discomfort at this time. Resident was alert and oriented x4 with all upper and lower extremity functioning. Resident able to explain that she was assisted to sit on the floor by CNA since she could not bear weight. All vital signs within reach b/p 127/66, pulse 64, temp 98. Resident successfully assisted to bed using Hoyer lift.<BR/>A record review of Resident #1's Progress Notes by LVN D, dated 01/18/23, revealed At approximately 0700 Aide called stating that resident was on floor. Writer went to room resident was sitting on floor head leaning to assigned aides leg, who was standing beside resident's bed. Vitals remain within normal limit. No temperature noted. Resident complain of pain to right shoulder and arm. Assessment completed mild inflammation noted on site and painful to touch. Staff instructed to immobilize arm (not to move arm). MD notified. New order received to send resident to the ER for further evaluation. Medication audited noted administration of Tylenol 3 at 0600. Schedule gabapentin of 600 mg administered at this time. 911 call at approximately 0715 and resident was sent out to the ER [hospital] at 0725. RP Notified and aware of hospital of choice. <BR/>A record review of Resident #1's hospital paperwork, dated 01/19/23, revealed she was admitted to the hospital on [DATE] at 7:58 AM due to right shoulder pain from a fall. The hospital record revealed x-rays were completed on Resident #1's right shoulder and she was diagnosed with a closed fracture of neck of right humerus, initial encounter.<BR/>An observation and an interview on 02/09/23 at 10:19 AM, revealed Resident #1's right arm was in a sling. Resident #1 stated she had fall a couple of times in the facility, but she did not recall the details or the dates of the falls. Resident #1 stated in the last fall she was sent to the hospital and her arm was broken. She stated her arm was very sore. Resident #1 stated each time she fell it was while she was being transferred in and out of bed. She stated in the last fall she was being put in the bed and her paralyzed leg (right side) got stuck while she was being turned towards the bed. Resident #1 stated the CNA could not hold her up and they slid to the floor. She stated there was only one CNA transferring her in or out of bed each time she fell. <BR/>In an interview on 02/09/23 at 12:23 PM, the ADMN and DON, the ADMN stated Resident #1 was a 2-persons assist and after the fall on 01/18/23, she was changed to Hoyer lift for transfers. The ADMN stated both falls were with agency staff, but their facility staff all knew Resident #1 was a 2-person assist. The DON stated staff were in-serviced after each fall. The ADMN stated when agency staff worked at the facility, they were supposed to round with a facility staff member at the beginning of their shift. The ADMN stated the facility staff were supposed to go over the resident's needs, such as transfer status during the rounds. <BR/>In an interview on 02/09/23 at 1:14 PM, the Nurse Manager stated she was aware of the falls from 01/15/23 and 01/18/23. She stated she in-serviced staff about falls and transfers after each incident. The Nurse Manager stated when agency staff arrived, they were supposed to check in with the charge nurse and they would receive their assignment. She stated whoever the agency staff was relieving they were supposed to round with them, and discuss resident's needs, such as transfers. The Nurse Manager stated they had started using more agency around the times of the incidents, so she did an in-service about rounding. The Nurse Manager stated CNA B was assigned to round with CNA E. She stated she did not know about CNA A because this happened in the evening after she left for the day. <BR/>In an interview on 02/09/23 at 1:46 PM, CNA E stated she worked on 01/18/23 and was assigned to do rounds with CNA B. She stated she provided CNA B with a cheat sheet, which had info about the residents, which included who was incontinent, who needed help with feeding, and transfer requirements, such as who needed a Hoyer lift. CNA E stated Resident #1 was a two-persons transfer and when they rounded, she told the agency CNA B to let her know when she needed help with transfers. She said Resident #1 is a larger lady, so she doesn't know why CNA B would try to transfer her by herself. CNA E stated facility staff always used two people. <BR/>In a phone interview on 02/10/23 at 2:48 PM, LVN C stated on 01/15/23, he was called into Resident #1's room by CNA A. He stated CNA A said she was getting Resident #1 out of her wheelchair to put her in the bed. LVN C stated CNA A said she could not hold resident up by herself and so they slide down to the floor. LVN C stated Resident #1 was a 2-persons assist. He stated he had always observed facility staff using two CNAs when transferring Resident #1 to and from bed, but CNA A was agency. <BR/>LVN C stated he asked CNA A why she attempted to transfer Resident #1 by herself, without asking for help. He stated CNA A said she told Resident #1 she was going to get help and Resident #1 told her she was able to stand by herself and only needed one aide to help her. LVN C stated CNA A said she believed what the resident said, so she attempted to transfer her. LVN C stated Resident #1 is a larger lady and CNA A said she could not hold her weight, when Resident #1 stood out of the wheelchair, so they slide to the ground. LVN C stated agency staff are usually paired with a facility staff to do rounds, but he was not sure if she completed rounds because he worked a 12 hr. shift on the weekends and CNA A had already started her shift before he arrived. <BR/>On 02/13/23 at 2:10 PM, the Administrator communicated she had attempted to get CNA A's phone number from the staffing agency via email and by phone and was unable to get her number. <BR/>In a phone interview on 02/09/23 at 5:49 PM, LVN D stated on 01/18/23 she was called to Resident #1's room by CNA B, who told her she was transferring Resident #1 from the bed and could not hold her up, so she lowered Resident #1 to the floor. LVN D stated Resident #1 was a 2-persons transfer and maybe because CNA B was agency she did not know. LVN D stated she had never seen facility CNAs transferring the resident by themselves. She stated when agency CNAs checked in, she was supposed to pair them with a facility CNA to do rounds. LVN D stated during rounds, the facility CNA was supposed to educate the agency CNAs on the resident's needs, such as how they were transferred. LVN D stated she did pair CNA B with a facility CNA. She stated she did not recall who she was paired with, but she was sure she paired her. <BR/>In a phone interview on 02/10/23 at 10:41 AM, CNA B stated she was agency staff and she had worked at the facility twice before 01/18/23. CNA B stated she was not sure if Resident #1 was a 2-persons assist for transfers. CNA B stated when she had worked with Resident #1 before, she had transferred her by herself, and she was able to pivot her good side to help with transfer. She stated Resident #1 was ready to get up and into her wheelchair so she could go smoke. CNA B stated she was changing Resident #1's brief and stood her up to pull up the brief. CNA B stated she had a weak side that she could not really move, so she was holding her up under her arm on the weak side, which was her right side. She stated Resident #1 was standing and as she pulled her brief up, and suddenly Resident #1 started screaming that her arm was hurting, and she could not hold on. CNA B stated she lowered Resident #1 to the floor to ensure she doesn't hit her head. She stated she did not move resident and called for a nurse. CNA B stated she was in-serviced on falls and transfers after the incident. She stated she did do rounds with another CNA (doesn't recall her name) at the beginning of her shift. CNA B stated when she rounded with the CNA, she was telling her who required Hoyer lift and what the resident needed help with. She stated the CNA did not provide a paper with the resident's needs. CNA B stated when she was rounding with the CNA and they got to Resident #1's room, the CNA told her to start with Resident #1 first because if she missed her first smoke break then she would get upset. CNA B stated the CNA never told her Resident #1 required two people to transfer her, but she did tell her if she needed help with Resident #1, then let her know.<BR/>A record review of the facility's in-services revealed staff were in-serviced on falls and transfers on 01/16/23 and 01/18/23. A further review revealed staff were in-serviced on 01/12/23 on Rounding oncoming shift: CNAs round with CNAs and Nurses round with Nurses. <BR/>A record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, dated 2003, revealed Purpose: The purposes of this procedure are to allow the resident to bout of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure: Note: This procedure may require two (2) persons. H. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #6) of 3 residents reviewed for Respiratory Care.<BR/>The facility failed to ensure that Resident #6's nasal cannula and tubing was off the floor, properly stored when not in use, and her humidifier bottle water was dated.<BR/>These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>Review of Resident #6's Face Sheet, dated 04/01/25, reflected the resident was a [AGE] year-old female was initially admitted on [DATE], and again on 08/20/2024. The resident was diagnosed with alcohol dependence with alcohol induced persisting dementia (cognitive decline from alcohol use), Chronic pain, History of falling, benign neoplasm of left bronchus and lung (non-cancerous tumor in the lung).<BR/>Review of Resident #6's Comprehensive MDS Assessment, dated 03/20/2024, revealed the resident BIMS score was 9, indicating she was moderately impaired cognitively. Functional Abilities and Goals revealed Resident #6 requires set up and clean up for oral hygiene and upper body dressing. She requires supervision and touching assistance for toileting hygiene, lower body dressing, putting on and taking off footwear, and personal hygiene. She requires partial moderate assistance with showering and bathing. The Comprehensive MDS Assessment indicated the resident was receiving hospice care.<BR/>Review of Resident #6's Comprehensive Care Plan, dated 01/15/2025, reflected the resident was on hospice. One of the interventions was to monitor for signs and symptoms of respiratory distress.<BR/>Review of Resident #6's Physician's Order, dated 12/05/2024, reflected Admit to hospice for lung cancer.<BR/>Review of Resident #6's Physician's Order, dated 12/05/2024, reflected Ipratropium-Albuterol Solution 0.5 - 2.5 (3) MG/3ML .3 milliliter inhale orally as needed for SOB or wheezing via nebulizer.<BR/>Observation and interview on 04/01/2024 at 12:38 PM revealed Resident #6 sitting on the side of her bed, awake. The resident nasal cannula and tubing were observed on the ground, and the water bottle was not dated. on oxygen therapy via nasal cannula at 3 liters per minute and was connected to an oxygen concentrator. The resident said it was okay to open his drawer. Inside the drawer, was a nebulizer with a breathing mask connected to it. The breathing mask was not bagged. The resident said she was given a breathing treatment every morning. She said the nurse would put it on and the nurse would take it off when it was done. She said she was not aware where the nurse would put it after the breathing treatment. She said she did not notice the tubing on the floor. <BR/>In an interview on 04/01/2025 at 4:16 PM with LVN E, revealed LVN E was the charge nurse for the 2PM to 10 PM shift. She said all nursing staff are responsible for conducting rounds and monitoring resident treatment devices and equipment for safe operations and clean devices. All respiratory equipment should be dated, labeled, clean, and stored when not in use. She stated resident tubing found on the floor, or unbagged when not in use, should be removed, discarded, and installing new equipment and dating. She said the risk to the resident could result in respiratory infections or overuse of equipment. <BR/>In an interview with the ADON on 04/01/2025 at 3:45 PM, the ADON stated the nasal cannula and tubing for respiratory equipment should be bagged when not in use. She said not bagging them could result in cross contamination and respiratory infection. She said the expectation was for the nursing staff to bag all the respiratory apparatuses used by the residents when not in use . She said she would coordinate with the DON pertaining to education and in-services about respiratory care. She said she would include checking on the respiratory apparatuses being bagged during her walk around and water bottles on the concentrator are dated. <BR/>In an interview with the DON on 04/01/2025 at 4:04 PM, the DON stated the nasal cannula, tubing should be stored properly when not in use to keep them clean. She said if those breathing apparatuses were not bagged, were exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, and oxygen administration could be compromised. She said the nasal cannula and tubing should be discarded and replaced when found on the floor, undated, and not stored in a clean back with date. She said the nursing staff installing the humidifier bottles on concentrators should always be dated to prevent overuse. She said the staff should monitor during rounds and ensure the equipment was dated as soon as they saw it because they never knew when they could come back to the resident's room. She said moving forward, she would make an in-service and re-educate the staff about dating tubing, storing when not in use and ensure the bottle for the nebulizer was dated upon administering or replacing equipment. <BR/>In an interview with the Administrator on 04/01/2024 at 4:55 PM, the Administrator stated everything that the residents were using should be kept clean to prevent infection. She said the expectation was for the staff to be trained proficiently, follow basic protocols, and ask if something needed clarification. She said they would monitor the staff and discuss the issue. <BR/>Record review of facility's policy, Respiratory Policies and Procedures 2.0 Nasal Canula revised June 1, 2006, revealed Policy: Oxygen therapy via nasal cannula is administered as ordered by a physician .Oxygen is set up, delivered, and monitored by a licensed nurse or a respiratory therapist. Purpose: To provide oxygen concentrations (approximately 22-52%) at per minute Process: Replace entire set-up every seven day. Date and store in treatment bag when not in use If using a non-disposable humidifier, change bottle every seven days and change water every 24 hours to prevent bacterial contamination .date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #2) of five residents reviewed for abuse. <BR/>The facility failed to prevent Resident #2 from being abused by Resident #1 on the secure unit, who had a history of being verbally and physically aggressive to other residents. Resident #1 physically attacked Resident #2 which resulted in him being sent to the hospital and sustained a serious injury to his right eye on 12/29/24. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/29/24 and ended on 12/29/24. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death. <BR/>Findings included: <BR/>1.<BR/>Record review of Resident #1's face sheet, dated 01/16/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses which included: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skill), unspecified, unsteadiness on feet, cognitive communication deficit, personal history of transient ischemic attack (a short period of symptoms similar to those of a stroke), and cerebral infarction (stroke) without residual deficits and personal history of traumatic brain injury (a head injury causing damage to the brain by external force or mechanism. It causes long term complications or death). <BR/>Record review of Resident #1's quarterly MDS assessment, dated /30/24, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Resident#1 coded behavior for wandered daily. <BR/>Record review of Resident #1's care plan, initiated 06/06/24 and revised 10/25/24, reflected: the resident was at risk for behaviors: [Resident#1] has a potential for maladaptive behaviors .Physical aggression toward others .Verbally aggressive. Interventions included intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Administer medication as ordered. Monitor/document for side effects and effectiveness.<BR/>Record review of Resident#1 progress notes dated 05/09/24 to 01/16/25 reflected, Resident#1 had a history of being physically and verbally aggressive towards staff and residents. Progress notes reflected the incident on 12/29/24 was the first time a resident needed to be sent out to the hospital. <BR/>On 07/04/24, LVN B reported: Resident verbally abusive with other residents calling them idiots and zombies <BR/>On 07/09/24, LVN A reported: Ambulating in hall and stopped to yell at another resident that was confused<BR/>On 7/12/24, LVN B reported: Resident yelling at other residents calling them idiots and stupid this nurse reminded resident that he needs to respect the other residents<BR/>On 07/19/24, LVN B reported Resident yelling at another resident calling him a retard zombie resident redirected, resident walked away.<BR/>On 08/12/24 LVN B reported Resident mocking other residents CNA explained to resident that he needed to stop that behavior . Resident yelling at resident from room [Resident#1] states I will kick his ass if he comes to my room .<BR/>On 08/14/24, SSD reported SSD submitted referral to [Psy MD] for psych consult.<BR/>On 08/20/24 LVN B reported On Gabapentin 300 for aggressive behavior, resident yelling at residents at dining room table.<BR/>On 09/02/24, LVN B reported Resident verbally abusive with other residents<BR/>On 09/04/24, SSD reported IDT team care plan carried out by [DON, DOR, ADON], . Family seeking possible admission to all male unit, wanting to stay localized, per family request . Referral sent to [Facility] per family request.<BR/>On 10/20/24, LVN A reported [Resident#1] was observed unbuttoning and unzipping his jeans. He pulled his penis out and urinated on the floor. When ask to stop and go to his room he started yelling at staff. He was informed by this nurse . rest room. he was informed besides exposing himself to non-employees that it created a danger to residents staff.<BR/>On 10/23/24, P Admin reported Resident observed displaying agitating and aggressive behavior towards staff and other residents.<BR/>On 12/26/24, reported by LVN A [Resident#1] behaviors is getting worse and he is getting more aggressive both physically and verbally.<BR/>Record review of Resident #1's progress notes and incident report in the EHR, dated 12/29/24 by LVN C , reflected: Nursing description: This nurse called to hallway when heard hollering and yelling, resident as on floor bleeding, when I approach him, he said he was ???? [sic]unable to comprehend, Full body assessment laceration on his head and eye area. Called 911 and police and advised admin and other in group text also called them, contacted [Family member], left message to call. Police came [PD #] to get report, and info. then EMS came and evaluated and took to [Hospital]. [Resident#1] stated he did nothing, the whole incident was witnessed by Housekeeping, had her write out a statement. Description of action taken: Immediately look to see where blood was coming from head and right eye.<BR/>Record review of LA A's handwritten statement dated 12/31/24 reflected: To whom it may concern [LA A] was present when [Resident#1] was yelling down the hall he assaulted me. As [LA A] was putting linens in the closet on the unit. [LA A] looked down the hall and saw [Resident#1] push [Resident#2] down causing him to bleed. [LA A] yelled out for the nurse and she assisted [Resident#2]. Resident 21 was transported to hospital.<BR/>Record review of police report, dated 12/29/24, reflected: injured persons report by [Resident#1] to [Resident#2].<BR/>Record review of Psy consults reflected:<BR/>Record review of Psy consult, dated 10/28/24 reflected, Resident#1 increase Gabapentin for aggressive behavior. Continue Lexapro for depression. 10 mg, &frac12; tablet PO QD. Increase Neurontin 300 mg PO BID. <BR/>Record review of Psy consult, dated 12/09/24 reflected Resident#1 started Depakote 250 mg, BID. <BR/>Record review of Resident#1 January MAR reflected Resident#1 had received medication as ordered:<BR/>Aricept Tablet 10 MG (Donepezil HCl) Give 1 tablet by mouth one time a day for Dementia.<BR/>Depakote Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for Seizures and Aggressive Behaviors related to other seizures. <BR/>Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for Aggressive behavior.<BR/>2.<BR/>Record review of Resident #2's face sheet, dated 01/17/25, reflected an [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, muscle weakness (generalized), cognitive communication deficit, personal history of transient ischemic attack (a short period of symptoms similar to those of a stroke), and cerebral infarction (stroke) without residual deficits. <BR/>Record review of Resident #2's quarterly MDS assessment, dated 12/30/24, reflected his BIMS score was 04, which indicated severe cognitive impairment. Resident#2 coded behavior for wandered daily. <BR/>Record review of Resident #2's care plan, revised 9/30/24, reflected Resident#2 had behavior problem r/t dementia. Physical aggression towards other. Interventions included: Administer medications as ordered. Monitor/document for side effects. <BR/>Record review of Resident#2's hospital records dated 12/29/24 reflected: Resident#2 had right forehead with small laceration, large medial lower lid laceration. Lower puncta was displaced for temporally, past the midpoint of cornea. Resident#2 had to have right lower eyelid canalicular repair, repair of laceration on 01/02/25.<BR/>Record review of Resident #2's December 2024 progress notes reflected:<BR/>On 12/29/24, LVN C reported [Resident #2] Full body assessment laceration on his head and eye area. Called 911 . PD Incident report [number].<BR/>On 12/30/24, LVN C reported [Resident#2] returned from [Hospital] Resident has sutures to right eye and head from his injuries on 12/29/24.<BR/>On 01/02/25 resident returned from surgery has instructions for eye care and next 2 appointments this month.<BR/>In an interview on 01/16/25 at 1:21 PM, LVN D stated she worked at the facility for almost 3 weeks. Resident #1 was on Q15 monitoring since the incident on 12/29/24 with Resident#2. LVN D did not see the incident on 12/29/24. LVN D stated she has not witnessed any behaviors since the incident. <BR/>In an interview on 01/16/25 at 1:25 PM, CNA E stated she has worked in the facility for 3 months and Resident #1 had been verbally and physically aggressive toward residents and staff. CNA E did not witness the incident on 12/29/24. Resident#1 has been verbally aggressive and physically aggressive towards staff and verbal aggressive to residents CNA E stated she would redirect residents and the nurse on duty documents the Q15 monitoring. CNA E stated in the secure unit staff had to pay attention and stay alert to care for the residents. <BR/>In an interview on 01/16/25 at 1:45 PM, LA A stated she heard two residents yelling at each other and saw Resident#1 push Resident#2. Resident#2 fell face first and it was a lot of blood. LA A stated she called for help and the nurse came and provided help. LA A stated she had not witnessed more behaviors recently. LA A stated she would yell for help for a nurse when residents were being verbally/physically aggressive to each other.<BR/>Attempted to call LVN C on 01/17/25 at 5:40 PM and voicemail box was full.<BR/>Attempted to call LVN B on 01/17/25 at 5:42 PM and left voicemail.<BR/>Attempted to call LVN A on 01/17/25 at 5:45 PM and left voicemail.<BR/>Record review of the facility's policy titled Abuse/Neglect, revised 03/2018, reflected in part the following: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, Definitions . Abuse is the willful infliction of injury . Willful, as used in this definition of abuse, means the individual must have acted deliberately . C. Prevention The facility will provide the residents, families, and staff an environment free from abuse and neglect.<BR/>The non-compliance was identified as past non-compliance (PNC). The IJ began on 12/29/24 and ended on 12/29/24. The facility had corrected the non-compliance before the state's investigation began. On 02/11/25 at 1:00 PM the Administrator, DON and Corporate Nurse were notified of the PNC IJ. <BR/>The facility took the following actions to correct the non-compliance prior to the survey:<BR/>Record review of incident/accident reports, from 12/19/24 to 02/11/25, reflected no other incidents involved Resident#1. <BR/>Record review of in-service dated 12/29/24, reflected behavior management by DON to all staff members. <BR/>Record review of Q15 monitoring dated 12/29/24 to 01/07/25, by LVN C and LVN D showed Resident#1 was checked on every 15 minutes and no behaviors were documented. <BR/>Record review of order recap report dated 01/30/25 reflected, Depakote oral tablet delayed release 500mg (Divalproex Sodium) Give 1 tablet by mouth two times a day for Seizures and Aggressive Behaviors related to other seizures was increased by PCP.<BR/>In an interview on 01/16/25 at 3:00 PM the Administrator and the DON stated the Administrator had worked in the facility since 12/29/24 and the DON had worked in the facility since 12/20/24. The and the DON stated Resident#1 had no aggressive behaviors since they started at the facility. The Administrator stated they were looking for placement for Resident#1. <BR/>In an interview on 01/17/25 at 5:15 PM the Corporate Nurse and Administrator stated the facility had been searching for placement for Resident#1 and he has been denied placement because of his behaviors. The Corporate Nurse stated Resident#1 has not had behaviors since his Depakote has been increased. The corporate Nurse and Administrator stated Resident#1 was no longer on Q15 and he had no behaviors since the incident on 12/29/24. The corporate Nurse and Administrator stated Resident#1 was to be redirected when he displayed aggressive behavior, Resident#1 medications had been adjusted and Resident#1 was on Q15 monitoring for 72 hours.<BR/>In an interview on 01/20/25 at 12:15 PM LVN D stated Resident#1 had not had any behaviors in the past month. Resident#2 was able to see out of his eye and has not wanted to come out of his room today.<BR/>An observation on 1/16/25 at 1:30 PM both Resident#1 and Resident#2 were in their rooms asleep. <BR/> Observation of the secure unit on 01/20/25 from 12:15 PM to 1:45 PM revealed:<BR/>An attempted interview and observation on 01/30/25 at 12:30 PM, Resident#1 did not recall any incidents with the other resident. Resident#1 ate lunch and talked about his college. <BR/>An observation on 01/30/25 at 1:15 PM revealed Resident#2 was in the bed asleep. <BR/>An interview on 01/30/25 at 4:00 PM the Administrator stated Resident#1 had no behaviors since the incident and the facility was looking for placement for him and he was not accepted. <BR/>In an observation on 02/11/25 in the secure unit from 5:30 AM to 9:00 AM revealed:<BR/>In an observation on 02/11/25 at 5:40 AM revealed Resident#1 was no longer in the facility.<BR/>In an observation on 02/11/25 at 6:30 AM revealed Resident#2 was awake in his wheelchair. <BR/>Attempted to interview Resident#2 on 02/11/25 at 7:00 AM and he did not respond back. <BR/>Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM with LA A, LVN C, LVN D, LVN F, CNA E (1st and 2nd shift) staff were able to provide competency regarding in-service over ANE and behavior management. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE and how to care for resident with physical and verbal aggressions. <BR/>An interview on 02/11/25 at 5:45 AM to 9:30 AM with LVN B (overnight shift) and SC G, AD H, DON And Administrator (1shift) staff were able to provide competency regarding in-service over ANE and behavior management. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE and how to care for resident with physical and verbal aggressions. <BR/>In an interview on 02/11/25 at 7:00 AM the Administrator stated Resident#1 was transported to the new facility on 02/10/25. <BR/>Record review of Resident#2 follow-up appointment on 01/14/25 reflected: right eyelid laceration was healing well, no drainage. Continue current care, no change in current therapies. Forehead laceration was healed and no further treatment needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two of four residents (Resident #59 and 88) reviewed for resident rights.<BR/>CNA C failed to ensure the dignity of Residents #59 and #88 was respected during the breakfast meal when CNA C yelled in front of the residents at Laundry Aide D while they were being fed.<BR/>This failure could place residents who need assistance with eating at risk for weight loss and a decreased quality of life.<BR/>Findings included:<BR/>Review of Resident #88's face sheet, dated 12/18/24, revealed the resident was a [AGE] year-old female admitted on [DATE], with the diagnoses of cognitive communication deficit, dysphagia (difficulty swallowing), and legal blindness.<BR/>Review of Resident #88's quarterly MDS assessment, dated 11/15/24, revealed the resident was rarely/never understood. Resident #88 was dependent on staff on eating.<BR/>Review of Resident #88's care plan, dated 12/16/24, revealed the resident had a communication problem due to impaired hearing, impaired vision, and impaired cognition. Interventions included: Speak directly into ear when communicating with [Resident#88] .reduce environmental noise .Resident #88 also had maladaptive behaviors at times due to impaired cognition, new environment/disorientation, confusion, frustration, difficult communicating, and sensory impairments (blind/deaf). Interventions included: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed .<BR/>Review of Resident #59's face sheet, dated 12/18/24, revealed the resident was a [AGE] year-old female admitted on [DATE], with the diagnoses of major depressive disorder, cognitive communication deficit, and abnormal weight loss.<BR/>Review of Resident #59's quarterly MDS, dated [DATE], revealed a BIMS score of 00, which indicated the resident could not complete the interview or was rarely understood. Resident #59 was dependent on staff for eating.<BR/>Review of Resident #59's care plan, dated 12/14/24, revealed Resident #59 exhibited maladaptive behavior at times due to impaired cognition and frustration. Interventions included: Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resident #59 had a potential for a psychosocial well-being problem due to anxiety. Interventions included: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears.<BR/>Observation on 12/18/24 from 07:36 AM to 07:50 AM CNA C was observed feeding two residents at the same time before yelling across the dining room towards Laundry Aide D for two straws. Laundry Aide D then walked over to where CNA C was feeding Resident #59 and Resident #88 and stood over Resident #88 as she and CNA C chatted to each other on social matters.<BR/>Interview on 12/19/24 at 8:52 AM with CNA C revealed its proper to sit down and feed the resident, not stand over them, so that you can monitor them. She stated she did sometimes feed multiple residents at once and prefers to feed the residents she normally feeds. CNA C stated she yelled across the dining room again because laundry Aide D didn't answer. CNA C stated she was letting Laundry Aide D know she needed another pair of pants for the resident, which was why she was yelling. She stated it would not be polite to yell in front of someone. CNA C stated residents have the right to dignity and right to refuse showers, meals, medications, and the right to wear clothing. She stated residents could feel it wasn't polite if a resident's dignity was not respected.<BR/>Interview on 12/19/24 at 09:32 AM with Laundry Aide D revealed residents had the right to feel respected. She stated she was having a conversation about a party with CNA C. She stated residents would feel like they were not being respected. She stated residents did not understand her and CNA C's conversation. Laundry Aide D stated residents have a right to a dignified dining experience and they have a right to be respected.<BR/>Interview on 12/19/24 at 3:39 PM with the AIT revealed it was a resident's right issue when residents were not respected during lunch meals. She stated the best practice was to feed one resident at a time.<BR/>Review of facilities policy titled Residents Rights dated November 2021 reflected . The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .<BR/>Review of facility policy titled Feeding, Assistive/Complete with revision date 02/12/07 reflected read in part . The resident will achieve maximal participation in daily self-feeding .the resident will receive optimal nutritional intake with partial or complete assistance .Resident will be free from aspiration .Provide a pleasant environment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. <BR/>CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. <BR/>CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). <BR/>These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. <BR/>Findings include:<BR/> A record review of Resident #1's electronic face sheet, dated 02/09/23, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included muscle weakness, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one?sided weakness) following intracerebral hemorrhage (bleeding into the brain tissue) affecting right dominant side, muscle wasting and atrophy, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS of 15, which indicated the resident's cognition was intact. Resident #1's MDS revealed she required extensive assistance with two-persons physical assistance for the following ADLs: bed mobility, transfers, and toilet use. <BR/>A record review of Resident #1's Care Plan dated 10/13/22 revealed Resident #1 had an ADL self-care performance deficit related to weakness on right side upper and lower extremities with history of CVA impaired mobility for bed mobility, toilet use, transfers. The interventions included the following: Toilet Use: The resident requires Extensive Assist x2 providers; Transfer: Requires Extensive Assist x2 providers.<BR/>A record review of Resident #1's Progress Notes by LVN C, dated 01/15/23, revealed Resident was being transferred to bed by agency CNA when she became weak, and CNA lowered her slowly to the floor with no complications. Resident noted stable denied no pain or any discomfort at this time. Resident was alert and oriented x4 with all upper and lower extremity functioning. Resident able to explain that she was assisted to sit on the floor by CNA since she could not bear weight. All vital signs within reach b/p 127/66, pulse 64, temp 98. Resident successfully assisted to bed using Hoyer lift.<BR/>A record review of Resident #1's Progress Notes by LVN D, dated 01/18/23, revealed At approximately 0700 Aide called stating that resident was on floor. Writer went to room resident was sitting on floor head leaning to assigned aides leg, who was standing beside resident's bed. Vitals remain within normal limit. No temperature noted. Resident complain of pain to right shoulder and arm. Assessment completed mild inflammation noted on site and painful to touch. Staff instructed to immobilize arm (not to move arm). MD notified. New order received to send resident to the ER for further evaluation. Medication audited noted administration of Tylenol 3 at 0600. Schedule gabapentin of 600 mg administered at this time. 911 call at approximately 0715 and resident was sent out to the ER [hospital] at 0725. RP Notified and aware of hospital of choice. <BR/>A record review of Resident #1's hospital paperwork, dated 01/19/23, revealed she was admitted to the hospital on [DATE] at 7:58 AM due to right shoulder pain from a fall. The hospital record revealed x-rays were completed on Resident #1's right shoulder and she was diagnosed with a closed fracture of neck of right humerus, initial encounter.<BR/>An observation and an interview on 02/09/23 at 10:19 AM, revealed Resident #1's right arm was in a sling. Resident #1 stated she had fall a couple of times in the facility, but she did not recall the details or the dates of the falls. Resident #1 stated in the last fall she was sent to the hospital and her arm was broken. She stated her arm was very sore. Resident #1 stated each time she fell it was while she was being transferred in and out of bed. She stated in the last fall she was being put in the bed and her paralyzed leg (right side) got stuck while she was being turned towards the bed. Resident #1 stated the CNA could not hold her up and they slid to the floor. She stated there was only one CNA transferring her in or out of bed each time she fell. <BR/>In an interview on 02/09/23 at 12:23 PM, the ADMN and DON, the ADMN stated Resident #1 was a 2-persons assist and after the fall on 01/18/23, she was changed to Hoyer lift for transfers. The ADMN stated both falls were with agency staff, but their facility staff all knew Resident #1 was a 2-person assist. The DON stated staff were in-serviced after each fall. The ADMN stated when agency staff worked at the facility, they were supposed to round with a facility staff member at the beginning of their shift. The ADMN stated the facility staff were supposed to go over the resident's needs, such as transfer status during the rounds. <BR/>In an interview on 02/09/23 at 1:14 PM, the Nurse Manager stated she was aware of the falls from 01/15/23 and 01/18/23. She stated she in-serviced staff about falls and transfers after each incident. The Nurse Manager stated when agency staff arrived, they were supposed to check in with the charge nurse and they would receive their assignment. She stated whoever the agency staff was relieving they were supposed to round with them, and discuss resident's needs, such as transfers. The Nurse Manager stated they had started using more agency around the times of the incidents, so she did an in-service about rounding. The Nurse Manager stated CNA B was assigned to round with CNA E. She stated she did not know about CNA A because this happened in the evening after she left for the day. <BR/>In an interview on 02/09/23 at 1:46 PM, CNA E stated she worked on 01/18/23 and was assigned to do rounds with CNA B. She stated she provided CNA B with a cheat sheet, which had info about the residents, which included who was incontinent, who needed help with feeding, and transfer requirements, such as who needed a Hoyer lift. CNA E stated Resident #1 was a two-persons transfer and when they rounded, she told the agency CNA B to let her know when she needed help with transfers. She said Resident #1 is a larger lady, so she doesn't know why CNA B would try to transfer her by herself. CNA E stated facility staff always used two people. <BR/>In a phone interview on 02/10/23 at 2:48 PM, LVN C stated on 01/15/23, he was called into Resident #1's room by CNA A. He stated CNA A said she was getting Resident #1 out of her wheelchair to put her in the bed. LVN C stated CNA A said she could not hold resident up by herself and so they slide down to the floor. LVN C stated Resident #1 was a 2-persons assist. He stated he had always observed facility staff using two CNAs when transferring Resident #1 to and from bed, but CNA A was agency. <BR/>LVN C stated he asked CNA A why she attempted to transfer Resident #1 by herself, without asking for help. He stated CNA A said she told Resident #1 she was going to get help and Resident #1 told her she was able to stand by herself and only needed one aide to help her. LVN C stated CNA A said she believed what the resident said, so she attempted to transfer her. LVN C stated Resident #1 is a larger lady and CNA A said she could not hold her weight, when Resident #1 stood out of the wheelchair, so they slide to the ground. LVN C stated agency staff are usually paired with a facility staff to do rounds, but he was not sure if she completed rounds because he worked a 12 hr. shift on the weekends and CNA A had already started her shift before he arrived. <BR/>On 02/13/23 at 2:10 PM, the Administrator communicated she had attempted to get CNA A's phone number from the staffing agency via email and by phone and was unable to get her number. <BR/>In a phone interview on 02/09/23 at 5:49 PM, LVN D stated on 01/18/23 she was called to Resident #1's room by CNA B, who told her she was transferring Resident #1 from the bed and could not hold her up, so she lowered Resident #1 to the floor. LVN D stated Resident #1 was a 2-persons transfer and maybe because CNA B was agency she did not know. LVN D stated she had never seen facility CNAs transferring the resident by themselves. She stated when agency CNAs checked in, she was supposed to pair them with a facility CNA to do rounds. LVN D stated during rounds, the facility CNA was supposed to educate the agency CNAs on the resident's needs, such as how they were transferred. LVN D stated she did pair CNA B with a facility CNA. She stated she did not recall who she was paired with, but she was sure she paired her. <BR/>In a phone interview on 02/10/23 at 10:41 AM, CNA B stated she was agency staff and she had worked at the facility twice before 01/18/23. CNA B stated she was not sure if Resident #1 was a 2-persons assist for transfers. CNA B stated when she had worked with Resident #1 before, she had transferred her by herself, and she was able to pivot her good side to help with transfer. She stated Resident #1 was ready to get up and into her wheelchair so she could go smoke. CNA B stated she was changing Resident #1's brief and stood her up to pull up the brief. CNA B stated she had a weak side that she could not really move, so she was holding her up under her arm on the weak side, which was her right side. She stated Resident #1 was standing and as she pulled her brief up, and suddenly Resident #1 started screaming that her arm was hurting, and she could not hold on. CNA B stated she lowered Resident #1 to the floor to ensure she doesn't hit her head. She stated she did not move resident and called for a nurse. CNA B stated she was in-serviced on falls and transfers after the incident. She stated she did do rounds with another CNA (doesn't recall her name) at the beginning of her shift. CNA B stated when she rounded with the CNA, she was telling her who required Hoyer lift and what the resident needed help with. She stated the CNA did not provide a paper with the resident's needs. CNA B stated when she was rounding with the CNA and they got to Resident #1's room, the CNA told her to start with Resident #1 first because if she missed her first smoke break then she would get upset. CNA B stated the CNA never told her Resident #1 required two people to transfer her, but she did tell her if she needed help with Resident #1, then let her know.<BR/>A record review of the facility's in-services revealed staff were in-serviced on falls and transfers on 01/16/23 and 01/18/23. A further review revealed staff were in-serviced on 01/12/23 on Rounding oncoming shift: CNAs round with CNAs and Nurses round with Nurses. <BR/>A record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, dated 2003, revealed Purpose: The purposes of this procedure are to allow the resident to bout of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure: Note: This procedure may require two (2) persons. H. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

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 1 (medication cart) of 1 medication cart on the memory care unit reviewed for pharmacy services<BR/>The facility failed to ensure discontinued medication were removed from the medication cart. Resident #1's Diazepam that was DC on 12/30/24 was in the narcotic box on the secure unit medication cart.<BR/>This failure could place residents at risk of unnecessary medication error and/or lead to possible harm or drug diversion.<BR/>The findings included:<BR/>Interview on 5/13/25 at 9:50 PM LVN A stated when medications were wasted, they should be crushed and disposed of and two people, 2 nurses, were to sign off on the narcotics sheet and document medication was wasted. <BR/>Observation and record review on 05/13/25 at 11:00 PM revealed a secure unit narcotic sheet that was not filled out completely for Resident #1's Diazepam 5 mg tablet. Review of Resident#1's Diazepam 5mg narcotic sheet reflected the 10th pill was given with no date and no signature. Further review revealed the 9th pill was removed on 4/11 /25and on 5/4/25 the 8th pill was marked off as wasted. Observation of Resident #1's Diazepam 5 mg package reflected the medication was still in the bubble pack for the 8th tablet. Observation of the Diazepam bubble package revealed medication was filled on 11/12/24. Review of the Diazepam narcotic sheet revealed the Diazepam was put on the medication cart on 11/14/25. <BR/>Record review of Resident #1's order summary revealed to give 1 tablet Diazepam by mouth every 6 hours as needed and not to exceed 3 daily until 12/30/24 for anxiety.<BR/>Record review of Resident#1's November MAR reflected Diazepam was administered on 4/11/24.<BR/>Record review of Resident #1's March 2025 MAR reflected Diazepam was not a listed medication. <BR/>Interview on 05/13/25 at 11:00 PM LVN A stated Resident#1's Diazepam was DC and the DON was responsible for coming to pick up the DC medication from the medication cart. LVN A stated when medication was wasted two nursing staff would sign off on the medication. LVN A stated narcotics were crushed and put in water.<BR/>Interview on 05/14/25 at 12:15 PM the DON stated she had not been informed of staff taking narcotic medications for personal use off the medication cart. <BR/>Interview and observation on 5/14/25 at 1:43 PM the DON stated Resident #1's 5mg Diazepam was DC on 12/30/24. She stated that DC medication needed to be brought to her as soon as possible. The DON stated that nurses was responsible for taking DC medications off the medication cart. The DON stated the pharmacy comes every other month to destroy medications. The DON stated residents are at risk of being given medications that are no longer needed. The DON stated when medications are wasted two nursing staff members are supposed to sign off. Observed the CN leave out of the DON, and she went to pull the DC medication off the secure unit cart. The CN stated the nurse must have written the number backwards instead of 04/11/24 it should have been 11/04/24. <BR/>Record review of the facility policy titled, Medication Administration Procedures revealed, 3. Open the unit dose package only when you are administering medication directly to the resident.<BR/>Record review of the policy titled Controlled Medication Disposal, undated, revealed, 3. Schedule II, III, IV and V medications remaining in the facility after the resident has been discharged , or the order<BR/>discontinued, are disposed either in the facility by legally authorized personnel, Director of Nursing, and Consultant Pharmacist .<BR/>Record review of the facility policy titled, Discontinued Medications, undated, reflected : Policy .When medications are discontinued by physician order, . the medications are marked appropriately and destroyed .Procedure 1. If a physician discontinues a medication .the medication container is marked the date discontinuance is indicated along with the initials of the nurse. 2. Medications awaiting disposal are stored in a locked secure area designated for that purpose until disposed of medications are removed from the medication cart immediately upon receipt of an order to discontinue avoiding inadvertent administration. 3. Discontinued medications are destroyed in accordance with destruction policy and procedure .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional standard for 1 of 2 medication rooms (Med Room A) reviewed for storage of drugs.<BR/>ADON A failed to ensure medications were secured and not left out in the open outside Med Room A.<BR/>This could affect residents by placing them at risk of medication not meeting therapeutic levels, misuse and diversion.<BR/>Findings included:<BR/>Review of Resident #12's face sheet, dated 12/19/24, revealed the resident was a [AGE] year-old male readmitted on [DATE] with the diagnoses of epilepsy (seizure disorder), schizophrenia ( a serious mental health condition that affects a person's thoughts, feelings and behaviors), and essential hypertension (high-blood pressure).<BR/>Review of Resident #51's face sheet, dated 12/19/24, revealed the resident was a [AGE] year-old male admitted on [DATE] with the diagnoses of type 2 diabetes, heart failure, and personal history of transient ischemic attack (TIA, and cerebral infarction (stroke).<BR/>Review of Resident #26's face sheet, dated 12/19/24, revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses of transient cerebral ischemic attack (stroke), seizures, and anxiety disorder.<BR/>Observation on 12/17/24 at 10:33 AM revealed ADON A left the following medication outside Med Room A on top of a cart; 4 boxes of breathing treatment medication, inhaler albuterol inhalation medication, Afrin nose spray medication, and Geri Tussin DM cough medication 473 mL bottle. Resident #12 was observed walking by the medications twice and Resident #26 was observed pushing Resident #51 past the medications. The door to Med Room A was closed and locked. ADON A was inside the med room.<BR/>In an interview with ADON A on 12/17/24 at 10:47 AM, she stated Med Room A had a window and she could see the cart with the medications. She stated that she did not see Residents #12, #26, and #51 pass by the cart because of the med room window view. ADON A stated she should have taken the cart inside Med Room A and not left it outside where residents had access to the medications. She stated the risk to the resident was that they could take the medications and hurt themselves. She stated it was her responsibility to secure medications when they were in her possession. <BR/>Interview on 12/19/24 at 3:39 PM with the AIT revealed she expected medications to be secured and stored based on facility. She stated if the ADON did not follow policy, it was the DON's responsibility to ensure the ADON was following policy.<BR/>Record review of facility policy titled labelling of Container, revision date April 2007, reflected policy statement All medications maintained in the facility shall be properly labelled in accordance with current state and federal regulations. Policy interpretation and implementations .read in part 1. Medications labels must be legible at all times. 3. Labels for individual drug containers shall include all necessary information such as a) Residents name, f) Date medication was dispensed, h) Expiration date .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for:<BR/>1. <BR/>The facility failed to ensure food items, placed in the refrigerator, were dated, and labeled appropriately. <BR/>This failure could affect residents by placing them at risk for food-borne illness. <BR/>Findings included:<BR/>An observation and interview on 11/12/2023, at 9:37am, revealed two prepared salads, in containers sealed in cellophane, not labeled nor dated. Dietary Aide A stated she put the salads in the refrigerator, got busy with other task, and forgot to date and label the salads. Dietary Aide A stated the importance of dating and labeling food items put in refrigerators, is to inform other staff how long the items have been in the refrigerator so residents will not get food borne illness. <BR/>In an interview with the Dietary Manager, on 11/14/2023, at 11:55a.m., it was stated that her expectation for her staff is to date, label, and seal foods that are put in the refrigerators when they are stored in the refrigerators. <BR/>Review of the facility's Food Storage undated policy, on 11-14-2023 at 3:00pm, stated that Perishable items that are refrigerated are dated .and used within 7 days. <BR/>Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation 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. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech therapy-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as required in the resident's comprehensive plan of care for 2 of 2 residents (Resident #1 and Resident #111) reviewed for specialized rehabilitative services.<BR/>The facility failed to screen Resident #1 and Resident #111 for physical therapy.<BR/>This failure could place residents who required rehabilitative services at risk of a decline or decrease in their physical capabilities.<BR/>Findings included:<BR/>Review of Resident # 1's face sheet, dated 12/19/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, personal history of transient ischemic attack (stroke), heart failure and chronic obstructive pulmonary disease. <BR/>Review of Resident #1's care plan, dated 11/13/2024, revealed Resident #1 has an ADL Self Care Performance Deficit with interventions that included PT/OT evaluation and treatment as per MD orders. <BR/>Review of Resident #1's order summary report dated 12/19/2024 revealed no orders for physical therapy.<BR/>Review of Resident # 111's face sheet, dated 12/19/24, revealed the resident was a [AGE] year-old female admitted on [DATE] with the diagnoses of diastolic heart failure (still left heart ventricle), muscle weakness, and personal history of transient ischemic attack (stroke).<BR/>Review of resident # 111's physician orders revealed no mention of physical therapy ordered, only occupational therapy, which was ordered 10/07/24 for three days a week for 30 days.<BR/>Interview on 12/17/24 at 10:02 AM with Resident # 111 revealed the resident had lived in the facility for three months but she has not had any therapy. She stated she wanted to walk. Resident #111 stated OT only did therapy on her hands and not her legs. <BR/>Interview on 12/19/24 at 11:44 AM with the DOR revealed he had been at the facility for two weeks . He stated the goal with new admissions was to be screened for therapy within 48 hours, in which they would screen for PT, OT, and ST. He stated if residents were found to be in decline or weak, they would be screened as positive for therapy services. The DOR stated Residents #1 and #111 were not screened for PT. He stated quarterly, residents were reassessed to see where they were in therapy and at what level, which would be relayed to the physician to sign for new orders for therapy. He stated the risk of residents not being screened for therapy for residents who may need services could be a risk of contractures, decreased bed mobility, and increased need for assistants.<BR/>Interview on 12/19/24 at 12:26 PM with the Corporate RN revealed when it comes to screening for therapy, it would depend on facility to facility as well as the resident. She stated she would double-check the facility procedures. She stated Resident #1 and Resident #111 may have been overlooked in between DORs, as the new one just started. She stated ideally residents should be screened around admission. She stated the resident may not need therapy, but the facility would typically screen anyway to identify any deficits or to confirm there are no issues that would require therapy. The Corporate RN stated it also depended on payor source as well. She stated she was not sure how often therapy screened. She stated usually if a change in condition was identified or a fall, the facility would screen. She stated staff would talk in morning meetings, including the DOR and clinical staff, to identify residents who may have had falls from day to day and over the weekend. Therapist would then screen the residents identified and come up with a plan. The Corporate RN stated the PRN PT would just do baseline screening and establish plan of care/treatment care; PTAs would follow treatment plans established by PT. She stated there may not always be a PT, but they would come when an evaluation was needed. The Corporate RN stated they do have staffed PTA and COTAs that would do the treatments . Care meetings were conducted weekly, which would allow the facility time to identify concerns. She stated usually therapy would constantly look to screen as many residents as they could. The Corporate RN stated she would have to get therapy to see if there was a certain timeframe for screening. She stated the risk of not getting screened for PT if there was a change of condition or at admission was the resident may not be as independent, require more care, and may not get services that they need. She stated if the resident fell, she would expect staff to screen the resident for physical therapy services.<BR/>Review of Resident # 111's medical record revealed no screening for physical therapy. <BR/>In an interview on 12/19/24 at 2:06 PM, the Corporate RN stated she could not find a specific policy on screening for therapy and stated the admission policy included the IDT meeting in which therapy would have identified the resident for physical therapy screening.<BR/>Interview on 12/19/24 at 3:15 PM with the AIT revealed the expectation of therapy was for all residents to be screened for services. She stated the DOR was new and they were positive the residents would be picked up for services needed once the DOR had more time. The risk to the residents not being screened was their function could decline. The AIT stated the facility had morning meetings and therapy would stay behind for incident reports. She stated standard morning meetings happen so that residents were not missed. She stated the DOR would be responsible for ensuring all residents were screened for therapy. The AIT stated the expectation she had for therapy was to follow facility policy. She stated once the facility obtains a new DON, they would conduct more in-services. At this time, the facility was short-staffed and they were rushing through their work. <BR/>Review of the facility's Admission/Readmission policy, dated 2003, revealed, .initiate an interdisciplinary plan of care for the resident and place a copy on the clinical record .

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 1 (medication cart) of 1 medication cart on the memory care unit reviewed for pharmacy services<BR/>The facility failed to ensure discontinued medication were removed from the medication cart. Resident #1's Diazepam that was DC on 12/30/24 was in the narcotic box on the secure unit medication cart.<BR/>This failure could place residents at risk of unnecessary medication error and/or lead to possible harm or drug diversion.<BR/>The findings included:<BR/>Interview on 5/13/25 at 9:50 PM LVN A stated when medications were wasted, they should be crushed and disposed of and two people, 2 nurses, were to sign off on the narcotics sheet and document medication was wasted. <BR/>Observation and record review on 05/13/25 at 11:00 PM revealed a secure unit narcotic sheet that was not filled out completely for Resident #1's Diazepam 5 mg tablet. Review of Resident#1's Diazepam 5mg narcotic sheet reflected the 10th pill was given with no date and no signature. Further review revealed the 9th pill was removed on 4/11 /25and on 5/4/25 the 8th pill was marked off as wasted. Observation of Resident #1's Diazepam 5 mg package reflected the medication was still in the bubble pack for the 8th tablet. Observation of the Diazepam bubble package revealed medication was filled on 11/12/24. Review of the Diazepam narcotic sheet revealed the Diazepam was put on the medication cart on 11/14/25. <BR/>Record review of Resident #1's order summary revealed to give 1 tablet Diazepam by mouth every 6 hours as needed and not to exceed 3 daily until 12/30/24 for anxiety.<BR/>Record review of Resident#1's November MAR reflected Diazepam was administered on 4/11/24.<BR/>Record review of Resident #1's March 2025 MAR reflected Diazepam was not a listed medication. <BR/>Interview on 05/13/25 at 11:00 PM LVN A stated Resident#1's Diazepam was DC and the DON was responsible for coming to pick up the DC medication from the medication cart. LVN A stated when medication was wasted two nursing staff would sign off on the medication. LVN A stated narcotics were crushed and put in water.<BR/>Interview on 05/14/25 at 12:15 PM the DON stated she had not been informed of staff taking narcotic medications for personal use off the medication cart. <BR/>Interview and observation on 5/14/25 at 1:43 PM the DON stated Resident #1's 5mg Diazepam was DC on 12/30/24. She stated that DC medication needed to be brought to her as soon as possible. The DON stated that nurses was responsible for taking DC medications off the medication cart. The DON stated the pharmacy comes every other month to destroy medications. The DON stated residents are at risk of being given medications that are no longer needed. The DON stated when medications are wasted two nursing staff members are supposed to sign off. Observed the CN leave out of the DON, and she went to pull the DC medication off the secure unit cart. The CN stated the nurse must have written the number backwards instead of 04/11/24 it should have been 11/04/24. <BR/>Record review of the facility policy titled, Medication Administration Procedures revealed, 3. Open the unit dose package only when you are administering medication directly to the resident.<BR/>Record review of the policy titled Controlled Medication Disposal, undated, revealed, 3. Schedule II, III, IV and V medications remaining in the facility after the resident has been discharged , or the order<BR/>discontinued, are disposed either in the facility by legally authorized personnel, Director of Nursing, and Consultant Pharmacist .<BR/>Record review of the facility policy titled, Discontinued Medications, undated, reflected : Policy .When medications are discontinued by physician order, . the medications are marked appropriately and destroyed .Procedure 1. If a physician discontinues a medication .the medication container is marked the date discontinuance is indicated along with the initials of the nurse. 2. Medications awaiting disposal are stored in a locked secure area designated for that purpose until disposed of medications are removed from the medication cart immediately upon receipt of an order to discontinue avoiding inadvertent administration. 3. Discontinued medications are destroyed in accordance with destruction policy and procedure .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 4 residents (Resident #5) reviewed for preadmission screenings.<BR/>The facility failed to refer Resident #5 for PASRR Evaluation after a positive Level 1 PASRR 1 screening. <BR/>This failure could place residents at risk of receiving inadequate care.<BR/>The surveyor was unable to interview and observe Resident #5, as he was discharged on 11/02/24.<BR/>Record review of Resident # 5's face sheet dated 12/04/24 revealed that he was a 68 -year-old male who admitted to the facility on [DATE] and discharged on 11/02/24. His active diagnosis included: cognitive communication deficit (difficulty communicating caused by cognitive impairment), anxiety disorder (fear and worrying) and depression disorder (mood of sadness).<BR/>Record review of Resident #5's admission MDS dated [DATE], reflected a BIMS score of 12 indicating that he was moderately impaired cognitively. Section D addressed the resident's depression and feeling down with a total severity score of 3, indicating minimal depression. Review of Section N addressed Resident #5's MD orders for anxiety and depression medications. <BR/>Record review of Resident #5 's care plan dated 10/25/24 did not address his positive PASRR Level I for mental illness at the time of his admission. <BR/>Record review of Resident #5's MD orders on 12/04/24 reflected a referral for Psychiatric assessment. There were no orders for therapy, medication management for depression and anxiety noted. <BR/>Record review of Resident #5's Level 1 PASRR screening for dated 10/24/24 indicated he had a mental Illness on Section C0100, and it was not documented in Resident #5's electrical file at the time of his admission. At the time of investigation 12/03/24 there was no documentation addressing the resident PASRR process for PASRR Level 1 and PASRR Level 2.<BR/>Record review of Resident #5's Trauma informed dated 10/31/24 completed by the SW reflected score of 40.0 indicating he had a history of homelessness, mental disorders, anxiety, depression, Life threatening illness, serious accident resulting in limited mobility, fear, Got into some bad drugs, and believed I witchcraft., concluding that he had multiple life events that was affecting his mental status.<BR/>Record review of Resident #5's consent for services with Psychiatric [NAME] Service dated 10-31-24 reflected A recommendation and referral for services has been made to Psychiatric Consult Service by your treating physician for specialized care of your emotional and mental health. Our office, according to your respective insurance carrier, will bill fees for services .With this understanding, I [Resident #5] give consent for services and request that payment under my medical signed by [Resident #5]. Indicating that Resident #5 was referred for mental health services based on mental health illness documentation from his positive PASRR, and trauma informed social history assessment dated [DATE]. <BR/> The facility did not have an active social worker at the time of the investigation, therefore there was no interview.<BR/>Interview with the ADM on 12/04/24 at 3:52 PM, she stated she was a licenses Social Worker, and she was covering social worker task until the position was filled. She was aware that Resident # 5 was diagnosed with bipolar disorder, and the facility was to notify the stated appointed local authority within 24 to 48 hours after admission of the positive PASRR Level 1. The ADM stated that she had not received any training on the PASRR process, and the MDS was responsible for all notifications and documenting information in the resident file of the completed task. The ADM said that the risk of not following the PASRR notification process, following up with third party referral, and documenting service task and timelines in the resident's file could result in untimely mental health treatment, increased anxiety and depression, and behaviors. The Administrator stated that it was her responsibility and the corporate nurse to ensure all clinical task were completed timely.<BR/>Interview on 12/04/24 at 4:05 PM with the MDS Coordinator RN-L and LVN -A revealed that she was not aware of the timeline or the facility policy notifying state dedicated authority for positive Level I PASRR residents. She will go and review the policy. RN-L returned and stated that the facility policy states that the level 1 PASRR positive are uploaded by the MDS coordinator to Simple LTC and wait for the local authority to respond RN L said after reviewing her emails, she found an email correspondence dated 10/28/24, from the local authority that the PASRR email was received. RN-L said she did not follow up with the agency nor documented the email. RN-L said that the potential risk to a resident for not ensuring the referral process was documented and completed could result in resident not receiving the necessary services for mental illness.<BR/>Record review on 12/04/24 of corresponding email provided by RN-L from HCDS dated 10/28/24 at 4:04 AM reflected Please provide me with the Face Sheet, order summary, Care Plan, MDS, and Clinical's (Hospital) for the following individuals in your facility: [Resident #5]. After receiving the above information, PASRR will try to schedule a time and date with the facility to come. The PE evaluation document was not filed in Resident # 5's medical records.<BR/>Record review of RN-L dated 12/04/24 at 5:09 PM reflected below is the email communication with [local state authority] regarding scheduling of [Resident #5's] PE prior to his discharge. The PE evaluation document was not filed in Resident # 5's medical records.<BR/>In the interview with RN-L dated 12/04/24 at 5:25 PM stated that as I was looking closer, [Resident #5] did indeed have the PE completed prior to discharging. I just didn't register it when I was looking in SIMPLE, I apologize. It was completed 11/01/24, and he was deemed negative. The PE is attached.<BR/>Record review of Resident #5's PASRR Evaluation reflected that the MI evaluation was initiated on 10/30/24 completed by QMHP reflected in Section C that C0100 Primary DX of Dementia and C0200 severe Dementia Symptoms were answered no. C0600 was answered yes for Disruption in normal living situation requiring supportive services in the last 2 years. C0700 was answered yes for intervention by law enforcement. C0800 reflected based on the QMHP assessment, does this individual meet PASRR definition of mental illness, no. The date that this document was printed from https://secure.simpleltc.com/State/PL1/viewPE/1831208 dated 12/04/24 at 5:23 PM. This file was not in the resident medical records at the time of the investigation, and it was emailed prior to exit 12/04/24 at 5:45 PM. <BR/>Record review of the facility's titled PASRR Maintenance in the Active Paper Medical Record dated January 2018. Policy: It is the policy of this facility to ensure all PASRR Related forms and communication is maintained in the Resident's Medical Record under the PASRR Tab of the chart or electronically stored in the LTC Portal. PASRR record retention is permanent until informed otherwise. Person Responsible: Medical Records Procedure.<BR/>The following records will be filed under the PASRR Tab of the medical record:<BR/>Referring Entity (RE) PASRR Level (PL1) Screen for all Positive and Negative suspicion of MI. This includes NF PL1 and RE PL1's.<BR/>If the Residents is PASRR positive the following forms will follow:<BR/>LA (Local Authority) PASRR Evaluation (PE) Form for all confirmed Negative or Positive PE Forms. (Obtained from the LA). LA 1014 or Individual Service Plan (ISP) Forms. (Obtained from the LA). IDT Meeting (Printed from Simple LTC along with any handwritten notes or the handwritten IDT form prior to data entered and submitted to Simple LTC)<BR/>LA PSS (PASRR Specialized Service) (if applicable): Habilitative Therapy Communication Progress Notes: All communication to any outside entity regarding PASRR must be documented in PCC under Progress Notes, Printed and Placed in the MR under the PASRR Tab. This includes anytime communication occurs between the NF (Nursing Facility) and LA (Local Authority) or DME/CMWC (Durable Medical Equipment/Customized Manual Wheelchair) Vendors, the communication must be documented.<BR/>Review of state operations manager GUIDANCE &sect;483.20(k)(1)-(3) The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders, intellectual disabilities, and related conditions. This initial screening is referred to as Level I Identification of individuals with MD (mental disorder), ID (intellectual Disorder), (&sect;483.128) and is completed prior to admission to a nursing facility. The purpose of the Level I pre-admission screening is to identity individuals who have or may have MD/ID or a related condition, who would then require PASARR Level II evaluation and determination prior to admission to the facility. Level II PASARR is a comprehensive evaluation conducted by the appropriate state designated authority that determines whether an individual has MD (mental disorder), ID (intellectual Disorder), or a related condition as defined above, determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs. The Level II PASARR cannot be conducted by the nursing facility.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of resident's admission for 1 (Resident #5) of 4 residents reviewed for baseline care plans. <BR/>The facility failed to ensure Resident #5's baseline care plan addressed his Level 1 PASSR, mental illness, anxiety, and depression within 48 hours of resident's admission. <BR/>This failure could place the residents at increased risk of not having their individual needs identified, met and a decreased quality of life.<BR/>Findings included:<BR/>The surveyor was unable to interview and observe Resident #5, as he was discharged on 11/02/24.<BR/>Record review of Resident # 5's face sheet dated 12/04/24 revealed that he was a 68 -year-old male who admitted to the facility on [DATE] and discharged on 11/01/24. He had an active diagnosis of cognitive communication deficit (difficulty communicating caused by cognitive impairment), anxiety disorder (fear and worrying) and depression disorder (mood of sadness) with an onset date of 10/24/24.<BR/>In a record review of Resident #5's admission MDS dated [DATE], reflected a BIMS score of 12 indicating that he was moderately impaired cognitively. Section D addressed the resident's depression and feeling down total severity score of 3 indicating minimal depression. Section N addressed the residents MD orders for anxiety and depression medications. <BR/>In a record review of Resident #5 's baseline care plan and comprehensive care plan dated 10/25/24 reflected the had cognitive loss impaired cognitive function, interventions administer medications as ordered, communicate with resident/family/caregivers regarding resident capabilities and needs, dated 11/04/24. The care plan does not address resident did not address his positive PASRR Level I for mental illness, anxiety disorder, and depression disorder.<BR/>The facility does not currently have a DON; therefore, an interview was not completed.<BR/>In an interview on 12/04/24 at 3:52 PM with the ADM revealed due to the facility not having an onsite DON nurse or a dedicated nurse to complete care plans, all facility nurses, including herself were responsible for baseline care plan initiation and completion. The ADM stated that she expects the baseline care plan to be accurate and individualized to provide the necessary care to the resident to prevent a decline in abilities. The ADM stated that it was the responsibility of the DON, IDT meeting, and ADM to monitor and ensure that baseline care plans are completed timely. The ADM stated that the corporate nurse was visiting the building in the interim until a DON was hired. She has been using the MDS coordinator to assist with DON duties.<BR/>In an interview with MDS RN L on 12/04/24 at 4:05 PM, she stated that she was not responsible for monitoring care plans in the interim of DON hiring. She stated that she completed MDS assessments and occasionally answers nursing protocol clinically for the facility. She said the corporate nurse was visiting the building daily and remote to respond to daily clinical concerns. <BR/>The corporate nurse was not interviewed as she was in a meeting off site.<BR/>Record review of facility policy entitled Comprehensive Resident Centered Care Plans, undated Comprehensive Care Planning, the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR and the resident's representative(s)-The resident's goals for admission and desired outcomes. Comprehensive Care Plans: A comprehensive care plan will be-Developed within 7 days after completion of the comprehensive assessment. Prepared and/or contributed to by an interdisciplinary team, that includes but is not limited to- The attending physician. A registered nurse with responsibility for the resident. A nurse aide with responsibility for the resident. A member of food and nutrition services staff. To the extent practicable, the participation of the resident and the resident's representative(s). An explanation will be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. <BR/>CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. <BR/>CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). <BR/>These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. <BR/>Findings include:<BR/> A record review of Resident #1's electronic face sheet, dated 02/09/23, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included muscle weakness, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one?sided weakness) following intracerebral hemorrhage (bleeding into the brain tissue) affecting right dominant side, muscle wasting and atrophy, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS of 15, which indicated the resident's cognition was intact. Resident #1's MDS revealed she required extensive assistance with two-persons physical assistance for the following ADLs: bed mobility, transfers, and toilet use. <BR/>A record review of Resident #1's Care Plan dated 10/13/22 revealed Resident #1 had an ADL self-care performance deficit related to weakness on right side upper and lower extremities with history of CVA impaired mobility for bed mobility, toilet use, transfers. The interventions included the following: Toilet Use: The resident requires Extensive Assist x2 providers; Transfer: Requires Extensive Assist x2 providers.<BR/>A record review of Resident #1's Progress Notes by LVN C, dated 01/15/23, revealed Resident was being transferred to bed by agency CNA when she became weak, and CNA lowered her slowly to the floor with no complications. Resident noted stable denied no pain or any discomfort at this time. Resident was alert and oriented x4 with all upper and lower extremity functioning. Resident able to explain that she was assisted to sit on the floor by CNA since she could not bear weight. All vital signs within reach b/p 127/66, pulse 64, temp 98. Resident successfully assisted to bed using Hoyer lift.<BR/>A record review of Resident #1's Progress Notes by LVN D, dated 01/18/23, revealed At approximately 0700 Aide called stating that resident was on floor. Writer went to room resident was sitting on floor head leaning to assigned aides leg, who was standing beside resident's bed. Vitals remain within normal limit. No temperature noted. Resident complain of pain to right shoulder and arm. Assessment completed mild inflammation noted on site and painful to touch. Staff instructed to immobilize arm (not to move arm). MD notified. New order received to send resident to the ER for further evaluation. Medication audited noted administration of Tylenol 3 at 0600. Schedule gabapentin of 600 mg administered at this time. 911 call at approximately 0715 and resident was sent out to the ER [hospital] at 0725. RP Notified and aware of hospital of choice. <BR/>A record review of Resident #1's hospital paperwork, dated 01/19/23, revealed she was admitted to the hospital on [DATE] at 7:58 AM due to right shoulder pain from a fall. The hospital record revealed x-rays were completed on Resident #1's right shoulder and she was diagnosed with a closed fracture of neck of right humerus, initial encounter.<BR/>An observation and an interview on 02/09/23 at 10:19 AM, revealed Resident #1's right arm was in a sling. Resident #1 stated she had fall a couple of times in the facility, but she did not recall the details or the dates of the falls. Resident #1 stated in the last fall she was sent to the hospital and her arm was broken. She stated her arm was very sore. Resident #1 stated each time she fell it was while she was being transferred in and out of bed. She stated in the last fall she was being put in the bed and her paralyzed leg (right side) got stuck while she was being turned towards the bed. Resident #1 stated the CNA could not hold her up and they slid to the floor. She stated there was only one CNA transferring her in or out of bed each time she fell. <BR/>In an interview on 02/09/23 at 12:23 PM, the ADMN and DON, the ADMN stated Resident #1 was a 2-persons assist and after the fall on 01/18/23, she was changed to Hoyer lift for transfers. The ADMN stated both falls were with agency staff, but their facility staff all knew Resident #1 was a 2-person assist. The DON stated staff were in-serviced after each fall. The ADMN stated when agency staff worked at the facility, they were supposed to round with a facility staff member at the beginning of their shift. The ADMN stated the facility staff were supposed to go over the resident's needs, such as transfer status during the rounds. <BR/>In an interview on 02/09/23 at 1:14 PM, the Nurse Manager stated she was aware of the falls from 01/15/23 and 01/18/23. She stated she in-serviced staff about falls and transfers after each incident. The Nurse Manager stated when agency staff arrived, they were supposed to check in with the charge nurse and they would receive their assignment. She stated whoever the agency staff was relieving they were supposed to round with them, and discuss resident's needs, such as transfers. The Nurse Manager stated they had started using more agency around the times of the incidents, so she did an in-service about rounding. The Nurse Manager stated CNA B was assigned to round with CNA E. She stated she did not know about CNA A because this happened in the evening after she left for the day. <BR/>In an interview on 02/09/23 at 1:46 PM, CNA E stated she worked on 01/18/23 and was assigned to do rounds with CNA B. She stated she provided CNA B with a cheat sheet, which had info about the residents, which included who was incontinent, who needed help with feeding, and transfer requirements, such as who needed a Hoyer lift. CNA E stated Resident #1 was a two-persons transfer and when they rounded, she told the agency CNA B to let her know when she needed help with transfers. She said Resident #1 is a larger lady, so she doesn't know why CNA B would try to transfer her by herself. CNA E stated facility staff always used two people. <BR/>In a phone interview on 02/10/23 at 2:48 PM, LVN C stated on 01/15/23, he was called into Resident #1's room by CNA A. He stated CNA A said she was getting Resident #1 out of her wheelchair to put her in the bed. LVN C stated CNA A said she could not hold resident up by herself and so they slide down to the floor. LVN C stated Resident #1 was a 2-persons assist. He stated he had always observed facility staff using two CNAs when transferring Resident #1 to and from bed, but CNA A was agency. <BR/>LVN C stated he asked CNA A why she attempted to transfer Resident #1 by herself, without asking for help. He stated CNA A said she told Resident #1 she was going to get help and Resident #1 told her she was able to stand by herself and only needed one aide to help her. LVN C stated CNA A said she believed what the resident said, so she attempted to transfer her. LVN C stated Resident #1 is a larger lady and CNA A said she could not hold her weight, when Resident #1 stood out of the wheelchair, so they slide to the ground. LVN C stated agency staff are usually paired with a facility staff to do rounds, but he was not sure if she completed rounds because he worked a 12 hr. shift on the weekends and CNA A had already started her shift before he arrived. <BR/>On 02/13/23 at 2:10 PM, the Administrator communicated she had attempted to get CNA A's phone number from the staffing agency via email and by phone and was unable to get her number. <BR/>In a phone interview on 02/09/23 at 5:49 PM, LVN D stated on 01/18/23 she was called to Resident #1's room by CNA B, who told her she was transferring Resident #1 from the bed and could not hold her up, so she lowered Resident #1 to the floor. LVN D stated Resident #1 was a 2-persons transfer and maybe because CNA B was agency she did not know. LVN D stated she had never seen facility CNAs transferring the resident by themselves. She stated when agency CNAs checked in, she was supposed to pair them with a facility CNA to do rounds. LVN D stated during rounds, the facility CNA was supposed to educate the agency CNAs on the resident's needs, such as how they were transferred. LVN D stated she did pair CNA B with a facility CNA. She stated she did not recall who she was paired with, but she was sure she paired her. <BR/>In a phone interview on 02/10/23 at 10:41 AM, CNA B stated she was agency staff and she had worked at the facility twice before 01/18/23. CNA B stated she was not sure if Resident #1 was a 2-persons assist for transfers. CNA B stated when she had worked with Resident #1 before, she had transferred her by herself, and she was able to pivot her good side to help with transfer. She stated Resident #1 was ready to get up and into her wheelchair so she could go smoke. CNA B stated she was changing Resident #1's brief and stood her up to pull up the brief. CNA B stated she had a weak side that she could not really move, so she was holding her up under her arm on the weak side, which was her right side. She stated Resident #1 was standing and as she pulled her brief up, and suddenly Resident #1 started screaming that her arm was hurting, and she could not hold on. CNA B stated she lowered Resident #1 to the floor to ensure she doesn't hit her head. She stated she did not move resident and called for a nurse. CNA B stated she was in-serviced on falls and transfers after the incident. She stated she did do rounds with another CNA (doesn't recall her name) at the beginning of her shift. CNA B stated when she rounded with the CNA, she was telling her who required Hoyer lift and what the resident needed help with. She stated the CNA did not provide a paper with the resident's needs. CNA B stated when she was rounding with the CNA and they got to Resident #1's room, the CNA told her to start with Resident #1 first because if she missed her first smoke break then she would get upset. CNA B stated the CNA never told her Resident #1 required two people to transfer her, but she did tell her if she needed help with Resident #1, then let her know.<BR/>A record review of the facility's in-services revealed staff were in-serviced on falls and transfers on 01/16/23 and 01/18/23. A further review revealed staff were in-serviced on 01/12/23 on Rounding oncoming shift: CNAs round with CNAs and Nurses round with Nurses. <BR/>A record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, dated 2003, revealed Purpose: The purposes of this procedure are to allow the resident to bout of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure: Note: This procedure may require two (2) persons. H. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 (Resident #10 and Resident #11) of 9 residents reviewed for ADL care. <BR/>The facility failed to ensure Resident #10, and Resident #11 were provided showers as scheduled.<BR/>These failures could place residents at risk of not receiving services and a decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #11's admission record, dated 07/23/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, end stage renal disease, muscle weakness, and dependence on renal dialysis. <BR/>Record review of Resident #11's Quarterly MDS dated [DATE], reflected a BIMS score of 14, indicating intact cognition. Further review of the MDS revealed Resident #11 required partial/moderate assistance for showering/bathing. <BR/>Record review of Resident #11's Care plan, undated, did not indicate resident refused showers.<BR/>Record review of Resident #11's nurse notes from 03/30/2024 to 06/02/2024 did not indicate resident refused showers. <BR/>Record review of Resident #11's April 2024 ADL sheets reflected shower days were Monday, Wednesday and Friday and prn. Resident #11 received 4 out of 12 showers in April 2024. Showers were given on 04/22/24, 04/24/24, 04/26/24, and 04/29/24. On 04/03/24 and 04/12/24 there were blanks on the ADL sheet. On 04/01/24, 04/05/24, 04/10/24, 04/15/24, 04/17/24, and 04/19/24, 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #11's May 2024 ADL sheets revealed Resident #11 received 4 out of 13 showers in May 2024. Showers were given on 05/06/24, 05/08/24, 05/10/24, and 05/27/24. On 05/01/24, 05/03/24, 05/13/24, 05/17/24 and 05/24/24 there were blanks on the ADL sheet. On 05/15/24, 05/20/24, 05/22/24, and 05/29/24 an 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #11's nursing progress note, dated 06/02/2024, revealed [Resident #11] discharge to home. <BR/>Record review of Resident #10's admission record, dated 07/24/2024, revealed a [AGE] year-old-male who admitted to the facility on [DATE] with a diagnosis of paraplegia. <BR/>Record review of Resident #10's Quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition. Further review of the MDS revealed Resident #10 required supervision or touching assistance with showering/bathing. <BR/>Record review of Resident #10's May 2024 ADL sheets reflected shower days were Monday, Wednesday and Friday and prn. Resident #11 received 2 out of 11 showers in May 2024. Showers were given on 05/01/24 and 05/29/24. On 05/17/24 there was a blank on the ADL sheet. On 05/03/24, 05/08/24, 05/10/24, 05/13/24, 05/15/24, 05/20/24, and 05/22/24 an 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #10's June 2024 ADL sheets revealed Resident #11 received 2 out of 12 showers in June 2024. Showers were given on 06/21/24 and 06/29/24. On 06/10/24, 06/14/24, and 06/19/24 there were blanks on the ADL sheet. On 06/03/24, 06/05/24, 06/07/24, 06/12/24, 06/17/24, 06/24/24, 06/26/24 and 06/28/24 an 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #10's July 2024 ADL sheets revealed Resident #11 received 7 out of 11 showers in July 2024. Showers were given on 07/03/24, 07/05/24, 07/10/24, 07/11/24, and 07/17/24, 07/21/24 and 07/22/24. On 07/12/24, and 07/24/24 there were blanks on the ADL sheet. On 07/01/24, 07/08/24, 07/10/24, 07/15/24, 07/19/24 an 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #10's nursing progress notes from 05/01/2204 through 07/23/2024 did not indicated refusal of showers. <BR/>Interview on 07/24/2024 at 10:42 am, Resident #10 stated he does not get showers 3 times a week. He stated one of the CNA's will make sure he gets a bed bath when he works. Resident #10 stated his shower days were Monday, Wednesday, and Friday. Resident #10 stated the last time he had a shower or bed bath was on Monday (07/22/24). <BR/>Interview on 07/24/2024 at 1:34 pm the ADON stated even numbered rooms had shower days on Monday, Wednesday and Friday and odd numbered rooms had showed days on Tuesday, Thursday and Saturday. The ADON stated 6a-2p shift provided A bed showers and 2-10p shift provided B bed showers. She stated the CNA's showered residents, and they documented in POC. She said if a resident refused a shower, the CNA was supposed to go back and try again 3 times, then inform the nurse so the nurse will ask the resident. She said if the resident still refused then the nurse would document the refusal in a progress note. She stated CNAs were required to document when a shower was given or when refused and the IDT team checks POC for documentation. She stated if any documentation was missing the IDT team would go back to the staff to remind them to document.<BR/>Interview on 07/24/2024 at 2:17 pm CNA C stated if a resident refused a shower she would document, let the nurse know and tell the ADON. When asked about the blanks on the ADL sheet for Resident #11, she stated the showers were not given. When asked about the 8 activity did not occur she stated that meant a refusal. She stated MDS provided training for the CNA's on how to document ADL care.<BR/>Interview on 07/24/2024 at 2:35 pm, MDS Coordinator A stated they had done some training for CNAs on documentation related to ADL care. She said there was a different numbering system from 1-6, and CNAs would chart if the resident was independent, supervision, limited, extensive and total dependence, if activity did not occur or refused. When asked about the blanks on the ADL sheets, she stated she assumed the showers were not given. When asked about the code of 8 activity did not occur she stated she would talk with the other MDS Coordinator. <BR/>Interview on 07/24/2024 at 2:47 pm, the DON stated his expectation was if the resident got a shower, CNAs was supposed to document they were given one. If the resident refused, the CNA needed to let the nurse know. He stated if the resident kept refusing, they had to care plan that. He said it was important to document showers were given or refusals for reference and to know if the shower was given. He said the unit manager monitored that showers were given, and documentation was done. The DON said they did not have a policy on showers, just the schedule. <BR/>Interview on 07/24/2024 at 2:55 pm, MDS Coordinator B stated there should have been some documentation on the blank spots on the ADLS sheets. She said if the CNA coded it at an 8, it could have meant a number of things, like the resident refused or was out of the facility. <BR/>Interview on 07/24/2024 at 3:00 pm, CNA D she did not give Resident #11 or Resident #10 showers. She said if a resident refused a shower, she would leave then come back and try 3-4 times before she told the nurse. When asked if she documents the refusals, she said it only gives you 2 options either the shower or refused. She stated it was important to document to explain whether the person refused or did get a shower.<BR/>Record review of facility policy titled Bed bath, Complete undated, and Bath, Tub/Shower undated, reflected the procedure for a bed bath and shower, but did not reflect to document showers or refusals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and care to maintain good foot health by providing foot care and treatment, in accorance with professional standards of practice, including to prevent complications from the resident's medical condition, for four of eight residents (Residents #1, #2, #3 and #4) reviewed for foot care. <BR/>The facility failed ensure foot care, specifically trimming of toenails, was provided for Residents #1, #2, and #3.<BR/>This failure could result in residents developing fungal infections or other podiatric problems. <BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to that facility on 05/10/23 with diagnoses that included senile degeneration of the brain (severe decline in mental ability), high blood pressure, and delusions. <BR/>Review of Resident #1's quarterly MDS assessment, dated 02/23/24, revealed a BIMS score not calculated due to her mental condition. Her Functional Status indicated she was independent in her ADLs except for bathing which required substantial staff assistance. <BR/>Review of Resident #1's care plan, dated 03/04/24, indicated she was at risk for skin impairment related to cognitive deficits, and an ADL self-care deficit. <BR/>Review of Resident #2's undated admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, delusions, and difficulty walking. <BR/>Review of Resident #2's quarterly MDS assessement, dated 02/23/24, revealed a BIMS score that was not calculated because of the resident's mental status. Her Functional Status indicated she required assistance with all of her ADLs. <BR/>Review of Resident #2's care plan, dated 02/27/24, revealed she had an ADL self-care deficit related to her cognitive deficits, and she had impaired cognitive function related to dementia. <BR/>Review of Resident #3's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, cognitive communication deficit, and diabetes. <BR/>Review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score not calculated due to his mental status. His Functional Status indicated he was independent in all of his ADLs. <BR/>Review of Resident #3's care plan, dated 03/20/24, indicated he had skin impairment related to history of shingles, cognitive function impairment, and he had a ADL self-care deficit related to dementia. <BR/>Review of Resident #4's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (blood chemical imbalance causing brain shrinkage), communication deficit, and seizures. <BR/>Review of Resident #4's quarterly MDS assessment, dated 02/20/24, indicated a BIMS score of 14 indicating he was cognitively intact. His Functional Status indicated he was independent in his ADLs except for hygiene which required supervision. <BR/>Review of Resident #4's care plan, dated 03/20/24, reflected he had skin impairment related to shingles, and he was diagnosed with diabetes and had a self-care deficit. <BR/>Observation and interview on 04/07/24 with Resident #1 revealed she bathed herself and kept her room clean. Skin assessment, performed by RN A, revealed no bruising to Resident #1's body, no wounds to her feet, but her toenails were overgrown. The resident's left great toenail was thick and appeared to be blackened underneath the nail. <BR/>Observation on 04/07/24 at 11:43 AM revealed Resident #3's toenails were overgrown.<BR/>Observation on 04/07/24 at 11:48 AM revealed Resident #2's toenails were grossly overgrown, and the nails were thick and curved. <BR/>Interview on 04/07/24 at 11:50 AM with RN A revealed the nursing staff could trim all toenails, even diabetic residents, unless they were thick and deformed in which case they would see the podiatrist. <BR/>Observation and interview on 04/07/24 at 11:57 AM with Resident #4 revealed his toenaile swere severely overgrown. The resident could not recall the last time anyone had trimmed his toenails.<BR/>Interview on 04/07/24 at 12:31 PM with LVN B revealed all toenails had to be trimmed by the podiatrist, and the nursing staff did not do that.<BR/>Interview on 04/07/24 at 12:40 PM with the DON revealed nurses should trim all resident toenails unless they were thickened or deformed, in which case they would be referred to the Podiatrist, who visited quarterly.<BR/>Review of Podiatry visits for 02/23/24, 03/22/24, and 03/26/24 revealed Residents #1, #2, #3, and #4 had not been seen by the podiatrist. The residents were also not scheduled to see the Podiatrist on 04/17/24. <BR/>Review of the facility's undated policy Nail Care reflected:<BR/>Nail care is the regular care of the toenails and fingernails to promote cleanliness and skin integrity issues .<BR/>Goals:<BR/>1. Nail care will be performed regularly and safely.<BR/>2. The resident will be free from abnormal nail condition.<BR/>3. The resident will be free from infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 (Resident #10 and Resident #11) of 9 residents reviewed for ADL care. <BR/>The facility failed to ensure Resident #10, and Resident #11 were provided showers as scheduled.<BR/>These failures could place residents at risk of not receiving services and a decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #11's admission record, dated 07/23/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, end stage renal disease, muscle weakness, and dependence on renal dialysis. <BR/>Record review of Resident #11's Quarterly MDS dated [DATE], reflected a BIMS score of 14, indicating intact cognition. Further review of the MDS revealed Resident #11 required partial/moderate assistance for showering/bathing. <BR/>Record review of Resident #11's Care plan, undated, did not indicate resident refused showers.<BR/>Record review of Resident #11's nurse notes from 03/30/2024 to 06/02/2024 did not indicate resident refused showers. <BR/>Record review of Resident #11's April 2024 ADL sheets reflected shower days were Monday, Wednesday and Friday and prn. Resident #11 received 4 out of 12 showers in April 2024. Showers were given on 04/22/24, 04/24/24, 04/26/24, and 04/29/24. On 04/03/24 and 04/12/24 there were blanks on the ADL sheet. On 04/01/24, 04/05/24, 04/10/24, 04/15/24, 04/17/24, and 04/19/24, 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #11's May 2024 ADL sheets revealed Resident #11 received 4 out of 13 showers in May 2024. Showers were given on 05/06/24, 05/08/24, 05/10/24, and 05/27/24. On 05/01/24, 05/03/24, 05/13/24, 05/17/24 and 05/24/24 there were blanks on the ADL sheet. On 05/15/24, 05/20/24, 05/22/24, and 05/29/24 an 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #11's nursing progress note, dated 06/02/2024, revealed [Resident #11] discharge to home. <BR/>Record review of Resident #10's admission record, dated 07/24/2024, revealed a [AGE] year-old-male who admitted to the facility on [DATE] with a diagnosis of paraplegia. <BR/>Record review of Resident #10's Quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition. Further review of the MDS revealed Resident #10 required supervision or touching assistance with showering/bathing. <BR/>Record review of Resident #10's May 2024 ADL sheets reflected shower days were Monday, Wednesday and Friday and prn. Resident #11 received 2 out of 11 showers in May 2024. Showers were given on 05/01/24 and 05/29/24. On 05/17/24 there was a blank on the ADL sheet. On 05/03/24, 05/08/24, 05/10/24, 05/13/24, 05/15/24, 05/20/24, and 05/22/24 an 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #10's June 2024 ADL sheets revealed Resident #11 received 2 out of 12 showers in June 2024. Showers were given on 06/21/24 and 06/29/24. On 06/10/24, 06/14/24, and 06/19/24 there were blanks on the ADL sheet. On 06/03/24, 06/05/24, 06/07/24, 06/12/24, 06/17/24, 06/24/24, 06/26/24 and 06/28/24 an 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #10's July 2024 ADL sheets revealed Resident #11 received 7 out of 11 showers in July 2024. Showers were given on 07/03/24, 07/05/24, 07/10/24, 07/11/24, and 07/17/24, 07/21/24 and 07/22/24. On 07/12/24, and 07/24/24 there were blanks on the ADL sheet. On 07/01/24, 07/08/24, 07/10/24, 07/15/24, 07/19/24 an 8, 8 was entered on the ADL sheet indicating activity did not occur. <BR/>Record review of Resident #10's nursing progress notes from 05/01/2204 through 07/23/2024 did not indicated refusal of showers. <BR/>Interview on 07/24/2024 at 10:42 am, Resident #10 stated he does not get showers 3 times a week. He stated one of the CNA's will make sure he gets a bed bath when he works. Resident #10 stated his shower days were Monday, Wednesday, and Friday. Resident #10 stated the last time he had a shower or bed bath was on Monday (07/22/24). <BR/>Interview on 07/24/2024 at 1:34 pm the ADON stated even numbered rooms had shower days on Monday, Wednesday and Friday and odd numbered rooms had showed days on Tuesday, Thursday and Saturday. The ADON stated 6a-2p shift provided A bed showers and 2-10p shift provided B bed showers. She stated the CNA's showered residents, and they documented in POC. She said if a resident refused a shower, the CNA was supposed to go back and try again 3 times, then inform the nurse so the nurse will ask the resident. She said if the resident still refused then the nurse would document the refusal in a progress note. She stated CNAs were required to document when a shower was given or when refused and the IDT team checks POC for documentation. She stated if any documentation was missing the IDT team would go back to the staff to remind them to document.<BR/>Interview on 07/24/2024 at 2:17 pm CNA C stated if a resident refused a shower she would document, let the nurse know and tell the ADON. When asked about the blanks on the ADL sheet for Resident #11, she stated the showers were not given. When asked about the 8 activity did not occur she stated that meant a refusal. She stated MDS provided training for the CNA's on how to document ADL care.<BR/>Interview on 07/24/2024 at 2:35 pm, MDS Coordinator A stated they had done some training for CNAs on documentation related to ADL care. She said there was a different numbering system from 1-6, and CNAs would chart if the resident was independent, supervision, limited, extensive and total dependence, if activity did not occur or refused. When asked about the blanks on the ADL sheets, she stated she assumed the showers were not given. When asked about the code of 8 activity did not occur she stated she would talk with the other MDS Coordinator. <BR/>Interview on 07/24/2024 at 2:47 pm, the DON stated his expectation was if the resident got a shower, CNAs was supposed to document they were given one. If the resident refused, the CNA needed to let the nurse know. He stated if the resident kept refusing, they had to care plan that. He said it was important to document showers were given or refusals for reference and to know if the shower was given. He said the unit manager monitored that showers were given, and documentation was done. The DON said they did not have a policy on showers, just the schedule. <BR/>Interview on 07/24/2024 at 2:55 pm, MDS Coordinator B stated there should have been some documentation on the blank spots on the ADLS sheets. She said if the CNA coded it at an 8, it could have meant a number of things, like the resident refused or was out of the facility. <BR/>Interview on 07/24/2024 at 3:00 pm, CNA D she did not give Resident #11 or Resident #10 showers. She said if a resident refused a shower, she would leave then come back and try 3-4 times before she told the nurse. When asked if she documents the refusals, she said it only gives you 2 options either the shower or refused. She stated it was important to document to explain whether the person refused or did get a shower.<BR/>Record review of facility policy titled Bed bath, Complete undated, and Bath, Tub/Shower undated, reflected the procedure for a bed bath and shower, but did not reflect to document showers or refusals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. <BR/>CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. <BR/>CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). <BR/>These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. <BR/>Findings include:<BR/> A record review of Resident #1's electronic face sheet, dated 02/09/23, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included muscle weakness, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one?sided weakness) following intracerebral hemorrhage (bleeding into the brain tissue) affecting right dominant side, muscle wasting and atrophy, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS of 15, which indicated the resident's cognition was intact. Resident #1's MDS revealed she required extensive assistance with two-persons physical assistance for the following ADLs: bed mobility, transfers, and toilet use. <BR/>A record review of Resident #1's Care Plan dated 10/13/22 revealed Resident #1 had an ADL self-care performance deficit related to weakness on right side upper and lower extremities with history of CVA impaired mobility for bed mobility, toilet use, transfers. The interventions included the following: Toilet Use: The resident requires Extensive Assist x2 providers; Transfer: Requires Extensive Assist x2 providers.<BR/>A record review of Resident #1's Progress Notes by LVN C, dated 01/15/23, revealed Resident was being transferred to bed by agency CNA when she became weak, and CNA lowered her slowly to the floor with no complications. Resident noted stable denied no pain or any discomfort at this time. Resident was alert and oriented x4 with all upper and lower extremity functioning. Resident able to explain that she was assisted to sit on the floor by CNA since she could not bear weight. All vital signs within reach b/p 127/66, pulse 64, temp 98. Resident successfully assisted to bed using Hoyer lift.<BR/>A record review of Resident #1's Progress Notes by LVN D, dated 01/18/23, revealed At approximately 0700 Aide called stating that resident was on floor. Writer went to room resident was sitting on floor head leaning to assigned aides leg, who was standing beside resident's bed. Vitals remain within normal limit. No temperature noted. Resident complain of pain to right shoulder and arm. Assessment completed mild inflammation noted on site and painful to touch. Staff instructed to immobilize arm (not to move arm). MD notified. New order received to send resident to the ER for further evaluation. Medication audited noted administration of Tylenol 3 at 0600. Schedule gabapentin of 600 mg administered at this time. 911 call at approximately 0715 and resident was sent out to the ER [hospital] at 0725. RP Notified and aware of hospital of choice. <BR/>A record review of Resident #1's hospital paperwork, dated 01/19/23, revealed she was admitted to the hospital on [DATE] at 7:58 AM due to right shoulder pain from a fall. The hospital record revealed x-rays were completed on Resident #1's right shoulder and she was diagnosed with a closed fracture of neck of right humerus, initial encounter.<BR/>An observation and an interview on 02/09/23 at 10:19 AM, revealed Resident #1's right arm was in a sling. Resident #1 stated she had fall a couple of times in the facility, but she did not recall the details or the dates of the falls. Resident #1 stated in the last fall she was sent to the hospital and her arm was broken. She stated her arm was very sore. Resident #1 stated each time she fell it was while she was being transferred in and out of bed. She stated in the last fall she was being put in the bed and her paralyzed leg (right side) got stuck while she was being turned towards the bed. Resident #1 stated the CNA could not hold her up and they slid to the floor. She stated there was only one CNA transferring her in or out of bed each time she fell. <BR/>In an interview on 02/09/23 at 12:23 PM, the ADMN and DON, the ADMN stated Resident #1 was a 2-persons assist and after the fall on 01/18/23, she was changed to Hoyer lift for transfers. The ADMN stated both falls were with agency staff, but their facility staff all knew Resident #1 was a 2-person assist. The DON stated staff were in-serviced after each fall. The ADMN stated when agency staff worked at the facility, they were supposed to round with a facility staff member at the beginning of their shift. The ADMN stated the facility staff were supposed to go over the resident's needs, such as transfer status during the rounds. <BR/>In an interview on 02/09/23 at 1:14 PM, the Nurse Manager stated she was aware of the falls from 01/15/23 and 01/18/23. She stated she in-serviced staff about falls and transfers after each incident. The Nurse Manager stated when agency staff arrived, they were supposed to check in with the charge nurse and they would receive their assignment. She stated whoever the agency staff was relieving they were supposed to round with them, and discuss resident's needs, such as transfers. The Nurse Manager stated they had started using more agency around the times of the incidents, so she did an in-service about rounding. The Nurse Manager stated CNA B was assigned to round with CNA E. She stated she did not know about CNA A because this happened in the evening after she left for the day. <BR/>In an interview on 02/09/23 at 1:46 PM, CNA E stated she worked on 01/18/23 and was assigned to do rounds with CNA B. She stated she provided CNA B with a cheat sheet, which had info about the residents, which included who was incontinent, who needed help with feeding, and transfer requirements, such as who needed a Hoyer lift. CNA E stated Resident #1 was a two-persons transfer and when they rounded, she told the agency CNA B to let her know when she needed help with transfers. She said Resident #1 is a larger lady, so she doesn't know why CNA B would try to transfer her by herself. CNA E stated facility staff always used two people. <BR/>In a phone interview on 02/10/23 at 2:48 PM, LVN C stated on 01/15/23, he was called into Resident #1's room by CNA A. He stated CNA A said she was getting Resident #1 out of her wheelchair to put her in the bed. LVN C stated CNA A said she could not hold resident up by herself and so they slide down to the floor. LVN C stated Resident #1 was a 2-persons assist. He stated he had always observed facility staff using two CNAs when transferring Resident #1 to and from bed, but CNA A was agency. <BR/>LVN C stated he asked CNA A why she attempted to transfer Resident #1 by herself, without asking for help. He stated CNA A said she told Resident #1 she was going to get help and Resident #1 told her she was able to stand by herself and only needed one aide to help her. LVN C stated CNA A said she believed what the resident said, so she attempted to transfer her. LVN C stated Resident #1 is a larger lady and CNA A said she could not hold her weight, when Resident #1 stood out of the wheelchair, so they slide to the ground. LVN C stated agency staff are usually paired with a facility staff to do rounds, but he was not sure if she completed rounds because he worked a 12 hr. shift on the weekends and CNA A had already started her shift before he arrived. <BR/>On 02/13/23 at 2:10 PM, the Administrator communicated she had attempted to get CNA A's phone number from the staffing agency via email and by phone and was unable to get her number. <BR/>In a phone interview on 02/09/23 at 5:49 PM, LVN D stated on 01/18/23 she was called to Resident #1's room by CNA B, who told her she was transferring Resident #1 from the bed and could not hold her up, so she lowered Resident #1 to the floor. LVN D stated Resident #1 was a 2-persons transfer and maybe because CNA B was agency she did not know. LVN D stated she had never seen facility CNAs transferring the resident by themselves. She stated when agency CNAs checked in, she was supposed to pair them with a facility CNA to do rounds. LVN D stated during rounds, the facility CNA was supposed to educate the agency CNAs on the resident's needs, such as how they were transferred. LVN D stated she did pair CNA B with a facility CNA. She stated she did not recall who she was paired with, but she was sure she paired her. <BR/>In a phone interview on 02/10/23 at 10:41 AM, CNA B stated she was agency staff and she had worked at the facility twice before 01/18/23. CNA B stated she was not sure if Resident #1 was a 2-persons assist for transfers. CNA B stated when she had worked with Resident #1 before, she had transferred her by herself, and she was able to pivot her good side to help with transfer. She stated Resident #1 was ready to get up and into her wheelchair so she could go smoke. CNA B stated she was changing Resident #1's brief and stood her up to pull up the brief. CNA B stated she had a weak side that she could not really move, so she was holding her up under her arm on the weak side, which was her right side. She stated Resident #1 was standing and as she pulled her brief up, and suddenly Resident #1 started screaming that her arm was hurting, and she could not hold on. CNA B stated she lowered Resident #1 to the floor to ensure she doesn't hit her head. She stated she did not move resident and called for a nurse. CNA B stated she was in-serviced on falls and transfers after the incident. She stated she did do rounds with another CNA (doesn't recall her name) at the beginning of her shift. CNA B stated when she rounded with the CNA, she was telling her who required Hoyer lift and what the resident needed help with. She stated the CNA did not provide a paper with the resident's needs. CNA B stated when she was rounding with the CNA and they got to Resident #1's room, the CNA told her to start with Resident #1 first because if she missed her first smoke break then she would get upset. CNA B stated the CNA never told her Resident #1 required two people to transfer her, but she did tell her if she needed help with Resident #1, then let her know.<BR/>A record review of the facility's in-services revealed staff were in-serviced on falls and transfers on 01/16/23 and 01/18/23. A further review revealed staff were in-serviced on 01/12/23 on Rounding oncoming shift: CNAs round with CNAs and Nurses round with Nurses. <BR/>A record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, dated 2003, revealed Purpose: The purposes of this procedure are to allow the resident to bout of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure: Note: This procedure may require two (2) persons. H. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 4 residents (Resident's #1) reviewed for abuse.<BR/>1. The facility failed to implement their policy on reporting abuse for a resident-to-resident altercation that occurred on 02/18/2024 between Resident #1 and Resident #2.<BR/>2. The facility failed to implement their policy and procedures on investigating allegations of abuse for a resident-to-resident altercation that occurred on 02/18/2024 between Resident #1 and Resident #2.<BR/>These deficient practices could place residents at risk for abuse, neglect, and not having their needs met.<BR/>Findings include:<BR/>Resident #1<BR/>A record review of Resident #1's electronic face sheet, dated 02/21/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses which included dementia , abnormalities of gait (a change to your walking pattern) and mobility, and muscle weakness. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was able to complete a BIMS assessment and had a BIMS score of 0, which indicated his cognition was severely impaired. <BR/>A record review of Resident #1's Care Plan, revised 12/21/23, reflected Resident #1 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included Administer meds as ordered, Communicate with the resident/family/caregivers regarding residents capabilities and needs encourage therapeutic conversation as able. The Care Plan reflected Resident #1 had the potential to demonstrate physical behaviors. The interventions included . Communication provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately .Monitor/document/report to MD of danger to self and others . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. <BR/>Resident #2<BR/>A record review of Resident #2's electronic face sheet, dated 02/21/24, reflected Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective disorder bipolar type (experience psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - bipolar type (episodes of mania and sometimes depression)), psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), abnormalities of gait (a change to your walking pattern) and mobility, and altered mental status. <BR/>A record review of Resident #2's Optional State Assessment MDS, dated [DATE], reflected Resident #2 was able to complete a BIMS assessment and had a BIMS score of 3, which indicated his cognition was severely impaired. <BR/>A record review of Resident #2's Care Plan, revised 12/22/23, reflected Resident #2 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included . Communication: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV , radio, close door etc . The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. The Care Plan reflected Resident #2 had a potential to demonstrate physical/verbal behaviors due to poor impulse control and adjusting to facility. The interventions included Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . Notify the charge nurse of any physically abusive behaviors . Re-educate staff on redirection of aggressor, Relocate other residents as needed to prevent re-altercations.<BR/>A record review of the facility documents titled Even Nurses' Note- Behavior, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #1 had a resident-to-resident altercation in the dining room. The document indicated there were no injuries to Resident #1 when he was assessed, yet the document reflected LVN A notified the facility MD and Resident #1's family on 02/18/24 at 2:30 PM. <BR/>A record review of the facility documents titled Behavior Nurses Note 8 hr, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #2 had an argument with another resident and there were no changes to Resident #2 that required physician notification.<BR/>In an interview on 02/20/24 at 1:54 PM, LVN A stated she was PRN at the facility and worked on Sunday 02/18/24 in the MC unit. LVN A stated Resident #1 and Resident #2 got into an argument and fight. She stated she did not witness the incident. LVN A stated she was called to the dining room by a CNA (did not recall her name). She stated the CNA told her Resident #1 and Resident #2 were arguing and fighting and she had just broken them up. LVN A stated the CNA said the residents were fighting because one resident said the other stole from him. LVN A stated Resident #1 had a scratch above his eye and Resident #2 had no injuries. LVN A stated she assessed Resident #1's eye and contacted the MD and residents' family. LVN A stated the MD did not give her any new orders. She stated she notified the DON and the Administrator. LVN A stated the Administrator told her because she did not witness the incident, to hold off on doing the incident report, because she wanted to do an investigation. LVN A stated she did not complete the incident report and did not know if the Administrator completed the report. <BR/>In a phone interview on 02/21/24 at 10:28 AM, CNA B stated she worked in the MC unit on 02/18/24 from 6AM to 2PM. CNA B stated there was a verbal altercation between Resident #1 and Resident #2. She stated Resident #2 accused Resident #1 of stealing his truck, so they started arguing. CNA B stated she split the residents up and got them to calm down. She stated later when the residents were going outside to smoke, Resident #2 bumped Resident #1, but Resident #1 did not fall nor was he injured. CNA B stated she never witnessed a physical altercation between the residents on her shift. She stated she worked the following day on 02/19/24 and saw the scratch on Resident #1's eye. CNA B stated the scratch was not on Resident #1's eye on 02/18/24. CNA B stated she did not ask what happened to his eye nor did anyone tell her how he got the scratch. She stated she did not know if something happened after her shift ended at 2:00 PM . <BR/>An observation and interview on 02/21/24 at 11:03 AM revealed Resident #1 had a scratch approximately 1 inch in length, above his right eye. When Resident #1 was asked how he got the scratch on his eye, he appeared confused and said he did not know. Resident #1 was asked if he had gotten into any arguments or fights in the facility, he said no and he could not remember. <BR/>In an interview on 02/21/24 at 11:06 AM, Resident #2 stated he did not believe he hit anyone at the facility, but he sometimes could not remember things. He stated he did not get into any fights or arguments with other residents because he liked everyone at the facility. <BR/>In a phone interview on 02/21/24 at 12:16 PM, CNA C stated she worked on 02/18/24 and was scheduled for the 2-10 PM shift. CNA C stated she arrived to work late about 3/3:30 PM and things seemed crazy. She stated one of the residents told her Resident #1 and Resident #2 had a fight, but the resident often got confused so she did not know if it was true. CNA C stated she worked with CNA D and LVN A and neither of them mentioned there was an altercation between Resident #1 and Resident #2. CNA C stated she did see LVN A looking at Resident #1's eye and she took a picture of it. She stated she did see the scratch above Resident #1's eye. CNA C stated the scratch was not bleeding but it looked like a fresh scratch. CNA C stated she did not ask CNA D or LVN A how Resident #1 received the scratch .<BR/>In an interview on 02/21/24 at 12:26 PM, the Administrator stated LVN A called her on 02/18/24 and said she was called into the dining room by an aide because there was an argument between Resident #1 and Resident #2. The Administrator stated LVN A said the altercation happened during shift change and she did not witness the incident. The Administrator stated because LVN A did not witness the incident, she told her to hold off on completing an incident report because she wanted to investigate the situation. She stated she told her to make an event note in PCC. She stated she contacted CNA B, who was working 6-2PM. She stated CNA B told her she was in the dining room when Resident #1 and Resident #2 were arguing about a truck. She stated CNA B told her that nothing was physical, and they were only arguing, which she split them up. The Administrator stated LVN A and CNA B did not report to her that Resident #1 had a scratch above his eye. She stated she did not ask LVN A if she assessed the resident for any injuries. The Administrator stated she did observe the scratch above Resident #1's eye today. She stated she did not complete a report to the state because she was told it did not get physical and was only a verbal altercation. The Administrator stated she did investigate the situation by talking to all the staff who worked on Sunday and everyone she spoke to stated they did not witness anything physical. She stated she did not have any documentation of the investigation.<BR/>In a follow up interview on 02/21/24 at 1:23 PM, LVN A stated she did notify the Administrator that even though she did not witness the incident, she believed there was a physical altercation because Resident #1 had a scratch above his eye. She stated she did not know why the Administrator would say she did not notify her of the scratch above Resident #1's eye. She stated she told the Administrator she contacted the MD about the scratch on Resident #1's eye. LVN A stated she had the text message feed that she contacted the MD and would provide it.<BR/>A record review of LVN A's text feed reflected on Sunday (02/18/24) at 2:18 LVN A texted the MD and stated the following Good afternoon [Resident #1] and [Resident #2] got into a physical altercation. [Resident #2] being the aggressor. [Resident #1] has a laceration to his top left eye otherwise no c/o pain. The text revealed the MD responded Ok; does it need steri [stupa] . strips. LVN A responded to the MD with the following No Strips needed. They are both [are] up and ambulating throughout the unit. Will keep them separated and monitored. <BR/>In a phone interview on 02/21/24 at 1:54 PM, CNA D stated there was a physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch above his eye. CNA D stated she did not witness the incident. She stated she the worked 2-10 PM shift on 02/18/24. CNA D stated she heard screaming coming from the dining area and headed that way. She stated the altercation happened during the shift change, so everything was out of order. CNA D stated when she entered the dining room, CNA B and LVN A were in there and had broken them apart. CNA D stated Resident #1 had a scratch above his eye and the area looked a bit red. She stated she did see LVN A assessing and treating the scratch .<BR/>In a confidential interview, the facility staff member stated they were aware of the physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch on his eye because the facility had a group chat and LVN A notified everyone via the group chat. The facility staff member read the text message aloud, which said Resident #1 had a scratch above his eye. The facility staff member stated the Administrator was included on the facility's group chat. <BR/>A record review of the facility's policy titled Abuse/Neglect, dated 03/29/18, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse . E. Reporting: 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 . a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation . Resident to Resident: The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 4 residents (Residents #1 and Resident #2) reviewed for abuse.<BR/>The facility failed to report a resident-to-resident altercation that occurred on 02/18/24 between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of being notified.<BR/>This failure could place residents at risk for abuse. <BR/>Findings include:<BR/>Resident #1<BR/>A record review of Resident #1's electronic face sheet, dated 02/21/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses which included dementia , abnormalities of gait (a change to your walking pattern) and mobility, and muscle weakness. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was able to complete a BIMS assessment and had a BIMS score of 0, which indicated his cognition was severely impaired. <BR/>A record review of Resident #1's Care Plan, revised 12/21/23, reflected Resident #1 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included Administer meds as ordered, Communicate with the resident/family/caregivers regarding residents capabilities and needs encourage therapeutic conversation as able. The Care Plan reflected Resident #1 had the potential to demonstrate physical behaviors. The interventions included . Communication provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately .Monitor/document/report to MD of danger to self and others . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. <BR/>Resident #2<BR/>A record review of Resident #2's electronic face sheet, dated 02/21/24, reflected Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective disorder bipolar type (experience psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - bipolar type (episodes of mania and sometimes depression)), psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), abnormalities of gait (a change to your walking pattern) and mobility, and altered mental status. <BR/>A record review of Resident #2's Optional State Assessment MDS, dated [DATE], reflected Resident #2 was able to complete a BIMS assessment and had a BIMS score of 3, which indicated his cognition was severely impaired. <BR/>A record review of Resident #2's Care Plan, revised 12/22/23, reflected Resident #2 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included . Communication: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV , radio, close door etc . The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. The Care Plan reflected Resident #2 had a potential to demonstrate physical/verbal behaviors due to poor impulse control and adjusting to facility. The interventions included Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . Notify the charge nurse of any physically abusive behaviors . Re-educate staff on redirection of aggressor, Relocate other residents as needed to prevent re-altercations.<BR/>A record review of the facility documents titled Even Nurses' Note- Behavior, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #1 had a resident-to-resident altercation in the dining room. The document indicated there were no injuries to Resident #1 when he was assessed, yet the document reflected LVN A notified the facility MD and Resident #1's family on 02/18/24 at 2:30 PM. <BR/>A record review of the facility documents titled Behavior Nurses Note 8 hr, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #2 had an argument with another resident and there were no changes to Resident #2 that required physician notification.<BR/>In an interview on 02/20/24 at 1:54 PM, LVN A stated she was PRN at the facility and worked on Sunday 02/18/24 in the MC unit. LVN A stated Resident #1 and Resident #2 got into an argument and fight. She stated she did not witness the incident. LVN A stated she was called to the dining room by a CNA (did not recall her name). She stated the CNA told her Resident #1 and Resident #2 were arguing and fighting and she had just broken them up. LVN A stated the CNA said the residents were fighting because one resident said the other stole from him. LVN A stated Resident #1 had a scratch above his eye and Resident #2 had no injuries. LVN A stated she assessed Resident #1's eye and contacted the MD and residents' family. LVN A stated the MD did not give her any new orders. She stated she notified the DON and the Administrator. LVN A stated the Administrator told her because she did not witness the incident, to hold off on doing the incident report, because she wanted to do an investigation. LVN A stated she did not complete the incident report and did not know if the Administrator completed the report. <BR/>In a phone interview on 02/21/24 at 10:28 AM, CNA B stated she worked in the MC unit on 02/18/24 from 6AM to 2PM. CNA B stated there was a verbal altercation between Resident #1 and Resident #2. She stated Resident #2 accused Resident #1 of stealing his truck, so they started arguing. CNA B stated she split the residents up and got them to calm down. She stated later when the residents were going outside to smoke, Resident #2 bumped Resident #1, but Resident #1 did not fall nor was he injured. CNA B stated she never witnessed a physical altercation between the residents on her shift. She stated she worked the following day on 02/19/24 and saw the scratch on Resident #1's eye. CNA B stated the scratch was not on Resident #1's eye on 02/18/24. CNA B stated she did not ask what happened to his eye nor did anyone tell her how he got the scratch. She stated she did not know if something happened after her shift ended at 2:00 PM . <BR/>An observation and interview on 02/21/24 at 11:03 AM revealed Resident #1 had a scratch approximately 1 inch in length, above his right eye. When Resident #1 was asked how he got the scratch on his eye, he appeared confused and said he did not know. Resident #1 was asked if he had gotten into any arguments or fights in the facility, he said no and he could not remember. <BR/>In an interview on 02/21/24 at 11:06 AM, Resident #2 stated he did not believe he hit anyone at the facility, but he sometimes could not remember things. He stated he did not get into any fights or arguments with other residents because he liked everyone at the facility. <BR/>In a phone interview on 02/21/24 at 12:16 PM, CNA C stated she worked on 02/18/24 and was scheduled for the 2-10 PM shift. CNA C stated she arrived to work late about 3/3:30 PM and things seemed crazy. She stated one of the residents told her Resident #1 and Resident #2 had a fight, but the resident often got confused so she did not know if it was true. CNA C stated she worked with CNA D and LVN A and neither of them mentioned there was an altercation between Resident #1 and Resident #2. CNA C stated she did see LVN A looking at Resident #1's eye and she took a picture of it. She stated she did see the scratch above Resident #1's eye. CNA C stated the scratch was not bleeding but it looked like a fresh scratch. CNA C stated she did not ask CNA D or LVN A how Resident #1 received the scratch .<BR/>In an interview on 02/21/24 at 12:26 PM, the Administrator stated LVN A called her on 02/18/24 and said she was called into the dining room by an aide because there was an argument between Resident #1 and Resident #2. The Administrator stated LVN A said the altercation happened during shift change and she did not witness the incident. The Administrator stated because LVN A did not witness the incident, she told her to hold off on completing an incident report because she wanted to investigate the situation. She stated she told her to make an event note in PCC. She stated she contacted CNA B, who was working 6-2PM. She stated CNA B told her she was in the dining room when Resident #1 and Resident #2 were arguing about a truck. She stated CNA B told her that nothing was physical, and they were only arguing, which she split them up. The Administrator stated LVN A and CNA B did not report to her that Resident #1 had a scratch above his eye. She stated she did not ask LVN A if she assessed the resident for any injuries. The Administrator stated she did observe the scratch above Resident #1's eye today. She stated she did not complete a report to the state because she was told it did not get physical and was only a verbal altercation. The Administrator stated she did investigate the situation by talking to all the staff who worked on Sunday and everyone she spoke to stated they did not witness anything physical. She stated she did not have any documentation of the investigation.<BR/>In a follow up interview on 02/21/24 at 1:23 PM, LVN A stated she did notify the Administrator that even though she did not witness the incident, she believed there was a physical altercation because Resident #1 had a scratch above his eye. She stated she did not know why the Administrator would say she did not notify her of the scratch above Resident #1's eye. She stated she told the Administrator she contacted the MD about the scratch on Resident #1's eye. LVN A stated she had the text message feed that she contacted the MD and would provide it.<BR/>A record review of LVN A's text feed reflected on Sunday (02/18/24) at 2:18 LVN A texted the MD and stated the following Good afternoon [Resident #1] and [Resident #2] got into a physical altercation. [Resident #2] being the aggressor. [Resident #1] has a laceration to his top left eye otherwise no c/o pain. The text revealed the MD responded Ok; does it need steri [stupa] . strips. LVN A responded to the MD with the following No Strips needed. They are both [are] up and ambulating throughout the unit. Will keep them separated and monitored. <BR/>In a phone interview on 02/21/24 at 1:54 PM, CNA D stated there was a physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch above his eye. CNA D stated she did not witness the incident. She stated she the worked 2-10 PM shift on 02/18/24. CNA D stated she heard screaming coming from the dining area and headed that way. She stated the altercation happened during the shift change, so everything was out of order. CNA D stated when she entered the dining room, CNA B and LVN A were in there and had broken them apart. CNA D stated Resident #1 had a scratch above his eye and the area looked a bit red. She stated she did see LVN A assessing and treating the scratch .<BR/>In a confidential interview, the facility staff member stated they were aware of the physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch on his eye because the facility had a group chat and LVN A notified everyone via the group chat. The facility staff member read the text message aloud, which said Resident #1 had a scratch above his eye. The facility staff member stated the Administrator was included on the facility's group chat. <BR/>A record review of the facility's policy titled Abuse/Neglect, dated 03/29/18, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse . E. Reporting: 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 . a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation . Resident to Resident: The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. <BR/>CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. <BR/>CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). <BR/>These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. <BR/>Findings include:<BR/> A record review of Resident #1's electronic face sheet, dated 02/09/23, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included muscle weakness, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one?sided weakness) following intracerebral hemorrhage (bleeding into the brain tissue) affecting right dominant side, muscle wasting and atrophy, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS of 15, which indicated the resident's cognition was intact. Resident #1's MDS revealed she required extensive assistance with two-persons physical assistance for the following ADLs: bed mobility, transfers, and toilet use. <BR/>A record review of Resident #1's Care Plan dated 10/13/22 revealed Resident #1 had an ADL self-care performance deficit related to weakness on right side upper and lower extremities with history of CVA impaired mobility for bed mobility, toilet use, transfers. The interventions included the following: Toilet Use: The resident requires Extensive Assist x2 providers; Transfer: Requires Extensive Assist x2 providers.<BR/>A record review of Resident #1's Progress Notes by LVN C, dated 01/15/23, revealed Resident was being transferred to bed by agency CNA when she became weak, and CNA lowered her slowly to the floor with no complications. Resident noted stable denied no pain or any discomfort at this time. Resident was alert and oriented x4 with all upper and lower extremity functioning. Resident able to explain that she was assisted to sit on the floor by CNA since she could not bear weight. All vital signs within reach b/p 127/66, pulse 64, temp 98. Resident successfully assisted to bed using Hoyer lift.<BR/>A record review of Resident #1's Progress Notes by LVN D, dated 01/18/23, revealed At approximately 0700 Aide called stating that resident was on floor. Writer went to room resident was sitting on floor head leaning to assigned aides leg, who was standing beside resident's bed. Vitals remain within normal limit. No temperature noted. Resident complain of pain to right shoulder and arm. Assessment completed mild inflammation noted on site and painful to touch. Staff instructed to immobilize arm (not to move arm). MD notified. New order received to send resident to the ER for further evaluation. Medication audited noted administration of Tylenol 3 at 0600. Schedule gabapentin of 600 mg administered at this time. 911 call at approximately 0715 and resident was sent out to the ER [hospital] at 0725. RP Notified and aware of hospital of choice. <BR/>A record review of Resident #1's hospital paperwork, dated 01/19/23, revealed she was admitted to the hospital on [DATE] at 7:58 AM due to right shoulder pain from a fall. The hospital record revealed x-rays were completed on Resident #1's right shoulder and she was diagnosed with a closed fracture of neck of right humerus, initial encounter.<BR/>An observation and an interview on 02/09/23 at 10:19 AM, revealed Resident #1's right arm was in a sling. Resident #1 stated she had fall a couple of times in the facility, but she did not recall the details or the dates of the falls. Resident #1 stated in the last fall she was sent to the hospital and her arm was broken. She stated her arm was very sore. Resident #1 stated each time she fell it was while she was being transferred in and out of bed. She stated in the last fall she was being put in the bed and her paralyzed leg (right side) got stuck while she was being turned towards the bed. Resident #1 stated the CNA could not hold her up and they slid to the floor. She stated there was only one CNA transferring her in or out of bed each time she fell. <BR/>In an interview on 02/09/23 at 12:23 PM, the ADMN and DON, the ADMN stated Resident #1 was a 2-persons assist and after the fall on 01/18/23, she was changed to Hoyer lift for transfers. The ADMN stated both falls were with agency staff, but their facility staff all knew Resident #1 was a 2-person assist. The DON stated staff were in-serviced after each fall. The ADMN stated when agency staff worked at the facility, they were supposed to round with a facility staff member at the beginning of their shift. The ADMN stated the facility staff were supposed to go over the resident's needs, such as transfer status during the rounds. <BR/>In an interview on 02/09/23 at 1:14 PM, the Nurse Manager stated she was aware of the falls from 01/15/23 and 01/18/23. She stated she in-serviced staff about falls and transfers after each incident. The Nurse Manager stated when agency staff arrived, they were supposed to check in with the charge nurse and they would receive their assignment. She stated whoever the agency staff was relieving they were supposed to round with them, and discuss resident's needs, such as transfers. The Nurse Manager stated they had started using more agency around the times of the incidents, so she did an in-service about rounding. The Nurse Manager stated CNA B was assigned to round with CNA E. She stated she did not know about CNA A because this happened in the evening after she left for the day. <BR/>In an interview on 02/09/23 at 1:46 PM, CNA E stated she worked on 01/18/23 and was assigned to do rounds with CNA B. She stated she provided CNA B with a cheat sheet, which had info about the residents, which included who was incontinent, who needed help with feeding, and transfer requirements, such as who needed a Hoyer lift. CNA E stated Resident #1 was a two-persons transfer and when they rounded, she told the agency CNA B to let her know when she needed help with transfers. She said Resident #1 is a larger lady, so she doesn't know why CNA B would try to transfer her by herself. CNA E stated facility staff always used two people. <BR/>In a phone interview on 02/10/23 at 2:48 PM, LVN C stated on 01/15/23, he was called into Resident #1's room by CNA A. He stated CNA A said she was getting Resident #1 out of her wheelchair to put her in the bed. LVN C stated CNA A said she could not hold resident up by herself and so they slide down to the floor. LVN C stated Resident #1 was a 2-persons assist. He stated he had always observed facility staff using two CNAs when transferring Resident #1 to and from bed, but CNA A was agency. <BR/>LVN C stated he asked CNA A why she attempted to transfer Resident #1 by herself, without asking for help. He stated CNA A said she told Resident #1 she was going to get help and Resident #1 told her she was able to stand by herself and only needed one aide to help her. LVN C stated CNA A said she believed what the resident said, so she attempted to transfer her. LVN C stated Resident #1 is a larger lady and CNA A said she could not hold her weight, when Resident #1 stood out of the wheelchair, so they slide to the ground. LVN C stated agency staff are usually paired with a facility staff to do rounds, but he was not sure if she completed rounds because he worked a 12 hr. shift on the weekends and CNA A had already started her shift before he arrived. <BR/>On 02/13/23 at 2:10 PM, the Administrator communicated she had attempted to get CNA A's phone number from the staffing agency via email and by phone and was unable to get her number. <BR/>In a phone interview on 02/09/23 at 5:49 PM, LVN D stated on 01/18/23 she was called to Resident #1's room by CNA B, who told her she was transferring Resident #1 from the bed and could not hold her up, so she lowered Resident #1 to the floor. LVN D stated Resident #1 was a 2-persons transfer and maybe because CNA B was agency she did not know. LVN D stated she had never seen facility CNAs transferring the resident by themselves. She stated when agency CNAs checked in, she was supposed to pair them with a facility CNA to do rounds. LVN D stated during rounds, the facility CNA was supposed to educate the agency CNAs on the resident's needs, such as how they were transferred. LVN D stated she did pair CNA B with a facility CNA. She stated she did not recall who she was paired with, but she was sure she paired her. <BR/>In a phone interview on 02/10/23 at 10:41 AM, CNA B stated she was agency staff and she had worked at the facility twice before 01/18/23. CNA B stated she was not sure if Resident #1 was a 2-persons assist for transfers. CNA B stated when she had worked with Resident #1 before, she had transferred her by herself, and she was able to pivot her good side to help with transfer. She stated Resident #1 was ready to get up and into her wheelchair so she could go smoke. CNA B stated she was changing Resident #1's brief and stood her up to pull up the brief. CNA B stated she had a weak side that she could not really move, so she was holding her up under her arm on the weak side, which was her right side. She stated Resident #1 was standing and as she pulled her brief up, and suddenly Resident #1 started screaming that her arm was hurting, and she could not hold on. CNA B stated she lowered Resident #1 to the floor to ensure she doesn't hit her head. She stated she did not move resident and called for a nurse. CNA B stated she was in-serviced on falls and transfers after the incident. She stated she did do rounds with another CNA (doesn't recall her name) at the beginning of her shift. CNA B stated when she rounded with the CNA, she was telling her who required Hoyer lift and what the resident needed help with. She stated the CNA did not provide a paper with the resident's needs. CNA B stated when she was rounding with the CNA and they got to Resident #1's room, the CNA told her to start with Resident #1 first because if she missed her first smoke break then she would get upset. CNA B stated the CNA never told her Resident #1 required two people to transfer her, but she did tell her if she needed help with Resident #1, then let her know.<BR/>A record review of the facility's in-services revealed staff were in-serviced on falls and transfers on 01/16/23 and 01/18/23. A further review revealed staff were in-serviced on 01/12/23 on Rounding oncoming shift: CNAs round with CNAs and Nurses round with Nurses. <BR/>A record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, dated 2003, revealed Purpose: The purposes of this procedure are to allow the resident to bout of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure: Note: This procedure may require two (2) persons. H. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and care to maintain good foot health by providing foot care and treatment, in accorance with professional standards of practice, including to prevent complications from the resident's medical condition, for four of eight residents (Residents #1, #2, #3 and #4) reviewed for foot care. <BR/>The facility failed ensure foot care, specifically trimming of toenails, was provided for Residents #1, #2, and #3.<BR/>This failure could result in residents developing fungal infections or other podiatric problems. <BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to that facility on 05/10/23 with diagnoses that included senile degeneration of the brain (severe decline in mental ability), high blood pressure, and delusions. <BR/>Review of Resident #1's quarterly MDS assessment, dated 02/23/24, revealed a BIMS score not calculated due to her mental condition. Her Functional Status indicated she was independent in her ADLs except for bathing which required substantial staff assistance. <BR/>Review of Resident #1's care plan, dated 03/04/24, indicated she was at risk for skin impairment related to cognitive deficits, and an ADL self-care deficit. <BR/>Review of Resident #2's undated admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, delusions, and difficulty walking. <BR/>Review of Resident #2's quarterly MDS assessement, dated 02/23/24, revealed a BIMS score that was not calculated because of the resident's mental status. Her Functional Status indicated she required assistance with all of her ADLs. <BR/>Review of Resident #2's care plan, dated 02/27/24, revealed she had an ADL self-care deficit related to her cognitive deficits, and she had impaired cognitive function related to dementia. <BR/>Review of Resident #3's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, cognitive communication deficit, and diabetes. <BR/>Review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score not calculated due to his mental status. His Functional Status indicated he was independent in all of his ADLs. <BR/>Review of Resident #3's care plan, dated 03/20/24, indicated he had skin impairment related to history of shingles, cognitive function impairment, and he had a ADL self-care deficit related to dementia. <BR/>Review of Resident #4's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (blood chemical imbalance causing brain shrinkage), communication deficit, and seizures. <BR/>Review of Resident #4's quarterly MDS assessment, dated 02/20/24, indicated a BIMS score of 14 indicating he was cognitively intact. His Functional Status indicated he was independent in his ADLs except for hygiene which required supervision. <BR/>Review of Resident #4's care plan, dated 03/20/24, reflected he had skin impairment related to shingles, and he was diagnosed with diabetes and had a self-care deficit. <BR/>Observation and interview on 04/07/24 with Resident #1 revealed she bathed herself and kept her room clean. Skin assessment, performed by RN A, revealed no bruising to Resident #1's body, no wounds to her feet, but her toenails were overgrown. The resident's left great toenail was thick and appeared to be blackened underneath the nail. <BR/>Observation on 04/07/24 at 11:43 AM revealed Resident #3's toenails were overgrown.<BR/>Observation on 04/07/24 at 11:48 AM revealed Resident #2's toenails were grossly overgrown, and the nails were thick and curved. <BR/>Interview on 04/07/24 at 11:50 AM with RN A revealed the nursing staff could trim all toenails, even diabetic residents, unless they were thick and deformed in which case they would see the podiatrist. <BR/>Observation and interview on 04/07/24 at 11:57 AM with Resident #4 revealed his toenaile swere severely overgrown. The resident could not recall the last time anyone had trimmed his toenails.<BR/>Interview on 04/07/24 at 12:31 PM with LVN B revealed all toenails had to be trimmed by the podiatrist, and the nursing staff did not do that.<BR/>Interview on 04/07/24 at 12:40 PM with the DON revealed nurses should trim all resident toenails unless they were thickened or deformed, in which case they would be referred to the Podiatrist, who visited quarterly.<BR/>Review of Podiatry visits for 02/23/24, 03/22/24, and 03/26/24 revealed Residents #1, #2, #3, and #4 had not been seen by the podiatrist. The residents were also not scheduled to see the Podiatrist on 04/17/24. <BR/>Review of the facility's undated policy Nail Care reflected:<BR/>Nail care is the regular care of the toenails and fingernails to promote cleanliness and skin integrity issues .<BR/>Goals:<BR/>1. Nail care will be performed regularly and safely.<BR/>2. The resident will be free from abnormal nail condition.<BR/>3. The resident will be free from infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of six residents reviewed for quality of care.<BR/>The facility failed to ensure medication administration and storage protocols were implemented when the facility lost Resident # 1's medications (narcotics used for withdrawal symptoms) upon admission into the facility, which resulted in Resident #1 not receiving the medication and experiencing withdrawal symptoms.<BR/>The noncompliance was identified as PNC. The noncompliance began on 02/10/24 and ended on 02/15/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure placed residents at risk of not receiving care and services to meet their needs which could result in serious injury, illness, or death.<BR/>Findings included:<BR/>Review of Resident #1's Face Sheet, retrieved on 03/05/24, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included uncomplicated Opioid dependence (a strong desire or need to use opioids, experiencing tolerance or withdrawal symptoms when opioids are not used without any significant physical or psychological complications due to opioid use), uncomplicated Psychoactive substance abuse (a condition in which the use of one or more substances leads to a clinically significant impairment or distress), and other toxic Encephalopathy (a neurologic disorder caused by exposure to various toxic substances). <BR/>Review of Resident #1's MDS Assessment, dated 2/16/24, revealed the resident had a BIMS score of 15 suggesting the resident was cognitively intact. The resident's Mood Interview revealed the resident had expressed little interest or pleasure in doing things, felt down, depressed, or hopeless over a period of 2-6 days.<BR/>Review of the facility's PIR, dated 2/20/24, revealed Resident #1 was admitted to the facility and the nurse misplaced Resident #1's medication.<BR/>Review of Resident #1's Hospital Discharge orders, dated 2/10/24, revealed the resident was discharged from the hospital at 5:47 PM on 02/10/24. The medication list at discharge included buprenorphine-naloxone 4-1 mg Film with a start date of 02/09/2024 and an end date of 2/23/2024. The medication orders described the medication was to be taken daily for 14 days for opioid use disorder.<BR/>Review of Resident #1's MAR for February 2024, retrieved on 3/05/2024, revealed orders for the medication Buprenorphine HCl-Naloxone HCl Sublingual Film 4-1 to be administered until 2/26/24. The MAR revealed the resident was administered the medication starting on 2/13/24 and subsequently daily until 2/23/24. The resident did not receive the medication on 2/24/24. The resident was administered the medication again on 2/25/24 and 2/26/24. Resident #1 missed a total of 5 doses of his ordered medication.<BR/>There were no progress notes between 2/10 and 2/13 related to the missing medication.<BR/>Review of Resident #1's Progress Notes with an effective date range of 2/04/24 to 3/06/24 revealed the following:<BR/>Review of Progress Note dated 2/13/24 at 2:02 PM written by LVN C revealed a new admission follow-up assessment was conducted on Resident #1. The entry stated the resident had no complaint of pain and no aggressive behaviors were noted. <BR/>Review of Progress Note dated 2/15/24 at 11:11 AM written by RN E revealed the resident had no complaint of pain. <BR/>Review of Progress Note dated 2/16/24 at 11:26 AM written by LVN D revealed no concerns noted. <BR/>Review of Progress Note dated 2/16/24 at 3:18 PM written by RN H revealed Resident #1 had no complain of pain at this time. <BR/>Review of Progress Note dated 02/18/24 at 7:18 PM written by LVN E revealed Resident #1 was adjusting well to admission.<BR/>Review of Progress Noted dated 2/22/24 at 2:24 PM written by LVN D revealed a call was placed to the pharmacy to refill Buprenorphine HCl-Naloxone HCl sublingual Film 4-1 mg for Resident #1. A pharmacy representative advised the nurse there were no refills. The nurse notified Resident #1's physician to send a prescription for the resident. <BR/>Record review of RN G's personnel record revealed a current nursing license and a clear EMR. <BR/>Interview on 3/5/24 at 9:23 AM with the facility Administrator during the Entrance conference revealed that RN G stated that she had the medication on the desk at the nurse's station while she was admitting Resident #1. The administrator stated RN G was conducting the admission and walked away and when she came back, she realized the medication was gone. The administrator stated that RN G called her around 3:00 PM Sunday, 2/11/24, to let her know the medication was missing. The administrator stated RN G provided her the name of the missing medication and when the Administrator looked up the medication, she realized the missing medication was not a narcotic. The Administrator stated that she confirmed with the pharmacy that the missing medication was not a narcotic. The Administrator stated she called the hospital that discharged Resident #1 to confirm the medications that were sent to the facility with Resident #1, and they told her that the medications the hospital pharmacy sent to the facility with Resident #1 were left at the resident's bedside at the hospital. The Administrator stated that RN G stated that she was almost certain she saw the missing medication before it went missing.<BR/>Observation and audit on 3/5/24 at 12:45 PM of one of five medication carts. A count of the controlled substance medications and a review of the controlled medication log was conducted with MA A. No inaccuracies were noted.<BR/>Observation and audit on 3/5/24 at 12:54 PM of two of five medication carts. A count of the controlled substance medications and review of the controlled medication log was conducted with MA B. No inaccuracies were noted. <BR/>Interview on 3/5/24 at 1:25 PM with the DON revealed that only one of Resident #1's medication was missing. The DON stated the name of the medication was Naloxone. He stated Resident #1 missed two days of the medication. He stated that Resident #1 was assessed frequently for any side effects of the missed doses. The DON stated that during an interview with RN G, she stated that she left Resident #1's medication on the nurse's station desk in Station 2, walked away from the desk and when she returned, the medication was gone. The DON stated that Resident #1 was admitted into the facility on 2/10/24 around 7:00 PM, which was a Saturday night. The DON stated the missing medication was ordered from the pharmacy once it was discovered missing. He stated that because it was the weekend, the replacement took longer than usual. The DON stated the medication was controlled so they did not have it in stock at the facility. He stated that when a resident is admitted into the facility, their medication is counted to ensure an accurate medication count and that all medications are accounted for. The DON stated that it was common sense not to leave medication on the desk or cart unattended. The DON stated it was a risk to leave medication on the desk because it could go missing or a resident could take it, possibly causing harm to themselves. He stated the facility had regular in-service/training to educate the nurses on how to handle medication when the residents are admitted and how to store medications. The DON stated that Resident #1 did not suffer any adverse reactions because he was not previously taking the missing medication, so it did not matter if the medication was missed or that it was taken later than ordered as long as no harm came to the resident.<BR/>Interview on 3/5/24 at 2:00 PM with RN G revealed that she had never completed a new admission and was unaware of the process. RN G stated that she was completing the admission for Resident #1 on the evening of 2/10/24 and that Resident #1's medication was next to her on the desk. She stated that when she was ready to put Resident #1's medication in the drawer, the medication was missing. RN G stated she notified everyone that need to be informed and that she was suspended pending an investigation. She stated that LVN F arrived at 7:00 PM and was also near the desk prior to the medication going missing. RN G stated that she received one-on-one in-service when she returned to work. She stated that narcotic medication should be locked immediately. RN G stated the missing medication was sitting on the desk throughout the admission. She stated the medication was in a box and the whole box of the medication was gone. RN G stated another nurse was supposed to do the new admission of Resident #1 but left it up to her to finish up. She stated that the missing medication was on the desk in Station 2. RN G stated that she must've walked away and when she returned, the medication was gone. <BR/>Interview on 3/5/24 at 2:40 PM with Resident #1 revealed that he suffered withdrawal symptoms throughout the time he did not receive his medication such as bad nausea and bad stomach cramps. Resident #1 stated he knew his medication to control his withdrawal symptoms had been lost because he stated a staff member told him and he did not take it for a couple of days. He did not remember who the staff member was that told him.<BR/>Interview on 3/5/24 at 3:34 PM with LVN D revealed that she relieved RN G and that the medication was already missing. She stated that RN G told her that the medication went missing from the nurse's desk. LNV D stated that her shift was from 6AM to 6PM and that she took over from RN G. LVN D stated that RN G told her that she had reported the missing medication to the DON and the Administrator. She said she herself did not report it because it was the responsibility of the staff member who lost the medication. LVN D stated that if she had lost the medication then she would have reported it herself. She stated that she looked up the missing medication and stated the medication was not life threatening so it was not an issue. LVN D stated she completed an assessment on Resident #1 because he was a new admission but did not complete any special assessments for Resident #1 regarding his missing medications. <BR/>Interview on 3/5/24 at 4:37 PM with the DON revealed that he was informed about the missing medication on 2/11/24, on Sunday night. He stated the Administrator contacted him through a text message. The DON stated he called the Administrator immediately after receiving her text and the Administrator told him that she thought the missing medication was an over-the-counter medication. He stated that he called RN G and asked her to look for the medication and to call him back if she did not find it. The DON stated that RN G never called him back, so he figured she found the missing medication. He stated that when he returned to work on 2/12/24, he asked for Resident #1's medications and a staff member provided him with Resident #1's medications. The DON stated he did not realize that the missing medication was a controlled medication/narcotic until 2/13/24 at which time the police were notified. He stated that he did not ask RN G the name of the resident nor the name of the medication when he contacted her on 2/11/24. He said that on 2/12/24, a nurse called in the missing medication stat (immediately) to the pharmacy for a replacement. He said Resident #1 was not showing any signs of withdrawal. The DON stated that Resident #1 was assessed and was only found to be fatigued. <BR/>Interview on 3/5/24 at 4:59 PM with LVN F revealed he did not participate in Resident #1's admission into the facility or his care.<BR/>Record review of the facility's Ordering Schedule II Controlled Medications policy dated 2003 showed, Medications listed in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications <BR/>Record review of the facility's Medication Administration Procedures policy dated 2003 showed, Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence .<BR/>Record review of the facility's Diversion of Medications policy dated 2003 showed, Immediately following the diversion<BR/>1. <BR/>Notify administration or person in charge<BR/>2. <BR/>Notify the police.<BR/>3. <BR/>Notify the Consultant Pharmacist.<BR/>4. <BR/>Screen employees who had potential contact with the missing medication<BR/>5. <BR/>Notify the IP as required.<BR/>6. <BR/>Itemize as closely as possible the items removed .<BR/>The facility implemented the following interventions to address the non-compliance:<BR/>Review of the facility's employees' drug tests conducted on 2/15/24 revealed 4 staff were tested yielding negative results.<BR/>Review of four of the facility's medication cart audits conducted on 2/15/24 revealed no inconsistencies in medication counts.<BR/>Review of the facility's AD Hoc QAPI meeting sign-in sheet dated 2/14/24 revealed the following contributors attended the meeting: Administrator, DON, ADONs, Medical Director, Social Worker, Dietary Manager, and Activity Director. <BR/>Review of the facility's one-on-one in-service (training) titled Mishandling of Control Medication upon admission dated 2/15/24 provided to RN G indicated RN G understood that when a resident is admitted with narcotic medications, the admitting nurse must confirm the count with one other nurse and secure the medication under lock as soon as it is confirmed correctly. Narcotic medication should not be left out unsupervised under any circumstances, it must be double locked immediately. Any inaccuracy should be reported immediately to the administrator and DON.<BR/>Review of the facility's in-service (training) titled Ordering Schedule II Controlled Medications sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting.<BR/>Review of the facility's in-service (training) titled Medication Administration Procedures sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting.<BR/>Review of the facility's in-service (training) titled Diversion of Medications sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, Medication counting procedure: Outgoing nurse and med aide must count together to make sure the count is right/correct and log in control meds at the time of meds administration. The sign-in sheet revealed 20 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated 2/14/24 conducted by the DON described the subject matter as, Medication Reconciliation. The sign-in sheet revealed 24 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the DON described the subject matter as, Drug Diversion/Storage. The sign-in sheet revealed 28 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, Timely reporting of incorrect control count/diversion/robbery immediately to DON/Admin (management). The sign-in sheet revealed 19 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, When a resident admits with a narcotic medication or a narcotic medication is delivered from the pharmacy the medication count must be confirmed by 2 nurses then secured under double lock as soon as the medication arrives and A narcotic medication should never be left out unsupervised under any circumstances. The sign-in sheet revealed 32 staff members were in attendance.<BR/>1. <BR/>Review of the facility's Drug Diversion Monitoring in which the DON and/or designee monitored the medication carts for 19 days to ensure the count sheet for all medication carts matched the doses remaining in the medication cards revealed no discrepancies were found as evidenced by the DON and/or designee's signatures. Drug Diversion Monitoring was conducted on the following dates: 2/14/24 through 2/25/24 and 2/27/24 through 3/04/24 for a total of 19 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 4 residents (Resident's #1) reviewed for abuse.<BR/>1. The facility failed to implement their policy on reporting abuse for a resident-to-resident altercation that occurred on 02/18/2024 between Resident #1 and Resident #2.<BR/>2. The facility failed to implement their policy and procedures on investigating allegations of abuse for a resident-to-resident altercation that occurred on 02/18/2024 between Resident #1 and Resident #2.<BR/>These deficient practices could place residents at risk for abuse, neglect, and not having their needs met.<BR/>Findings include:<BR/>Resident #1<BR/>A record review of Resident #1's electronic face sheet, dated 02/21/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses which included dementia , abnormalities of gait (a change to your walking pattern) and mobility, and muscle weakness. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was able to complete a BIMS assessment and had a BIMS score of 0, which indicated his cognition was severely impaired. <BR/>A record review of Resident #1's Care Plan, revised 12/21/23, reflected Resident #1 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included Administer meds as ordered, Communicate with the resident/family/caregivers regarding residents capabilities and needs encourage therapeutic conversation as able. The Care Plan reflected Resident #1 had the potential to demonstrate physical behaviors. The interventions included . Communication provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately .Monitor/document/report to MD of danger to self and others . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. <BR/>Resident #2<BR/>A record review of Resident #2's electronic face sheet, dated 02/21/24, reflected Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective disorder bipolar type (experience psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - bipolar type (episodes of mania and sometimes depression)), psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), abnormalities of gait (a change to your walking pattern) and mobility, and altered mental status. <BR/>A record review of Resident #2's Optional State Assessment MDS, dated [DATE], reflected Resident #2 was able to complete a BIMS assessment and had a BIMS score of 3, which indicated his cognition was severely impaired. <BR/>A record review of Resident #2's Care Plan, revised 12/22/23, reflected Resident #2 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included . Communication: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV , radio, close door etc . The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. The Care Plan reflected Resident #2 had a potential to demonstrate physical/verbal behaviors due to poor impulse control and adjusting to facility. The interventions included Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . Notify the charge nurse of any physically abusive behaviors . Re-educate staff on redirection of aggressor, Relocate other residents as needed to prevent re-altercations.<BR/>A record review of the facility documents titled Even Nurses' Note- Behavior, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #1 had a resident-to-resident altercation in the dining room. The document indicated there were no injuries to Resident #1 when he was assessed, yet the document reflected LVN A notified the facility MD and Resident #1's family on 02/18/24 at 2:30 PM. <BR/>A record review of the facility documents titled Behavior Nurses Note 8 hr, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #2 had an argument with another resident and there were no changes to Resident #2 that required physician notification.<BR/>In an interview on 02/20/24 at 1:54 PM, LVN A stated she was PRN at the facility and worked on Sunday 02/18/24 in the MC unit. LVN A stated Resident #1 and Resident #2 got into an argument and fight. She stated she did not witness the incident. LVN A stated she was called to the dining room by a CNA (did not recall her name). She stated the CNA told her Resident #1 and Resident #2 were arguing and fighting and she had just broken them up. LVN A stated the CNA said the residents were fighting because one resident said the other stole from him. LVN A stated Resident #1 had a scratch above his eye and Resident #2 had no injuries. LVN A stated she assessed Resident #1's eye and contacted the MD and residents' family. LVN A stated the MD did not give her any new orders. She stated she notified the DON and the Administrator. LVN A stated the Administrator told her because she did not witness the incident, to hold off on doing the incident report, because she wanted to do an investigation. LVN A stated she did not complete the incident report and did not know if the Administrator completed the report. <BR/>In a phone interview on 02/21/24 at 10:28 AM, CNA B stated she worked in the MC unit on 02/18/24 from 6AM to 2PM. CNA B stated there was a verbal altercation between Resident #1 and Resident #2. She stated Resident #2 accused Resident #1 of stealing his truck, so they started arguing. CNA B stated she split the residents up and got them to calm down. She stated later when the residents were going outside to smoke, Resident #2 bumped Resident #1, but Resident #1 did not fall nor was he injured. CNA B stated she never witnessed a physical altercation between the residents on her shift. She stated she worked the following day on 02/19/24 and saw the scratch on Resident #1's eye. CNA B stated the scratch was not on Resident #1's eye on 02/18/24. CNA B stated she did not ask what happened to his eye nor did anyone tell her how he got the scratch. She stated she did not know if something happened after her shift ended at 2:00 PM . <BR/>An observation and interview on 02/21/24 at 11:03 AM revealed Resident #1 had a scratch approximately 1 inch in length, above his right eye. When Resident #1 was asked how he got the scratch on his eye, he appeared confused and said he did not know. Resident #1 was asked if he had gotten into any arguments or fights in the facility, he said no and he could not remember. <BR/>In an interview on 02/21/24 at 11:06 AM, Resident #2 stated he did not believe he hit anyone at the facility, but he sometimes could not remember things. He stated he did not get into any fights or arguments with other residents because he liked everyone at the facility. <BR/>In a phone interview on 02/21/24 at 12:16 PM, CNA C stated she worked on 02/18/24 and was scheduled for the 2-10 PM shift. CNA C stated she arrived to work late about 3/3:30 PM and things seemed crazy. She stated one of the residents told her Resident #1 and Resident #2 had a fight, but the resident often got confused so she did not know if it was true. CNA C stated she worked with CNA D and LVN A and neither of them mentioned there was an altercation between Resident #1 and Resident #2. CNA C stated she did see LVN A looking at Resident #1's eye and she took a picture of it. She stated she did see the scratch above Resident #1's eye. CNA C stated the scratch was not bleeding but it looked like a fresh scratch. CNA C stated she did not ask CNA D or LVN A how Resident #1 received the scratch .<BR/>In an interview on 02/21/24 at 12:26 PM, the Administrator stated LVN A called her on 02/18/24 and said she was called into the dining room by an aide because there was an argument between Resident #1 and Resident #2. The Administrator stated LVN A said the altercation happened during shift change and she did not witness the incident. The Administrator stated because LVN A did not witness the incident, she told her to hold off on completing an incident report because she wanted to investigate the situation. She stated she told her to make an event note in PCC. She stated she contacted CNA B, who was working 6-2PM. She stated CNA B told her she was in the dining room when Resident #1 and Resident #2 were arguing about a truck. She stated CNA B told her that nothing was physical, and they were only arguing, which she split them up. The Administrator stated LVN A and CNA B did not report to her that Resident #1 had a scratch above his eye. She stated she did not ask LVN A if she assessed the resident for any injuries. The Administrator stated she did observe the scratch above Resident #1's eye today. She stated she did not complete a report to the state because she was told it did not get physical and was only a verbal altercation. The Administrator stated she did investigate the situation by talking to all the staff who worked on Sunday and everyone she spoke to stated they did not witness anything physical. She stated she did not have any documentation of the investigation.<BR/>In a follow up interview on 02/21/24 at 1:23 PM, LVN A stated she did notify the Administrator that even though she did not witness the incident, she believed there was a physical altercation because Resident #1 had a scratch above his eye. She stated she did not know why the Administrator would say she did not notify her of the scratch above Resident #1's eye. She stated she told the Administrator she contacted the MD about the scratch on Resident #1's eye. LVN A stated she had the text message feed that she contacted the MD and would provide it.<BR/>A record review of LVN A's text feed reflected on Sunday (02/18/24) at 2:18 LVN A texted the MD and stated the following Good afternoon [Resident #1] and [Resident #2] got into a physical altercation. [Resident #2] being the aggressor. [Resident #1] has a laceration to his top left eye otherwise no c/o pain. The text revealed the MD responded Ok; does it need steri [stupa] . strips. LVN A responded to the MD with the following No Strips needed. They are both [are] up and ambulating throughout the unit. Will keep them separated and monitored. <BR/>In a phone interview on 02/21/24 at 1:54 PM, CNA D stated there was a physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch above his eye. CNA D stated she did not witness the incident. She stated she the worked 2-10 PM shift on 02/18/24. CNA D stated she heard screaming coming from the dining area and headed that way. She stated the altercation happened during the shift change, so everything was out of order. CNA D stated when she entered the dining room, CNA B and LVN A were in there and had broken them apart. CNA D stated Resident #1 had a scratch above his eye and the area looked a bit red. She stated she did see LVN A assessing and treating the scratch .<BR/>In a confidential interview, the facility staff member stated they were aware of the physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch on his eye because the facility had a group chat and LVN A notified everyone via the group chat. The facility staff member read the text message aloud, which said Resident #1 had a scratch above his eye. The facility staff member stated the Administrator was included on the facility's group chat. <BR/>A record review of the facility's policy titled Abuse/Neglect, dated 03/29/18, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse . E. Reporting: 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 . a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation . Resident to Resident: The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations were thoroughly investigated for 1 of 4 residents (Residents #1) reviewed for abuse.<BR/>The facility failed to thoroughly investigate a resident-to-resident altercation that occurred on 02/18/24 between Resident #1 and Resident #2. <BR/>This failure could place residents at risk for abuse. <BR/>Findings include:<BR/>Resident #1<BR/>A record review of Resident #1's electronic face sheet, dated 02/21/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses which included dementia , abnormalities of gait (a change to your walking pattern) and mobility, and muscle weakness. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was able to complete a BIMS assessment and had a BIMS score of 0, which indicated his cognition was severely impaired. <BR/>A record review of Resident #1's Care Plan, revised 12/21/23, reflected Resident #1 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included Administer meds as ordered, Communicate with the resident/family/caregivers regarding residents capabilities and needs encourage therapeutic conversation as able. The Care Plan reflected Resident #1 had the potential to demonstrate physical behaviors. The interventions included . Communication provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately .Monitor/document/report to MD of danger to self and others . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. <BR/>Resident #2<BR/>A record review of Resident #2's electronic face sheet, dated 02/21/24, reflected Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective disorder bipolar type (experience psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - bipolar type (episodes of mania and sometimes depression)), psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), abnormalities of gait (a change to your walking pattern) and mobility, and altered mental status. <BR/>A record review of Resident #2's Optional State Assessment MDS, dated [DATE], reflected Resident #2 was able to complete a BIMS assessment and had a BIMS score of 3, which indicated his cognition was severely impaired. <BR/>A record review of Resident #2's Care Plan, revised 12/22/23, reflected Resident #2 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included . Communication: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV , radio, close door etc . The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. The Care Plan reflected Resident #2 had a potential to demonstrate physical/verbal behaviors due to poor impulse control and adjusting to facility. The interventions included Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . Notify the charge nurse of any physically abusive behaviors . Re-educate staff on redirection of aggressor, Relocate other residents as needed to prevent re-altercations.<BR/>A record review of the facility documents titled Even Nurses' Note- Behavior, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #1 had a resident-to-resident altercation in the dining room. The document indicated there were no injuries to Resident #1 when he was assessed, yet the document reflected LVN A notified the facility MD and Resident #1's family on 02/18/24 at 2:30 PM. <BR/>A record review of the facility documents titled Behavior Nurses Note 8 hr, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #2 had an argument with another resident and there were no changes to Resident #2 that required physician notification.<BR/>In an interview on 02/20/24 at 1:54 PM, LVN A stated she was PRN at the facility and worked on Sunday 02/18/24 in the MC unit. LVN A stated Resident #1 and Resident #2 got into an argument and fight. She stated she did not witness the incident. LVN A stated she was called to the dining room by a CNA (did not recall her name). She stated the CNA told her Resident #1 and Resident #2 were arguing and fighting and she had just broken them up. LVN A stated the CNA said the residents were fighting because one resident said the other stole from him. LVN A stated Resident #1 had a scratch above his eye and Resident #2 had no injuries. LVN A stated she assessed Resident #1's eye and contacted the MD and residents' family. LVN A stated the MD did not give her any new orders. She stated she notified the DON and the Administrator. LVN A stated the Administrator told her because she did not witness the incident, to hold off on doing the incident report, because she wanted to do an investigation. LVN A stated she did not complete the incident report and did not know if the Administrator completed the report. <BR/>In a phone interview on 02/21/24 at 10:28 AM, CNA B stated she worked in the MC unit on 02/18/24 from 6AM to 2PM. CNA B stated there was a verbal altercation between Resident #1 and Resident #2. She stated Resident #2 accused Resident #1 of stealing his truck, so they started arguing. CNA B stated she split the residents up and got them to calm down. She stated later when the residents were going outside to smoke, Resident #2 bumped Resident #1, but Resident #1 did not fall nor was he injured. CNA B stated she never witnessed a physical altercation between the residents on her shift. She stated she worked the following day on 02/19/24 and saw the scratch on Resident #1's eye. CNA B stated the scratch was not on Resident #1's eye on 02/18/24. CNA B stated she did not ask what happened to his eye nor did anyone tell her how he got the scratch. She stated she did not know if something happened after her shift ended at 2:00 PM . <BR/>An observation and interview on 02/21/24 at 11:03 AM revealed Resident #1 had a scratch approximately 1 inch in length, above his right eye. When Resident #1 was asked how he got the scratch on his eye, he appeared confused and said he did not know. Resident #1 was asked if he had gotten into any arguments or fights in the facility, he said no and he could not remember. <BR/>In an interview on 02/21/24 at 11:06 AM, Resident #2 stated he did not believe he hit anyone at the facility, but he sometimes could not remember things. He stated he did not get into any fights or arguments with other residents because he liked everyone at the facility. <BR/>In a phone interview on 02/21/24 at 12:16 PM, CNA C stated she worked on 02/18/24 and was scheduled for the 2-10 PM shift. CNA C stated she arrived to work late about 3/3:30 PM and things seemed crazy. She stated one of the residents told her Resident #1 and Resident #2 had a fight, but the resident often got confused so she did not know if it was true. CNA C stated she worked with CNA D and LVN A and neither of them mentioned there was an altercation between Resident #1 and Resident #2. CNA C stated she did see LVN A looking at Resident #1's eye and she took a picture of it. She stated she did see the scratch above Resident #1's eye. CNA C stated the scratch was not bleeding but it looked like a fresh scratch. CNA C stated she did not ask CNA D or LVN A how Resident #1 received the scratch .<BR/>In an interview on 02/21/24 at 12:26 PM, the Administrator stated LVN A called her on 02/18/24 and said she was called into the dining room by an aide because there was an argument between Resident #1 and Resident #2. The Administrator stated LVN A said the altercation happened during shift change and she did not witness the incident. The Administrator stated because LVN A did not witness the incident, she told her to hold off on completing an incident report because she wanted to investigate the situation. She stated she told her to make an event note in PCC. She stated she contacted CNA B, who was working 6-2PM. She stated CNA B told her she was in the dining room when Resident #1 and Resident #2 were arguing about a truck. She stated CNA B told her that nothing was physical, and they were only arguing, which she split them up. The Administrator stated LVN A and CNA B did not report to her that Resident #1 had a scratch above his eye. She stated she did not ask LVN A if she assessed the resident for any injuries. The Administrator stated she did observe the scratch above Resident #1's eye today. She stated she did not complete a report to the state because she was told it did not get physical and was only a verbal altercation. The Administrator stated she did investigate the situation by talking to all the staff who worked on Sunday and everyone she spoke to stated they did not witness anything physical. She stated she did not have any documentation of the investigation.<BR/>In a follow up interview on 02/21/24 at 1:23 PM, LVN A stated she did notify the Administrator that even though she did not witness the incident, she believed there was a physical altercation because Resident #1 had a scratch above his eye. She stated she did not know why the Administrator would say she did not notify her of the scratch above Resident #1's eye. She stated she told the Administrator she contacted the MD about the scratch on Resident #1's eye. LVN A stated she had the text message feed that she contacted the MD and would provide it.<BR/>A record review of LVN A's text feed reflected on Sunday (02/18/24) at 2:18 LVN A texted the MD and stated the following Good afternoon [Resident #1] and [Resident #2] got into a physical altercation. [Resident #2] being the aggressor. [Resident #1] has a laceration to his top left eye otherwise no c/o pain. The text revealed the MD responded Ok; does it need steri [stupa] . strips. LVN A responded to the MD with the following No Strips needed. They are both [are] up and ambulating throughout the unit. Will keep them separated and monitored. <BR/>In a phone interview on 02/21/24 at 1:54 PM, CNA D stated there was a physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch above his eye. CNA D stated she did not witness the incident. She stated she the worked 2-10 PM shift on 02/18/24. CNA D stated she heard screaming coming from the dining area and headed that way. She stated the altercation happened during the shift change, so everything was out of order. CNA D stated when she entered the dining room, CNA B and LVN A were in there and had broken them apart. CNA D stated Resident #1 had a scratch above his eye and the area looked a bit red. She stated she did see LVN A assessing and treating the scratch .<BR/>In a confidential interview, the facility staff member stated they were aware of the physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch on his eye because the facility had a group chat and LVN A notified everyone via the group chat. The facility staff member read the text message aloud, which said Resident #1 had a scratch above his eye. The facility staff member stated the Administrator was included on the facility's group chat. <BR/>A record review of the facility's policy titled Abuse/Neglect, dated 03/29/18, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse . E. Reporting: 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 . a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation . Resident to Resident: The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a physician signed and dated orders for 2 of 2 residents (Resident #66 and Resident #256) reviewed for medical records.<BR/>The facility failed to obtain orders for contact isolation for Resident #66 and Resident #256.<BR/>This failure placed residents at risk for not receiving appropriate care.<BR/>Findings included:<BR/>Record review of Resident #66's face sheet, dated 11/15/2023, revealed a [AGE] year-old female with original admission date of 12/22/2023 and readmission date of 10/02/2023. Resident #66's diagnoses included senile degeneration of brain, hemiplegia and hemiparesis following cerebral infarction affecting left side, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes. <BR/>Record review of Resident #66's admission MDS, dated [DATE], reflected a BIMS score of 14 indicating intact cognition.<BR/>Observation on 11/12/2023 at 11:38 a.m., of Resident #66's room revealed signage with report to nurse on door, PPE in organizer hanging on the door, and biohazard boxes in room.<BR/>Record review of Resident #66's physician orders revealed no orders for contact isolation. <BR/>Record review of Resident #66's nursing progress notes dated 10/16/2023 through 11/13/2023 revealed resident had been treated with antibiotics for ESBL.<BR/>Interview and record review on 11/13/2023 at 10:19 a.m., the ADON stated a gown and gloves was required before entering Resident #66's room. When asked how she knew a resident was on transmission-based precautions, she stated if a resident comes in at admission, the hospital tells them and they send paperwork. If found at the facility they have PPE set up on the door, notify staff what was going on and have an order. Surveyor asked ADON to show the order for Resident #66's isolation, ADON reviewed orders on her laptop and stated there was no order. She stated whoever checked the orders must have missed that part. She stated it was important to have an order for isolation so that all nurses were aware.<BR/>Record review of Resident #256's face sheet, dated 11/15/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included other low back pain, multiple sclerosis, and morbid obesity.<BR/>Record review of Resident #256's admission MDS, dated [DATE], reflected a BIMS score of 14 indicating intact cognition.<BR/>Record review of Resident #256's physician orders revealed no orders for contact isolation. <BR/>Record review of Resident #256's nursing progress notes dated 11/13/2023 reflected in part Resident completed Doxycycline for ESBL (Extended Spectrum Beta-Lactamase)(Extended Spectrum Beta-Lactamase. Beta-lactamases are enzymes produced by some bacteria that may make them resistant to some antibiotics) on 11/9/2023 . Obtain U/A with C&S .<BR/>Interview with Administrator on 11/15/2023 at 1:37 p.m., revealed there should have been orders and they fixed it afterwards. A policy for physician orders was requested. <BR/>Record review of facility policy titled Type and Duration of Precautions from Infection Control Policy and Procedure Manual 2018 reflected This facility will utilize Appendix A from the CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings to determine the type of precautions used and their duration. The facility will provide the least restrictive environment possible .<BR/>No policy on physician orders was provided by the time of exit.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for:<BR/>1. <BR/>The facility failed to ensure food items, placed in the refrigerator, were dated, and labeled appropriately. <BR/>This failure could affect residents by placing them at risk for food-borne illness. <BR/>Findings included:<BR/>An observation and interview on 11/12/2023, at 9:37am, revealed two prepared salads, in containers sealed in cellophane, not labeled nor dated. Dietary Aide A stated she put the salads in the refrigerator, got busy with other task, and forgot to date and label the salads. Dietary Aide A stated the importance of dating and labeling food items put in refrigerators, is to inform other staff how long the items have been in the refrigerator so residents will not get food borne illness. <BR/>In an interview with the Dietary Manager, on 11/14/2023, at 11:55a.m., it was stated that her expectation for her staff is to date, label, and seal foods that are put in the refrigerators when they are stored in the refrigerators. <BR/>Review of the facility's Food Storage undated policy, on 11-14-2023 at 3:00pm, stated that Perishable items that are refrigerated are dated .and used within 7 days. <BR/>Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation 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. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. <BR/>1. The facility failed to address Resident #1's multiple refusals of care and services on the comprehensive care plan<BR/>This failure could place residents at risk of not receiving the necessary care and services. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an admission date of 07/11/24. Resident #1 had diagnoses of Multiple Sclerosis (chronic disease that affects the brain and spinal cord), Cognitive Communication Deficit (communication difficulty), and History of Transient Ischemic Attack (brief interruption of blood flow to the brain). The face sheet noted a discharge date of 09/17/24. <BR/>Record review of Resident #1's Admitting MDS Assessment, dated 07/17/24, reflected Resident #1 had a BIMS score of 11, which meant Resident #1 had a moderate level of cognition. The MDS noted the resident did not exhibit any behaviors. <BR/>Record review of Resident #1's care plan with an initial date of 07/12/24, reflected no interventions for Resident #1's multiple refusals of wound care, perineal care, medication administration, or showers. <BR/>Record review of the progress notes on Resident #1's electronic record, dated, 05/08/25, reflected the following:<BR/>07/19/24 15:36 (3:36 PM)- Resident #1 refused wound debridement after multiple attempts, application of Nystatin Powder (antifungal medication for skin infections), application of Hydrocortisone External Cream (medication used to treat skin conditions) for wound care<BR/>07/23/24 at 16:17 (4:17 PM)- Resident #1 refused the application of Nystatin Powder for wound care<BR/>07/24/24 at 12:20 PM- Resident #1 refused the application of Hydrocortisone External Cream<BR/>08/01/24 at 9:38 AM- Resident #1 refused Pro-Stat AWC (protein drink for wound healing) 3 times<BR/>08/02/24 at 8:31 AM- Resident #1 refused Pro-Stat AWC 3 times<BR/>08/09/24 21:47 (9:47 PM)- Resident #1 refused a blood sugar check<BR/>08/10/24 at 8:37 AM- Resident #1 refused the application of Nystatin Powder and Hydrocortisone External Cream for wound care, cleansing of wound, and dressing change<BR/>08/10/24 at 8:45 AM- Resident #1 refused a shower<BR/>08/10/24 at 13:21 (1:21 PM)- Resident #1 refused a blood sugar check<BR/>In an interview on 05/08/25 at 2:30 PM, the DON stated she did not work at the facility when Resident #1 was living there. She stated the refusals should have been addressed and interventions should have been in place to encourage Resident #1 not to refuse care. The DON stated the risk of refusals not addressed was a possible decline in health. <BR/>In an interview on 05/08/25 at 2:40 PM, the Administrator stated she was not working at the facility last year when Resident #1 lived there. She stated the refusals should have been addressed so staff would know how to best assist the resident. She stated the risk would have been Resident #1 not receiving the services she needed. <BR/>Record review of the facility's undated policy, titled, Comprehensive Care Planning, reflected the following:<BR/>The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -<BR/>o <BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and<BR/>o <BR/>the right to refuse treatment<BR/>Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.<BR/>The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.<BR/>In situations where a resident's choice to decline care or treatment (e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempts to find alternative means to address the identified risk/need should be documented in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of six residents reviewed for quality of care.<BR/>The facility failed to ensure medication administration and storage protocols were implemented when the facility lost Resident # 1's medications (narcotics used for withdrawal symptoms) upon admission into the facility, which resulted in Resident #1 not receiving the medication and experiencing withdrawal symptoms.<BR/>The noncompliance was identified as PNC. The noncompliance began on 02/10/24 and ended on 02/15/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure placed residents at risk of not receiving care and services to meet their needs which could result in serious injury, illness, or death.<BR/>Findings included:<BR/>Review of Resident #1's Face Sheet, retrieved on 03/05/24, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included uncomplicated Opioid dependence (a strong desire or need to use opioids, experiencing tolerance or withdrawal symptoms when opioids are not used without any significant physical or psychological complications due to opioid use), uncomplicated Psychoactive substance abuse (a condition in which the use of one or more substances leads to a clinically significant impairment or distress), and other toxic Encephalopathy (a neurologic disorder caused by exposure to various toxic substances). <BR/>Review of Resident #1's MDS Assessment, dated 2/16/24, revealed the resident had a BIMS score of 15 suggesting the resident was cognitively intact. The resident's Mood Interview revealed the resident had expressed little interest or pleasure in doing things, felt down, depressed, or hopeless over a period of 2-6 days.<BR/>Review of the facility's PIR, dated 2/20/24, revealed Resident #1 was admitted to the facility and the nurse misplaced Resident #1's medication.<BR/>Review of Resident #1's Hospital Discharge orders, dated 2/10/24, revealed the resident was discharged from the hospital at 5:47 PM on 02/10/24. The medication list at discharge included buprenorphine-naloxone 4-1 mg Film with a start date of 02/09/2024 and an end date of 2/23/2024. The medication orders described the medication was to be taken daily for 14 days for opioid use disorder.<BR/>Review of Resident #1's MAR for February 2024, retrieved on 3/05/2024, revealed orders for the medication Buprenorphine HCl-Naloxone HCl Sublingual Film 4-1 to be administered until 2/26/24. The MAR revealed the resident was administered the medication starting on 2/13/24 and subsequently daily until 2/23/24. The resident did not receive the medication on 2/24/24. The resident was administered the medication again on 2/25/24 and 2/26/24. Resident #1 missed a total of 5 doses of his ordered medication.<BR/>There were no progress notes between 2/10 and 2/13 related to the missing medication.<BR/>Review of Resident #1's Progress Notes with an effective date range of 2/04/24 to 3/06/24 revealed the following:<BR/>Review of Progress Note dated 2/13/24 at 2:02 PM written by LVN C revealed a new admission follow-up assessment was conducted on Resident #1. The entry stated the resident had no complaint of pain and no aggressive behaviors were noted. <BR/>Review of Progress Note dated 2/15/24 at 11:11 AM written by RN E revealed the resident had no complaint of pain. <BR/>Review of Progress Note dated 2/16/24 at 11:26 AM written by LVN D revealed no concerns noted. <BR/>Review of Progress Note dated 2/16/24 at 3:18 PM written by RN H revealed Resident #1 had no complain of pain at this time. <BR/>Review of Progress Note dated 02/18/24 at 7:18 PM written by LVN E revealed Resident #1 was adjusting well to admission.<BR/>Review of Progress Noted dated 2/22/24 at 2:24 PM written by LVN D revealed a call was placed to the pharmacy to refill Buprenorphine HCl-Naloxone HCl sublingual Film 4-1 mg for Resident #1. A pharmacy representative advised the nurse there were no refills. The nurse notified Resident #1's physician to send a prescription for the resident. <BR/>Record review of RN G's personnel record revealed a current nursing license and a clear EMR. <BR/>Interview on 3/5/24 at 9:23 AM with the facility Administrator during the Entrance conference revealed that RN G stated that she had the medication on the desk at the nurse's station while she was admitting Resident #1. The administrator stated RN G was conducting the admission and walked away and when she came back, she realized the medication was gone. The administrator stated that RN G called her around 3:00 PM Sunday, 2/11/24, to let her know the medication was missing. The administrator stated RN G provided her the name of the missing medication and when the Administrator looked up the medication, she realized the missing medication was not a narcotic. The Administrator stated that she confirmed with the pharmacy that the missing medication was not a narcotic. The Administrator stated she called the hospital that discharged Resident #1 to confirm the medications that were sent to the facility with Resident #1, and they told her that the medications the hospital pharmacy sent to the facility with Resident #1 were left at the resident's bedside at the hospital. The Administrator stated that RN G stated that she was almost certain she saw the missing medication before it went missing.<BR/>Observation and audit on 3/5/24 at 12:45 PM of one of five medication carts. A count of the controlled substance medications and a review of the controlled medication log was conducted with MA A. No inaccuracies were noted.<BR/>Observation and audit on 3/5/24 at 12:54 PM of two of five medication carts. A count of the controlled substance medications and review of the controlled medication log was conducted with MA B. No inaccuracies were noted. <BR/>Interview on 3/5/24 at 1:25 PM with the DON revealed that only one of Resident #1's medication was missing. The DON stated the name of the medication was Naloxone. He stated Resident #1 missed two days of the medication. He stated that Resident #1 was assessed frequently for any side effects of the missed doses. The DON stated that during an interview with RN G, she stated that she left Resident #1's medication on the nurse's station desk in Station 2, walked away from the desk and when she returned, the medication was gone. The DON stated that Resident #1 was admitted into the facility on 2/10/24 around 7:00 PM, which was a Saturday night. The DON stated the missing medication was ordered from the pharmacy once it was discovered missing. He stated that because it was the weekend, the replacement took longer than usual. The DON stated the medication was controlled so they did not have it in stock at the facility. He stated that when a resident is admitted into the facility, their medication is counted to ensure an accurate medication count and that all medications are accounted for. The DON stated that it was common sense not to leave medication on the desk or cart unattended. The DON stated it was a risk to leave medication on the desk because it could go missing or a resident could take it, possibly causing harm to themselves. He stated the facility had regular in-service/training to educate the nurses on how to handle medication when the residents are admitted and how to store medications. The DON stated that Resident #1 did not suffer any adverse reactions because he was not previously taking the missing medication, so it did not matter if the medication was missed or that it was taken later than ordered as long as no harm came to the resident.<BR/>Interview on 3/5/24 at 2:00 PM with RN G revealed that she had never completed a new admission and was unaware of the process. RN G stated that she was completing the admission for Resident #1 on the evening of 2/10/24 and that Resident #1's medication was next to her on the desk. She stated that when she was ready to put Resident #1's medication in the drawer, the medication was missing. RN G stated she notified everyone that need to be informed and that she was suspended pending an investigation. She stated that LVN F arrived at 7:00 PM and was also near the desk prior to the medication going missing. RN G stated that she received one-on-one in-service when she returned to work. She stated that narcotic medication should be locked immediately. RN G stated the missing medication was sitting on the desk throughout the admission. She stated the medication was in a box and the whole box of the medication was gone. RN G stated another nurse was supposed to do the new admission of Resident #1 but left it up to her to finish up. She stated that the missing medication was on the desk in Station 2. RN G stated that she must've walked away and when she returned, the medication was gone. <BR/>Interview on 3/5/24 at 2:40 PM with Resident #1 revealed that he suffered withdrawal symptoms throughout the time he did not receive his medication such as bad nausea and bad stomach cramps. Resident #1 stated he knew his medication to control his withdrawal symptoms had been lost because he stated a staff member told him and he did not take it for a couple of days. He did not remember who the staff member was that told him.<BR/>Interview on 3/5/24 at 3:34 PM with LVN D revealed that she relieved RN G and that the medication was already missing. She stated that RN G told her that the medication went missing from the nurse's desk. LNV D stated that her shift was from 6AM to 6PM and that she took over from RN G. LVN D stated that RN G told her that she had reported the missing medication to the DON and the Administrator. She said she herself did not report it because it was the responsibility of the staff member who lost the medication. LVN D stated that if she had lost the medication then she would have reported it herself. She stated that she looked up the missing medication and stated the medication was not life threatening so it was not an issue. LVN D stated she completed an assessment on Resident #1 because he was a new admission but did not complete any special assessments for Resident #1 regarding his missing medications. <BR/>Interview on 3/5/24 at 4:37 PM with the DON revealed that he was informed about the missing medication on 2/11/24, on Sunday night. He stated the Administrator contacted him through a text message. The DON stated he called the Administrator immediately after receiving her text and the Administrator told him that she thought the missing medication was an over-the-counter medication. He stated that he called RN G and asked her to look for the medication and to call him back if she did not find it. The DON stated that RN G never called him back, so he figured she found the missing medication. He stated that when he returned to work on 2/12/24, he asked for Resident #1's medications and a staff member provided him with Resident #1's medications. The DON stated he did not realize that the missing medication was a controlled medication/narcotic until 2/13/24 at which time the police were notified. He stated that he did not ask RN G the name of the resident nor the name of the medication when he contacted her on 2/11/24. He said that on 2/12/24, a nurse called in the missing medication stat (immediately) to the pharmacy for a replacement. He said Resident #1 was not showing any signs of withdrawal. The DON stated that Resident #1 was assessed and was only found to be fatigued. <BR/>Interview on 3/5/24 at 4:59 PM with LVN F revealed he did not participate in Resident #1's admission into the facility or his care.<BR/>Record review of the facility's Ordering Schedule II Controlled Medications policy dated 2003 showed, Medications listed in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications <BR/>Record review of the facility's Medication Administration Procedures policy dated 2003 showed, Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence .<BR/>Record review of the facility's Diversion of Medications policy dated 2003 showed, Immediately following the diversion<BR/>1. <BR/>Notify administration or person in charge<BR/>2. <BR/>Notify the police.<BR/>3. <BR/>Notify the Consultant Pharmacist.<BR/>4. <BR/>Screen employees who had potential contact with the missing medication<BR/>5. <BR/>Notify the IP as required.<BR/>6. <BR/>Itemize as closely as possible the items removed .<BR/>The facility implemented the following interventions to address the non-compliance:<BR/>Review of the facility's employees' drug tests conducted on 2/15/24 revealed 4 staff were tested yielding negative results.<BR/>Review of four of the facility's medication cart audits conducted on 2/15/24 revealed no inconsistencies in medication counts.<BR/>Review of the facility's AD Hoc QAPI meeting sign-in sheet dated 2/14/24 revealed the following contributors attended the meeting: Administrator, DON, ADONs, Medical Director, Social Worker, Dietary Manager, and Activity Director. <BR/>Review of the facility's one-on-one in-service (training) titled Mishandling of Control Medication upon admission dated 2/15/24 provided to RN G indicated RN G understood that when a resident is admitted with narcotic medications, the admitting nurse must confirm the count with one other nurse and secure the medication under lock as soon as it is confirmed correctly. Narcotic medication should not be left out unsupervised under any circumstances, it must be double locked immediately. Any inaccuracy should be reported immediately to the administrator and DON.<BR/>Review of the facility's in-service (training) titled Ordering Schedule II Controlled Medications sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting.<BR/>Review of the facility's in-service (training) titled Medication Administration Procedures sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting.<BR/>Review of the facility's in-service (training) titled Diversion of Medications sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, Medication counting procedure: Outgoing nurse and med aide must count together to make sure the count is right/correct and log in control meds at the time of meds administration. The sign-in sheet revealed 20 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated 2/14/24 conducted by the DON described the subject matter as, Medication Reconciliation. The sign-in sheet revealed 24 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the DON described the subject matter as, Drug Diversion/Storage. The sign-in sheet revealed 28 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, Timely reporting of incorrect control count/diversion/robbery immediately to DON/Admin (management). The sign-in sheet revealed 19 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, When a resident admits with a narcotic medication or a narcotic medication is delivered from the pharmacy the medication count must be confirmed by 2 nurses then secured under double lock as soon as the medication arrives and A narcotic medication should never be left out unsupervised under any circumstances. The sign-in sheet revealed 32 staff members were in attendance.<BR/>1. <BR/>Review of the facility's Drug Diversion Monitoring in which the DON and/or designee monitored the medication carts for 19 days to ensure the count sheet for all medication carts matched the doses remaining in the medication cards revealed no discrepancies were found as evidenced by the DON and/or designee's signatures. Drug Diversion Monitoring was conducted on the following dates: 2/14/24 through 2/25/24 and 2/27/24 through 3/04/24 for a total of 19 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of six residents reviewed for quality of care.<BR/>The facility failed to ensure medication administration and storage protocols were implemented when the facility lost Resident # 1's medications (narcotics used for withdrawal symptoms) upon admission into the facility, which resulted in Resident #1 not receiving the medication and experiencing withdrawal symptoms.<BR/>The noncompliance was identified as PNC. The noncompliance began on 02/10/24 and ended on 02/15/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure placed residents at risk of not receiving care and services to meet their needs which could result in serious injury, illness, or death.<BR/>Findings included:<BR/>Review of Resident #1's Face Sheet, retrieved on 03/05/24, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included uncomplicated Opioid dependence (a strong desire or need to use opioids, experiencing tolerance or withdrawal symptoms when opioids are not used without any significant physical or psychological complications due to opioid use), uncomplicated Psychoactive substance abuse (a condition in which the use of one or more substances leads to a clinically significant impairment or distress), and other toxic Encephalopathy (a neurologic disorder caused by exposure to various toxic substances). <BR/>Review of Resident #1's MDS Assessment, dated 2/16/24, revealed the resident had a BIMS score of 15 suggesting the resident was cognitively intact. The resident's Mood Interview revealed the resident had expressed little interest or pleasure in doing things, felt down, depressed, or hopeless over a period of 2-6 days.<BR/>Review of the facility's PIR, dated 2/20/24, revealed Resident #1 was admitted to the facility and the nurse misplaced Resident #1's medication.<BR/>Review of Resident #1's Hospital Discharge orders, dated 2/10/24, revealed the resident was discharged from the hospital at 5:47 PM on 02/10/24. The medication list at discharge included buprenorphine-naloxone 4-1 mg Film with a start date of 02/09/2024 and an end date of 2/23/2024. The medication orders described the medication was to be taken daily for 14 days for opioid use disorder.<BR/>Review of Resident #1's MAR for February 2024, retrieved on 3/05/2024, revealed orders for the medication Buprenorphine HCl-Naloxone HCl Sublingual Film 4-1 to be administered until 2/26/24. The MAR revealed the resident was administered the medication starting on 2/13/24 and subsequently daily until 2/23/24. The resident did not receive the medication on 2/24/24. The resident was administered the medication again on 2/25/24 and 2/26/24. Resident #1 missed a total of 5 doses of his ordered medication.<BR/>There were no progress notes between 2/10 and 2/13 related to the missing medication.<BR/>Review of Resident #1's Progress Notes with an effective date range of 2/04/24 to 3/06/24 revealed the following:<BR/>Review of Progress Note dated 2/13/24 at 2:02 PM written by LVN C revealed a new admission follow-up assessment was conducted on Resident #1. The entry stated the resident had no complaint of pain and no aggressive behaviors were noted. <BR/>Review of Progress Note dated 2/15/24 at 11:11 AM written by RN E revealed the resident had no complaint of pain. <BR/>Review of Progress Note dated 2/16/24 at 11:26 AM written by LVN D revealed no concerns noted. <BR/>Review of Progress Note dated 2/16/24 at 3:18 PM written by RN H revealed Resident #1 had no complain of pain at this time. <BR/>Review of Progress Note dated 02/18/24 at 7:18 PM written by LVN E revealed Resident #1 was adjusting well to admission.<BR/>Review of Progress Noted dated 2/22/24 at 2:24 PM written by LVN D revealed a call was placed to the pharmacy to refill Buprenorphine HCl-Naloxone HCl sublingual Film 4-1 mg for Resident #1. A pharmacy representative advised the nurse there were no refills. The nurse notified Resident #1's physician to send a prescription for the resident. <BR/>Record review of RN G's personnel record revealed a current nursing license and a clear EMR. <BR/>Interview on 3/5/24 at 9:23 AM with the facility Administrator during the Entrance conference revealed that RN G stated that she had the medication on the desk at the nurse's station while she was admitting Resident #1. The administrator stated RN G was conducting the admission and walked away and when she came back, she realized the medication was gone. The administrator stated that RN G called her around 3:00 PM Sunday, 2/11/24, to let her know the medication was missing. The administrator stated RN G provided her the name of the missing medication and when the Administrator looked up the medication, she realized the missing medication was not a narcotic. The Administrator stated that she confirmed with the pharmacy that the missing medication was not a narcotic. The Administrator stated she called the hospital that discharged Resident #1 to confirm the medications that were sent to the facility with Resident #1, and they told her that the medications the hospital pharmacy sent to the facility with Resident #1 were left at the resident's bedside at the hospital. The Administrator stated that RN G stated that she was almost certain she saw the missing medication before it went missing.<BR/>Observation and audit on 3/5/24 at 12:45 PM of one of five medication carts. A count of the controlled substance medications and a review of the controlled medication log was conducted with MA A. No inaccuracies were noted.<BR/>Observation and audit on 3/5/24 at 12:54 PM of two of five medication carts. A count of the controlled substance medications and review of the controlled medication log was conducted with MA B. No inaccuracies were noted. <BR/>Interview on 3/5/24 at 1:25 PM with the DON revealed that only one of Resident #1's medication was missing. The DON stated the name of the medication was Naloxone. He stated Resident #1 missed two days of the medication. He stated that Resident #1 was assessed frequently for any side effects of the missed doses. The DON stated that during an interview with RN G, she stated that she left Resident #1's medication on the nurse's station desk in Station 2, walked away from the desk and when she returned, the medication was gone. The DON stated that Resident #1 was admitted into the facility on 2/10/24 around 7:00 PM, which was a Saturday night. The DON stated the missing medication was ordered from the pharmacy once it was discovered missing. He stated that because it was the weekend, the replacement took longer than usual. The DON stated the medication was controlled so they did not have it in stock at the facility. He stated that when a resident is admitted into the facility, their medication is counted to ensure an accurate medication count and that all medications are accounted for. The DON stated that it was common sense not to leave medication on the desk or cart unattended. The DON stated it was a risk to leave medication on the desk because it could go missing or a resident could take it, possibly causing harm to themselves. He stated the facility had regular in-service/training to educate the nurses on how to handle medication when the residents are admitted and how to store medications. The DON stated that Resident #1 did not suffer any adverse reactions because he was not previously taking the missing medication, so it did not matter if the medication was missed or that it was taken later than ordered as long as no harm came to the resident.<BR/>Interview on 3/5/24 at 2:00 PM with RN G revealed that she had never completed a new admission and was unaware of the process. RN G stated that she was completing the admission for Resident #1 on the evening of 2/10/24 and that Resident #1's medication was next to her on the desk. She stated that when she was ready to put Resident #1's medication in the drawer, the medication was missing. RN G stated she notified everyone that need to be informed and that she was suspended pending an investigation. She stated that LVN F arrived at 7:00 PM and was also near the desk prior to the medication going missing. RN G stated that she received one-on-one in-service when she returned to work. She stated that narcotic medication should be locked immediately. RN G stated the missing medication was sitting on the desk throughout the admission. She stated the medication was in a box and the whole box of the medication was gone. RN G stated another nurse was supposed to do the new admission of Resident #1 but left it up to her to finish up. She stated that the missing medication was on the desk in Station 2. RN G stated that she must've walked away and when she returned, the medication was gone. <BR/>Interview on 3/5/24 at 2:40 PM with Resident #1 revealed that he suffered withdrawal symptoms throughout the time he did not receive his medication such as bad nausea and bad stomach cramps. Resident #1 stated he knew his medication to control his withdrawal symptoms had been lost because he stated a staff member told him and he did not take it for a couple of days. He did not remember who the staff member was that told him.<BR/>Interview on 3/5/24 at 3:34 PM with LVN D revealed that she relieved RN G and that the medication was already missing. She stated that RN G told her that the medication went missing from the nurse's desk. LNV D stated that her shift was from 6AM to 6PM and that she took over from RN G. LVN D stated that RN G told her that she had reported the missing medication to the DON and the Administrator. She said she herself did not report it because it was the responsibility of the staff member who lost the medication. LVN D stated that if she had lost the medication then she would have reported it herself. She stated that she looked up the missing medication and stated the medication was not life threatening so it was not an issue. LVN D stated she completed an assessment on Resident #1 because he was a new admission but did not complete any special assessments for Resident #1 regarding his missing medications. <BR/>Interview on 3/5/24 at 4:37 PM with the DON revealed that he was informed about the missing medication on 2/11/24, on Sunday night. He stated the Administrator contacted him through a text message. The DON stated he called the Administrator immediately after receiving her text and the Administrator told him that she thought the missing medication was an over-the-counter medication. He stated that he called RN G and asked her to look for the medication and to call him back if she did not find it. The DON stated that RN G never called him back, so he figured she found the missing medication. He stated that when he returned to work on 2/12/24, he asked for Resident #1's medications and a staff member provided him with Resident #1's medications. The DON stated he did not realize that the missing medication was a controlled medication/narcotic until 2/13/24 at which time the police were notified. He stated that he did not ask RN G the name of the resident nor the name of the medication when he contacted her on 2/11/24. He said that on 2/12/24, a nurse called in the missing medication stat (immediately) to the pharmacy for a replacement. He said Resident #1 was not showing any signs of withdrawal. The DON stated that Resident #1 was assessed and was only found to be fatigued. <BR/>Interview on 3/5/24 at 4:59 PM with LVN F revealed he did not participate in Resident #1's admission into the facility or his care.<BR/>Record review of the facility's Ordering Schedule II Controlled Medications policy dated 2003 showed, Medications listed in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications <BR/>Record review of the facility's Medication Administration Procedures policy dated 2003 showed, Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence .<BR/>Record review of the facility's Diversion of Medications policy dated 2003 showed, Immediately following the diversion<BR/>1. <BR/>Notify administration or person in charge<BR/>2. <BR/>Notify the police.<BR/>3. <BR/>Notify the Consultant Pharmacist.<BR/>4. <BR/>Screen employees who had potential contact with the missing medication<BR/>5. <BR/>Notify the IP as required.<BR/>6. <BR/>Itemize as closely as possible the items removed .<BR/>The facility implemented the following interventions to address the non-compliance:<BR/>Review of the facility's employees' drug tests conducted on 2/15/24 revealed 4 staff were tested yielding negative results.<BR/>Review of four of the facility's medication cart audits conducted on 2/15/24 revealed no inconsistencies in medication counts.<BR/>Review of the facility's AD Hoc QAPI meeting sign-in sheet dated 2/14/24 revealed the following contributors attended the meeting: Administrator, DON, ADONs, Medical Director, Social Worker, Dietary Manager, and Activity Director. <BR/>Review of the facility's one-on-one in-service (training) titled Mishandling of Control Medication upon admission dated 2/15/24 provided to RN G indicated RN G understood that when a resident is admitted with narcotic medications, the admitting nurse must confirm the count with one other nurse and secure the medication under lock as soon as it is confirmed correctly. Narcotic medication should not be left out unsupervised under any circumstances, it must be double locked immediately. Any inaccuracy should be reported immediately to the administrator and DON.<BR/>Review of the facility's in-service (training) titled Ordering Schedule II Controlled Medications sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting.<BR/>Review of the facility's in-service (training) titled Medication Administration Procedures sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting.<BR/>Review of the facility's in-service (training) titled Diversion of Medications sign-in sheet dated and conducted on 2/14/24 indicated 26 staff members attended the meeting.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, Medication counting procedure: Outgoing nurse and med aide must count together to make sure the count is right/correct and log in control meds at the time of meds administration. The sign-in sheet revealed 20 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated 2/14/24 conducted by the DON described the subject matter as, Medication Reconciliation. The sign-in sheet revealed 24 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the DON described the subject matter as, Drug Diversion/Storage. The sign-in sheet revealed 28 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, Timely reporting of incorrect control count/diversion/robbery immediately to DON/Admin (management). The sign-in sheet revealed 19 staff members were in attendance.<BR/>Review of the facility's in-service (training) dated and conducted on 2/14/24 and administered by the Administrator and DON described the subject matter as, When a resident admits with a narcotic medication or a narcotic medication is delivered from the pharmacy the medication count must be confirmed by 2 nurses then secured under double lock as soon as the medication arrives and A narcotic medication should never be left out unsupervised under any circumstances. The sign-in sheet revealed 32 staff members were in attendance.<BR/>1. <BR/>Review of the facility's Drug Diversion Monitoring in which the DON and/or designee monitored the medication carts for 19 days to ensure the count sheet for all medication carts matched the doses remaining in the medication cards revealed no discrepancies were found as evidenced by the DON and/or designee's signatures. Drug Diversion Monitoring was conducted on the following dates: 2/14/24 through 2/25/24 and 2/27/24 through 3/04/24 for a total of 19 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident that were accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of clinical records.<BR/>1. The Wound Care Nurse failed to document Resident #1's physician's orders for the treatment of his surgical wound on the bottom of his amputated leg. <BR/>2. LVN B failed to accurately document Resident #1's Weekly Skin Assessments on 04/10/23, 04/12/23, and 04/19/23 in his clinical record.<BR/>Findings included:<BR/>A record review of Resident #1's Facesheet reflected that Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, fluid overload, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, generalized edema, and acquired absence of right leg below knee. <BR/>A record review of Resident #1's Comprehensive MDS assessment dated [DATE] reflected, Resident #1 had a BIMS score of 09, which indicated the resident's cognition was moderately impaired. Further review of the MDS section M1040. Other Ulcers, Wounds, and Skin Problems revealed Resident #1 had open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion). <BR/>A record review of Resident #1's Care Plan dated 04/04/23, revealed a focus in integumentary and that Resident #1 had actual impairment to skin integrity r/t: surgical procedures AEB: R(Right) BKA BL inguinal surgical incisions BL thigh surgical incisions skin tear to hand. The goal included Resident #1 will have no complications r/t his surgical sites through the review date. Some of the interventions included Follow facility protocols for treatment of injury. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration (occurs when skin is in contact with moisture for too long) etc. to MD.<BR/>A record review of Resident #1's Physician Discharge summary, dated [DATE], revealed there were no wound care orders.<BR/>Review of Resident #1's Order Summary Report dated April 2023 reflected: Weekly skin assessment and nursing summary one time a day every Fri with start date of 04/07/23.<BR/>A record review of Resident #1's TAR revealed there were no treatments for the surgical incision sites on the bottom of Resident #1's amputated leg and thigh.<BR/>A record review of Resident #1's Weekly Skin Assessments completed by LVN B, dated 04/10/23, 04/12/23, and 04/19/23, revealed there were no surgical incisions or skin issues documented for Resident #1. <BR/>In a phone interview with the Wound Care Nurse on 04/26/23 at 12:49 PM, she stated on 04/20/23 Resident #1 came to her in the hall and said his wound was draining. She stated she examined the surgical incisions on the bottom of Resident #1's amputated leg and thigh. She stated the surgical wound on the bottom of his amputated leg was draining so she contacted the MD and got orders for treatment. The Wound Care Nurse stated she forgot to put the orders in his clinical record. She stated it was her responsibility, but she got really busy that day and just forgot to put them in. She stated she did work the next day on 04/21/23 and was still very busy and forgot to put them in Resident #1's clinical record. She stated the risk to the resident was him not receiving treatment for his wounds. <BR/>In an interview on 04/26/23 at 2:30 PM LVN B stated he completed the Weekly Skin Assessments on 04/10/23, 04/12/23, and 04/19/23. He stated he filled them out incorrectly and did not document Resident #1's surgical incisions on the bottom of his amputated leg and thigh. He stated he did not observe Resident #1's skin on 04/19/23 but had observed Resident #1's skin several times before and was aware of his surgical wounds. LVN B stated he just made an error in completed Resident #1's skin assessments. He stated the risk to the residents from this error was that the residents may not receive appropriate care or treatment. <BR/>In an interview on 04/25/2023 at 4:05 PM, the DON stated he was aware that LVN B had documented his skin assessments incorrectly. He stated staff were being in-serviced on accurately completing the skin assessments. The DON stated the risk of not accurately documenting the skin assessments was that skin issues could go unnoticed and untreated. He stated he also spoke with the MD , who confirmed he had given orders on 04/20/23 to the Wound Care Nurse regarding Resident #1's surgical wound. The DON stated he did input the orders and back dated them to 04/20/23. He stated staff not putting the orders in caused a risk to residents because they may not get the treatment they needed. He stated he started an in-service with the nursing staff. <BR/>Review of the facility policy titled Documentation, undated, revealed Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports and summary sheets (daily, weekly, monthly, discharge) . Goal . 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed . Procedure . 8. Document in the clinical record regarding notification of the physician of abnormal diagnostic test or laboratory results and any new orders or follow-up from the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. <BR/>CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. <BR/>CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). <BR/>These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. <BR/>Findings include:<BR/> A record review of Resident #1's electronic face sheet, dated 02/09/23, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included muscle weakness, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one?sided weakness) following intracerebral hemorrhage (bleeding into the brain tissue) affecting right dominant side, muscle wasting and atrophy, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS of 15, which indicated the resident's cognition was intact. Resident #1's MDS revealed she required extensive assistance with two-persons physical assistance for the following ADLs: bed mobility, transfers, and toilet use. <BR/>A record review of Resident #1's Care Plan dated 10/13/22 revealed Resident #1 had an ADL self-care performance deficit related to weakness on right side upper and lower extremities with history of CVA impaired mobility for bed mobility, toilet use, transfers. The interventions included the following: Toilet Use: The resident requires Extensive Assist x2 providers; Transfer: Requires Extensive Assist x2 providers.<BR/>A record review of Resident #1's Progress Notes by LVN C, dated 01/15/23, revealed Resident was being transferred to bed by agency CNA when she became weak, and CNA lowered her slowly to the floor with no complications. Resident noted stable denied no pain or any discomfort at this time. Resident was alert and oriented x4 with all upper and lower extremity functioning. Resident able to explain that she was assisted to sit on the floor by CNA since she could not bear weight. All vital signs within reach b/p 127/66, pulse 64, temp 98. Resident successfully assisted to bed using Hoyer lift.<BR/>A record review of Resident #1's Progress Notes by LVN D, dated 01/18/23, revealed At approximately 0700 Aide called stating that resident was on floor. Writer went to room resident was sitting on floor head leaning to assigned aides leg, who was standing beside resident's bed. Vitals remain within normal limit. No temperature noted. Resident complain of pain to right shoulder and arm. Assessment completed mild inflammation noted on site and painful to touch. Staff instructed to immobilize arm (not to move arm). MD notified. New order received to send resident to the ER for further evaluation. Medication audited noted administration of Tylenol 3 at 0600. Schedule gabapentin of 600 mg administered at this time. 911 call at approximately 0715 and resident was sent out to the ER [hospital] at 0725. RP Notified and aware of hospital of choice. <BR/>A record review of Resident #1's hospital paperwork, dated 01/19/23, revealed she was admitted to the hospital on [DATE] at 7:58 AM due to right shoulder pain from a fall. The hospital record revealed x-rays were completed on Resident #1's right shoulder and she was diagnosed with a closed fracture of neck of right humerus, initial encounter.<BR/>An observation and an interview on 02/09/23 at 10:19 AM, revealed Resident #1's right arm was in a sling. Resident #1 stated she had fall a couple of times in the facility, but she did not recall the details or the dates of the falls. Resident #1 stated in the last fall she was sent to the hospital and her arm was broken. She stated her arm was very sore. Resident #1 stated each time she fell it was while she was being transferred in and out of bed. She stated in the last fall she was being put in the bed and her paralyzed leg (right side) got stuck while she was being turned towards the bed. Resident #1 stated the CNA could not hold her up and they slid to the floor. She stated there was only one CNA transferring her in or out of bed each time she fell. <BR/>In an interview on 02/09/23 at 12:23 PM, the ADMN and DON, the ADMN stated Resident #1 was a 2-persons assist and after the fall on 01/18/23, she was changed to Hoyer lift for transfers. The ADMN stated both falls were with agency staff, but their facility staff all knew Resident #1 was a 2-person assist. The DON stated staff were in-serviced after each fall. The ADMN stated when agency staff worked at the facility, they were supposed to round with a facility staff member at the beginning of their shift. The ADMN stated the facility staff were supposed to go over the resident's needs, such as transfer status during the rounds. <BR/>In an interview on 02/09/23 at 1:14 PM, the Nurse Manager stated she was aware of the falls from 01/15/23 and 01/18/23. She stated she in-serviced staff about falls and transfers after each incident. The Nurse Manager stated when agency staff arrived, they were supposed to check in with the charge nurse and they would receive their assignment. She stated whoever the agency staff was relieving they were supposed to round with them, and discuss resident's needs, such as transfers. The Nurse Manager stated they had started using more agency around the times of the incidents, so she did an in-service about rounding. The Nurse Manager stated CNA B was assigned to round with CNA E. She stated she did not know about CNA A because this happened in the evening after she left for the day. <BR/>In an interview on 02/09/23 at 1:46 PM, CNA E stated she worked on 01/18/23 and was assigned to do rounds with CNA B. She stated she provided CNA B with a cheat sheet, which had info about the residents, which included who was incontinent, who needed help with feeding, and transfer requirements, such as who needed a Hoyer lift. CNA E stated Resident #1 was a two-persons transfer and when they rounded, she told the agency CNA B to let her know when she needed help with transfers. She said Resident #1 is a larger lady, so she doesn't know why CNA B would try to transfer her by herself. CNA E stated facility staff always used two people. <BR/>In a phone interview on 02/10/23 at 2:48 PM, LVN C stated on 01/15/23, he was called into Resident #1's room by CNA A. He stated CNA A said she was getting Resident #1 out of her wheelchair to put her in the bed. LVN C stated CNA A said she could not hold resident up by herself and so they slide down to the floor. LVN C stated Resident #1 was a 2-persons assist. He stated he had always observed facility staff using two CNAs when transferring Resident #1 to and from bed, but CNA A was agency. <BR/>LVN C stated he asked CNA A why she attempted to transfer Resident #1 by herself, without asking for help. He stated CNA A said she told Resident #1 she was going to get help and Resident #1 told her she was able to stand by herself and only needed one aide to help her. LVN C stated CNA A said she believed what the resident said, so she attempted to transfer her. LVN C stated Resident #1 is a larger lady and CNA A said she could not hold her weight, when Resident #1 stood out of the wheelchair, so they slide to the ground. LVN C stated agency staff are usually paired with a facility staff to do rounds, but he was not sure if she completed rounds because he worked a 12 hr. shift on the weekends and CNA A had already started her shift before he arrived. <BR/>On 02/13/23 at 2:10 PM, the Administrator communicated she had attempted to get CNA A's phone number from the staffing agency via email and by phone and was unable to get her number. <BR/>In a phone interview on 02/09/23 at 5:49 PM, LVN D stated on 01/18/23 she was called to Resident #1's room by CNA B, who told her she was transferring Resident #1 from the bed and could not hold her up, so she lowered Resident #1 to the floor. LVN D stated Resident #1 was a 2-persons transfer and maybe because CNA B was agency she did not know. LVN D stated she had never seen facility CNAs transferring the resident by themselves. She stated when agency CNAs checked in, she was supposed to pair them with a facility CNA to do rounds. LVN D stated during rounds, the facility CNA was supposed to educate the agency CNAs on the resident's needs, such as how they were transferred. LVN D stated she did pair CNA B with a facility CNA. She stated she did not recall who she was paired with, but she was sure she paired her. <BR/>In a phone interview on 02/10/23 at 10:41 AM, CNA B stated she was agency staff and she had worked at the facility twice before 01/18/23. CNA B stated she was not sure if Resident #1 was a 2-persons assist for transfers. CNA B stated when she had worked with Resident #1 before, she had transferred her by herself, and she was able to pivot her good side to help with transfer. She stated Resident #1 was ready to get up and into her wheelchair so she could go smoke. CNA B stated she was changing Resident #1's brief and stood her up to pull up the brief. CNA B stated she had a weak side that she could not really move, so she was holding her up under her arm on the weak side, which was her right side. She stated Resident #1 was standing and as she pulled her brief up, and suddenly Resident #1 started screaming that her arm was hurting, and she could not hold on. CNA B stated she lowered Resident #1 to the floor to ensure she doesn't hit her head. She stated she did not move resident and called for a nurse. CNA B stated she was in-serviced on falls and transfers after the incident. She stated she did do rounds with another CNA (doesn't recall her name) at the beginning of her shift. CNA B stated when she rounded with the CNA, she was telling her who required Hoyer lift and what the resident needed help with. She stated the CNA did not provide a paper with the resident's needs. CNA B stated when she was rounding with the CNA and they got to Resident #1's room, the CNA told her to start with Resident #1 first because if she missed her first smoke break then she would get upset. CNA B stated the CNA never told her Resident #1 required two people to transfer her, but she did tell her if she needed help with Resident #1, then let her know.<BR/>A record review of the facility's in-services revealed staff were in-serviced on falls and transfers on 01/16/23 and 01/18/23. A further review revealed staff were in-serviced on 01/12/23 on Rounding oncoming shift: CNAs round with CNAs and Nurses round with Nurses. <BR/>A record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, dated 2003, revealed Purpose: The purposes of this procedure are to allow the resident to bout of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure: Note: This procedure may require two (2) persons. H. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) to incorporate the recommendations and submit a complete and accurate request for nursing facility specialized services in LTC Online Portal for three of six residents (Residents #38, #47, and #79) reviewed for Pre-admission Screening and Resident Review (PASRR).<BR/>1. The facility failed to conduct an accurate PASRR Level 1 screening and complete Form 1012 (Mental Illness/Dementia Resident Review) for Resident #38. The PASRR Level 1 screening indicated Resident #38 did not have a mental illness, intellectual disability, or other related developmental disabilities; however, Resident #38 admitted to the facility with a diagnosis of major depressive disorder and delusional disorders. <BR/>2. The facility failed to conduct an accurate PASRR Level 1 screening and complete Form 1012 (Mental Illness/Dementia Resident Review) for Resident #47. The PASRR Level 1 screening indicated Resident #47 did not have a mental illness, intellectual disability, or other related developmental disabilities; however, Resident #47 admitted to the facility with a diagnosis of schizoaffective disorder and unspecified intellectual disabilities. <BR/>3. The facility failed to conduct an accurate PASRR Level 1 screening and complete Form 1012 (Mental Illness/Dementia Resident Review) in a timely manner for Resident #79. The PASRR Level 1 screening indicated Resident #79 did not have any diagnoses of mental illness, intellectual disability, or other related developmental disabilities; however, Resident #79 admitted to the facility with a diagnosis of manic episodes and was diagnosed with paranoid schizophrenia and bipolar disorder the following year.<BR/>This failure could place all residents identified as intellectually and/or developmentally disabled at risk of not receiving specialized services and equipment to meet their needs.<BR/>Findings included:<BR/>1. Record review of Resident #38's face sheet, dated 09/29/22, revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE]. Resident #38's diagnoses included: senile degeneration of the brain (Dementia), major depressive disorder (mood disorder), anxiety disorder, delusional disorder and cognitive communication deficit. <BR/>Record review of Resident #38's admission orders revealed he was diagnosed with major depressive disorder, delusional disorder and senile degeneration of the brain all on 11/22/21. <BR/>Record review of Resident #38's PASRR Level 1 Screening, dated 11/19/21 and completed by the facility's former MDS Coordinator, revealed Resident #38:<BR/>-was negative for mental illness, <BR/>-was negative for intellectual disability, and<BR/>-was negative for developmental disability. <BR/>Review of Resident #38's Quarterly MDS assessment, dated 07/21/22, revealed Resident #38's BIMS was not conducted due to mental status. Resident #38's MDS reflected that he had diagnoses of Non-Alzheimer's Dementia, Depression, and Psychotic disorder. <BR/>Review of Resident #38's care plan, dated 09/28/22, indicated Resident #38 exhibited maladaptive behaviors related to Dementia and poor impulse control. Interventions included: administer medications as ordered, assess, and anticipate needs, provide physical and verbal cues to alleviate anxiety, provide gentle redirection, and intervene before agitation escalates. <BR/>2. Record review of Resident #47's face sheet, dated 09/29/22, revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE]. Resident #47's diagnoses included: senile degeneration of the brain (Dementia), impulse disorder (inability to maintain self-control), schizoaffective disorder (mood disorder), depression, anorexia (eating disorder), and insomnia (sleep disorder). <BR/>Record review of Resident #47's admission orders revealed he was diagnosed with senile degeneration of the brain, schizoaffective disorder, and depression all on 11/15/21. <BR/>Record review of Resident #47's PASRR Level 1 Screening, dated 11/15/21 and completed by a social worker at the discharging hospital, revealed Resident #47:<BR/>-was negative for mental illness, <BR/>-was negative for intellectual disability, and<BR/>-was negative for developmental disability. <BR/>Review of Resident #47's Quarterly MDS assessment, dated 07/17/22, revealed Resident #47's BIMS was not conducted due to mental status. Resident #47's MDS reflected that he had diagnoses of Non-Alzheimer's Dementia, Depression, and Schizophrenia. <BR/>Review of Resident #47's care plan, dated 03/24/22, indicated Resident #47 had the potential to physically aggressive related to resident-to-resident altercation. Interventions included: analyze time of day, places, circumstances, triggers and what de-escalates behavior, document and assess for contributing sensory deficits. The care plan also reflected that Resident #47 received antipsychotic medications related to schizoaffective disorder, and antidepressant medications related to insomnia and depression. <BR/>3. Record review of Resident #79's face sheet, dated 09/29/22, revealed the resident was an [AGE] year-old male, admitted to the facility on [DATE]. Resident #79's diagnoses included: senile degeneration of the brain (dementia), manic episode without psychotic symptoms, manic episode unspecified, delusional disorder, paranoid schizophrenia (mental illness), and bipolar disorder (mental illness). <BR/>Review of Resident #79's admission orders revealed he was diagnosed with manic episode unspecified on 05/25/18, manic episode without psychotic symptoms on 05/27/18, delusional disorder on 05/27/18, paranoid schizophrenia on 03/13/19, senile degeneration of the brain on 06/20/19, and bipolar disorder on 10/23/19.<BR/>Record review of Resident #79's PASRR Level 1 Screening, dated 05/25/18, and completed by a social worker at the discharging hospital, revealed Resident #79:<BR/>-was negative for mental illness, <BR/>-was negative for intellectual disability, and<BR/>-was negative for developmental disability. <BR/>Review of Resident #79's EHR revealed the facility completed Form 1012 (Mental Illness/Dementia Resident Review) for him on 10/20/19, several months after Resident #79's diagnoses of paranoid schizophrenia, manic episode and delusional disorder. <BR/>Review of Resident #79's Quarterly MDS assessment, dated 08/20/22, revealed Resident #79's BIMS was a 3, which indicated severe cognitive impairment. Resident #79's MDS reflected he had diagnoses of Bipolar Disorder, Psychotic Disorder, and Schizophrenia. <BR/>Review of Resident #79's care plan, dated 07/18/22, indicated Resident #79 received psychiatric services related to mental illness. Interventions included: psychiatrist would conduct visits as needed. The care plan reflected that Resident #79 was sometimes resistive to care related to paranoia, delusions, and cognition impairment. Interventions included: allow resident to make decisions about treatment regime, educate resident/family/caregivers on possible outcomes of non-compliance, encourage participation, give clear explanation of care activities, reassure resident and praise appropriate behaviors. The care plan also reflected that Resident #79 received antipsychotic medications related to schizophrenia, and antidepressant medications for mood stabilizer. <BR/>Interview on 09/29/22 at 11:20 AM with the MDS Nurse revealed she had worked as the area MDS Nurse for the company for about 2 years but had only been exclusively at the facility for about 2 weeks. She stated it was the facility's policy to fill out a 1012 Form after any negative Level 1 pre-screening and/or when there was a new diagnosis of mental illness or intellectual disability, to determine if a resident required further assessment for PASRR services. The MDS Nurse stated if a resident was admitted from a hospital with a negative Level 1 pre-screening, and there was evidence of mental illness or intellectual disability, the facility would need to request a corrected Level 1 pre-screening or complete one themselves. She denied being able to find any documents indicating that the state designated authority was made aware of either of the residents possibly needing services. The MDS Nurse stated it was her responsibility to review all PASRR assessments; however, she did not work for the facility at the time Residents #38, #47 and #79 were admitted to the facility. She stated that it would have been the responsibility of the former MDS nurse to correct the PASRR assessments and completed the 1012 Forms. She stated the risk of an inaccurate PASRR screening could be an inappropriate placement and lack of treatment and services for the resident.<BR/>Interview on 09/29/22 at 1:41 PM with the DON revealed nursing reviewed the clinical part of the admission documents. The DON stated as part of the review, the MDS Nurse was responsible for reviewing PASRR assessments. The DON stated the process was for the admissions department to put together the referral packet, then send it out to all other departments for review, including the MDS Nurse for a PASRR review. The DON stated if the MDS Nurse found an issue with the PASRR screening, the facility would either not accept the resident or they would assess for additional services needed to better help Residents #38, #47 and #79. <BR/>Interview on 09/29/22 at 1:48 PM with the Administrator revealed when a resident was referred to the facility, an email thread was sent out, including to the administrator, business office, clinical team and MDS Nurse. She stated all departments would review their portion of the admission documents to determine if the resident was appropriate for facility. The Administrator stated it was the responsibility of the MDS Nurse to review PASRR screenings and complete 1012 forms. She stated her expectation was for the MDS Nurse to further review all PASRR screenings coming from outside entities/hospitals to ensure that they were accurate. The Administrator stated if the PASRR screenings were not accurate, her expectation would be for the MDS Nurse to request a correction or complete an updated screening herself. She stated that the facility was under fairly new administration and that none of the previous PASRR assessments had been audited or reviewed. The Administrator stated the risk of residents not having an accurate PASRR screening could be a delay in needed specialized services. <BR/>Review of facility's policy titles Pre-admission Screening and Resident Review (PASRR), dated November 2017, revealed in part the following:<BR/>Policy: Pre-admission screening is coordinated for residents identified to have a mental disorder and/or intellectual disability in accordance with Federal and State law. <BR/>Purpose: To ensure individuals with mental disorder and intellectual disabilities receive the care and services they need in the most appropriate setting. <BR/>Procedure:<BR/>-The facility follows state-specific instructions for the coordination of PASRR.<BR/>-The Admissions Coordinator in consultation with the DON identifies residents requiring a PASRR during the Pre-admission process.<BR/>-The Admissions Coordinator coordinates the completion of the PASRR and ensures the facility receives a copy of the PASRR report, including specialized services, prior to review for admission. <BR/>-Upon a significant change in status assessment, Nursing will refer residents currently diagnosed with or residents newly evident or possible mental disorder, intellectual disability, or related condition for a PASRR level II review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. <BR/>1. The facility failed to address Resident #1's multiple refusals of care and services on the comprehensive care plan<BR/>This failure could place residents at risk of not receiving the necessary care and services. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an admission date of 07/11/24. Resident #1 had diagnoses of Multiple Sclerosis (chronic disease that affects the brain and spinal cord), Cognitive Communication Deficit (communication difficulty), and History of Transient Ischemic Attack (brief interruption of blood flow to the brain). The face sheet noted a discharge date of 09/17/24. <BR/>Record review of Resident #1's Admitting MDS Assessment, dated 07/17/24, reflected Resident #1 had a BIMS score of 11, which meant Resident #1 had a moderate level of cognition. The MDS noted the resident did not exhibit any behaviors. <BR/>Record review of Resident #1's care plan with an initial date of 07/12/24, reflected no interventions for Resident #1's multiple refusals of wound care, perineal care, medication administration, or showers. <BR/>Record review of the progress notes on Resident #1's electronic record, dated, 05/08/25, reflected the following:<BR/>07/19/24 15:36 (3:36 PM)- Resident #1 refused wound debridement after multiple attempts, application of Nystatin Powder (antifungal medication for skin infections), application of Hydrocortisone External Cream (medication used to treat skin conditions) for wound care<BR/>07/23/24 at 16:17 (4:17 PM)- Resident #1 refused the application of Nystatin Powder for wound care<BR/>07/24/24 at 12:20 PM- Resident #1 refused the application of Hydrocortisone External Cream<BR/>08/01/24 at 9:38 AM- Resident #1 refused Pro-Stat AWC (protein drink for wound healing) 3 times<BR/>08/02/24 at 8:31 AM- Resident #1 refused Pro-Stat AWC 3 times<BR/>08/09/24 21:47 (9:47 PM)- Resident #1 refused a blood sugar check<BR/>08/10/24 at 8:37 AM- Resident #1 refused the application of Nystatin Powder and Hydrocortisone External Cream for wound care, cleansing of wound, and dressing change<BR/>08/10/24 at 8:45 AM- Resident #1 refused a shower<BR/>08/10/24 at 13:21 (1:21 PM)- Resident #1 refused a blood sugar check<BR/>In an interview on 05/08/25 at 2:30 PM, the DON stated she did not work at the facility when Resident #1 was living there. She stated the refusals should have been addressed and interventions should have been in place to encourage Resident #1 not to refuse care. The DON stated the risk of refusals not addressed was a possible decline in health. <BR/>In an interview on 05/08/25 at 2:40 PM, the Administrator stated she was not working at the facility last year when Resident #1 lived there. She stated the refusals should have been addressed so staff would know how to best assist the resident. She stated the risk would have been Resident #1 not receiving the services she needed. <BR/>Record review of the facility's undated policy, titled, Comprehensive Care Planning, reflected the following:<BR/>The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -<BR/>o <BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and<BR/>o <BR/>the right to refuse treatment<BR/>Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.<BR/>The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.<BR/>In situations where a resident's choice to decline care or treatment (e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempts to find alternative means to address the identified risk/need should be documented in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, the facility failed to review and revise care plans for 2 (Residents #1 and #2) of 5 residents reviewed for care plan revision.<BR/>The facility failed to revise Resident #1 and #2's care plans to reflect their need for direct supervision while smoking. <BR/>This failure could place the residents at risk of harm to themselves or other residents<BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included paralysis, seizures, stroke affecting left side, and cardiac pacemaker.<BR/>Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating she was cognitively intact. Her Functional Status indicated she required a wheelchair for mobility, and limited assistance with her ADLs. <BR/>Review of Resident #1's care plan revealed she did not have a focus area on smoking and/or smoking with supervision.<BR/>Review of Resident #1's monthly Safe Smoking Assessment, dated 04/20/24, reflected: This resident requires direct supervision while smoking .All smoking materials will be kept at the nurses station. <BR/>Observation and interview on 04/20/24 at 3:20 PM revealed Resident #1 was in the smoking area with a lit cigarette and smoking with no staff present to monitor. Resident #1 extinguished the cigarette when the DON and the surveyor approached her. Resident #1 denied smoking. Ash from a cigarette was observed on her pants leg, and a suspected cigarette burn hole in her pants was near the same spot. The DON brushed away the ash and asked Resident #1 when the burn in her pants had occurred. Resident #1 stated it had happened about a month ago. <BR/>Review of Resident #2's undated admission Record revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included diabetes, history of falls, heart failure, and amputation of the left leg above the knee. <BR/>Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 15 indicating she was cognitively intact. Her Functional Status indicated she required minimal assistance for her ADLs. <BR/>Review of Resident #2's care plan, dated 03/19/24, revealed she did not have a focus area on smoking with supervision. <BR/>Review of Resident #2's Safe Smoking Assessment, dated 04/20/24 reflected This resident requires direct supervision while smoking All smoking materials will be kept at the nurses station. <BR/>Observation and interview on 04/20/24 at 3:20 PM revealed Resident #2 was in the smoking area with a lit cigarette and no staff supervision. Resident #2 continued to smoke when the DON and the surveyor approached her. The DON advised the resident that it was not a designated smoke time and asked who had lit her cigarette. Resident #2 refused to answer the DON. Resident #2 had no obvious burns to her hands or her clothing. <BR/>Interview on 04/20/24 at 3:30 PM the DON stated residents were only allowed to smoke at designated times when staff were present to monitor them. Resident smoke times began at 7:30 AM and were every other hour throughout the day. The DON stated CNAs rotate the monitoring of smoke times throughout the day. The DON stated it was hard to keep the residents from smoking on the off times because they sneak cigarettes from outside the facility, and smoke any time t hey wanted to. The DON stated the risk of residents smoking unsupervised were they could harm themselves or another resident with a lit cigarette. <BR/>Review of the facility's undated policy Comprehensive Care Planning, reflected:<BR/>The resident's care plan will be reviewed after each Admission, Quarterly, Annually and/or Significant Change MDS assessment, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. <BR/>CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. <BR/>CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). <BR/>These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. <BR/>Findings include:<BR/> A record review of Resident #1's electronic face sheet, dated 02/09/23, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included muscle weakness, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one?sided weakness) following intracerebral hemorrhage (bleeding into the brain tissue) affecting right dominant side, muscle wasting and atrophy, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS of 15, which indicated the resident's cognition was intact. Resident #1's MDS revealed she required extensive assistance with two-persons physical assistance for the following ADLs: bed mobility, transfers, and toilet use. <BR/>A record review of Resident #1's Care Plan dated 10/13/22 revealed Resident #1 had an ADL self-care performance deficit related to weakness on right side upper and lower extremities with history of CVA impaired mobility for bed mobility, toilet use, transfers. The interventions included the following: Toilet Use: The resident requires Extensive Assist x2 providers; Transfer: Requires Extensive Assist x2 providers.<BR/>A record review of Resident #1's Progress Notes by LVN C, dated 01/15/23, revealed Resident was being transferred to bed by agency CNA when she became weak, and CNA lowered her slowly to the floor with no complications. Resident noted stable denied no pain or any discomfort at this time. Resident was alert and oriented x4 with all upper and lower extremity functioning. Resident able to explain that she was assisted to sit on the floor by CNA since she could not bear weight. All vital signs within reach b/p 127/66, pulse 64, temp 98. Resident successfully assisted to bed using Hoyer lift.<BR/>A record review of Resident #1's Progress Notes by LVN D, dated 01/18/23, revealed At approximately 0700 Aide called stating that resident was on floor. Writer went to room resident was sitting on floor head leaning to assigned aides leg, who was standing beside resident's bed. Vitals remain within normal limit. No temperature noted. Resident complain of pain to right shoulder and arm. Assessment completed mild inflammation noted on site and painful to touch. Staff instructed to immobilize arm (not to move arm). MD notified. New order received to send resident to the ER for further evaluation. Medication audited noted administration of Tylenol 3 at 0600. Schedule gabapentin of 600 mg administered at this time. 911 call at approximately 0715 and resident was sent out to the ER [hospital] at 0725. RP Notified and aware of hospital of choice. <BR/>A record review of Resident #1's hospital paperwork, dated 01/19/23, revealed she was admitted to the hospital on [DATE] at 7:58 AM due to right shoulder pain from a fall. The hospital record revealed x-rays were completed on Resident #1's right shoulder and she was diagnosed with a closed fracture of neck of right humerus, initial encounter.<BR/>An observation and an interview on 02/09/23 at 10:19 AM, revealed Resident #1's right arm was in a sling. Resident #1 stated she had fall a couple of times in the facility, but she did not recall the details or the dates of the falls. Resident #1 stated in the last fall she was sent to the hospital and her arm was broken. She stated her arm was very sore. Resident #1 stated each time she fell it was while she was being transferred in and out of bed. She stated in the last fall she was being put in the bed and her paralyzed leg (right side) got stuck while she was being turned towards the bed. Resident #1 stated the CNA could not hold her up and they slid to the floor. She stated there was only one CNA transferring her in or out of bed each time she fell. <BR/>In an interview on 02/09/23 at 12:23 PM, the ADMN and DON, the ADMN stated Resident #1 was a 2-persons assist and after the fall on 01/18/23, she was changed to Hoyer lift for transfers. The ADMN stated both falls were with agency staff, but their facility staff all knew Resident #1 was a 2-person assist. The DON stated staff were in-serviced after each fall. The ADMN stated when agency staff worked at the facility, they were supposed to round with a facility staff member at the beginning of their shift. The ADMN stated the facility staff were supposed to go over the resident's needs, such as transfer status during the rounds. <BR/>In an interview on 02/09/23 at 1:14 PM, the Nurse Manager stated she was aware of the falls from 01/15/23 and 01/18/23. She stated she in-serviced staff about falls and transfers after each incident. The Nurse Manager stated when agency staff arrived, they were supposed to check in with the charge nurse and they would receive their assignment. She stated whoever the agency staff was relieving they were supposed to round with them, and discuss resident's needs, such as transfers. The Nurse Manager stated they had started using more agency around the times of the incidents, so she did an in-service about rounding. The Nurse Manager stated CNA B was assigned to round with CNA E. She stated she did not know about CNA A because this happened in the evening after she left for the day. <BR/>In an interview on 02/09/23 at 1:46 PM, CNA E stated she worked on 01/18/23 and was assigned to do rounds with CNA B. She stated she provided CNA B with a cheat sheet, which had info about the residents, which included who was incontinent, who needed help with feeding, and transfer requirements, such as who needed a Hoyer lift. CNA E stated Resident #1 was a two-persons transfer and when they rounded, she told the agency CNA B to let her know when she needed help with transfers. She said Resident #1 is a larger lady, so she doesn't know why CNA B would try to transfer her by herself. CNA E stated facility staff always used two people. <BR/>In a phone interview on 02/10/23 at 2:48 PM, LVN C stated on 01/15/23, he was called into Resident #1's room by CNA A. He stated CNA A said she was getting Resident #1 out of her wheelchair to put her in the bed. LVN C stated CNA A said she could not hold resident up by herself and so they slide down to the floor. LVN C stated Resident #1 was a 2-persons assist. He stated he had always observed facility staff using two CNAs when transferring Resident #1 to and from bed, but CNA A was agency. <BR/>LVN C stated he asked CNA A why she attempted to transfer Resident #1 by herself, without asking for help. He stated CNA A said she told Resident #1 she was going to get help and Resident #1 told her she was able to stand by herself and only needed one aide to help her. LVN C stated CNA A said she believed what the resident said, so she attempted to transfer her. LVN C stated Resident #1 is a larger lady and CNA A said she could not hold her weight, when Resident #1 stood out of the wheelchair, so they slide to the ground. LVN C stated agency staff are usually paired with a facility staff to do rounds, but he was not sure if she completed rounds because he worked a 12 hr. shift on the weekends and CNA A had already started her shift before he arrived. <BR/>On 02/13/23 at 2:10 PM, the Administrator communicated she had attempted to get CNA A's phone number from the staffing agency via email and by phone and was unable to get her number. <BR/>In a phone interview on 02/09/23 at 5:49 PM, LVN D stated on 01/18/23 she was called to Resident #1's room by CNA B, who told her she was transferring Resident #1 from the bed and could not hold her up, so she lowered Resident #1 to the floor. LVN D stated Resident #1 was a 2-persons transfer and maybe because CNA B was agency she did not know. LVN D stated she had never seen facility CNAs transferring the resident by themselves. She stated when agency CNAs checked in, she was supposed to pair them with a facility CNA to do rounds. LVN D stated during rounds, the facility CNA was supposed to educate the agency CNAs on the resident's needs, such as how they were transferred. LVN D stated she did pair CNA B with a facility CNA. She stated she did not recall who she was paired with, but she was sure she paired her. <BR/>In a phone interview on 02/10/23 at 10:41 AM, CNA B stated she was agency staff and she had worked at the facility twice before 01/18/23. CNA B stated she was not sure if Resident #1 was a 2-persons assist for transfers. CNA B stated when she had worked with Resident #1 before, she had transferred her by herself, and she was able to pivot her good side to help with transfer. She stated Resident #1 was ready to get up and into her wheelchair so she could go smoke. CNA B stated she was changing Resident #1's brief and stood her up to pull up the brief. CNA B stated she had a weak side that she could not really move, so she was holding her up under her arm on the weak side, which was her right side. She stated Resident #1 was standing and as she pulled her brief up, and suddenly Resident #1 started screaming that her arm was hurting, and she could not hold on. CNA B stated she lowered Resident #1 to the floor to ensure she doesn't hit her head. She stated she did not move resident and called for a nurse. CNA B stated she was in-serviced on falls and transfers after the incident. She stated she did do rounds with another CNA (doesn't recall her name) at the beginning of her shift. CNA B stated when she rounded with the CNA, she was telling her who required Hoyer lift and what the resident needed help with. She stated the CNA did not provide a paper with the resident's needs. CNA B stated when she was rounding with the CNA and they got to Resident #1's room, the CNA told her to start with Resident #1 first because if she missed her first smoke break then she would get upset. CNA B stated the CNA never told her Resident #1 required two people to transfer her, but she did tell her if she needed help with Resident #1, then let her know.<BR/>A record review of the facility's in-services revealed staff were in-serviced on falls and transfers on 01/16/23 and 01/18/23. A further review revealed staff were in-serviced on 01/12/23 on Rounding oncoming shift: CNAs round with CNAs and Nurses round with Nurses. <BR/>A record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, dated 2003, revealed Purpose: The purposes of this procedure are to allow the resident to bout of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure: Note: This procedure may require two (2) persons. H. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for two (Residents #80 & #33) of three residents reviewed for dental services. <BR/>The facility failed to assist in providing routine dental services for Resident #80 and #33.<BR/>This failure could affect residents by placing them at risk for oral complications, dental pain, and diminished quality of life. <BR/>Findings included:<BR/>Review of Resident #80's EHR revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included end stage heart failure, stroke, heart attack, and hardening of the arteries requiring heart bypass surgery. <BR/>Review of Resident #80's MDS, dated [DATE], revealed a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he was independent in his ADLs with the exception of dressing and personal hygiene. His Oral/Dental Status did not indicate broken or loose-fitting dentures and no pain with chewing. <BR/>Review of Resident #80's care plan, dated 6/13/22, revealed he was not care planned for any dental health issues. <BR/>Review of Resident #80's admission Physical Assessment, dated 12/02/19, indicated the resident had broken teeth and no dentures. <BR/>Review of Resident #33's EHR revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke with left sided paralysis, anxiety, and chronic neck pain.<BR/>Review of Resident #33's MDS, dated [DATE], revealed a BIMS score of 14, indicating he was cognitively intact. His Functional Status indicated he required assistance with all of his ADLs. His Oral/Dental Status indicated no broken or loose-fitting dentures. <BR/>Review of resident #33's care plan, dated 08/04/22, revealed he had no risks related to dental issues . <BR/>Interview and observation on 09/27/22 at 10:37 AM Resident #80 stated he needed to see a dentist about getting dentures because it was sometimes hard to eat some of the food the facility served. He denied any pain when eating. He stated he had lost the majority of his teeth and the few that he had left were broken or damaged in some form or another. Observation of his teeth revealed the resident had a few teeth in his upper gums and a few in the lower. None of the teeth appeared healthy or clean. Resident #80 stated he had been told at some point by the Social Worker that his insurance did not cover dentures and that was why he did not have dentures. He did not follow up with the social worker, he thought he could not get dental services. He stated having dentures would let him eat more meat, which he loved. <BR/>Interview on 09/27/22 at 10:40 AM Resident #33 stated he had not seen a dentist since he was admitted to the facility. He stated he was told by the Social Worker that his insurance did not cover the dentist that came to the facility, he never followed up with her and she never followed up with him about finding another dentist. He stated he only needed a good dental cleaning; he did not have any other dental issues. <BR/>Interview on 09/28/22 at 1:43 PM Social Worker B stated residents contacted her when they wanted to see the dentist and she put them on the list. Social Worker B stated the dentist came once a month to the facility to see the residents. She stated Resident #80 and #33's insurance did not cover the dentist that serviced the facility. She stated she had no notes in the residents' files from the previous social worker to indicate what attempts had been made to find an alternate dentist for the residents. She stated she would follow up with the residents and ensure they saw a dentist that accepted their insurance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure full visual privacy for 2 (Residents #6 and #7) of 5 residents reviewed for privacy.<BR/>The facility failed to provide privacy curtains for Residents #6 and #7 while their curtains were being laundered. <BR/>This failure could place the residents at risk of decreased feelings of self -worth. <BR/>Findings included:<BR/>Review of Resident #6's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included bone infection, diabetes, amputation of right leg below the knee, and Opioid abuse.<BR/>Review of Resident #6's admission MDS, dated [DATE], revealed a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicted he was mostly independent in his ADLs. <BR/>Review of Resident #6's care plan, dated 04/20/24, revealed he had a focus area for a surgical incision to his right toes and left leg requiring wound care and a focus area for the resident's self-care deficit. <BR/>Review of Resident #7's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, legal blindness, amputation of both feet, and high blood pressure. <BR/>Review of Resident #7's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicted he required extensive assistance with his ADLs. <BR/>Review of Resident #7's care plan, dated 03/30/24, revealed he had cognitively impairment related to stroke, and he had an ADL self-care deficit. <BR/>Observation on 04/20/24 at 9:20 AM revealed there were no privacy curtains in Resident #6 and #7's room. <BR/>Interview on 04/20/24 at 9:20 AM with Resident #6 revealed the privacy curtains had been removed on 04/13/24 because Resident #7 was reported to possibly have bed bugs. All linens and the curtains were taken to be laundered. Resident #6 stated he and Resident #7 were moved to another room while their room was treated. They were moved back into their room on 04/17/24, but their personal property was not moved back in and no new curtains were hung. Resident #6 stated Resident #7 required wound care, and sometimes incontinence care, and there was no privacy for him. <BR/>Interview on 04/20/24 at 9:24 AM with Resident #7 revealed he did not like the idea that he could be seen by anyone when he was exposed. He stated since he was blind, he depended on staff to provide privacy. <BR/>Interview on 04/20/24 at 4:00 PM with the Administrator revealed the privacy curtains for Resident #6 and #7 were in the process of being re-hung. She stated the curtains should have been replaced by maintenance as soon as the treatment for bed bugs had been completed, before the residents were moved back in. She did not know why that did not happen. The Administrator stated there was not a policy for priivacy curtains.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, and maintain a comfortable and safe temperature for 1 of 5 (room [ROOM NUMBER]) residents room and 1 of 1 common areas ( front lobby area) reviewed for environment in that:<BR/>Temperatures in the resident's room [ROOM NUMBER] and lobby area, were above the acceptable range (81 degrees Fahrenheit) for resident safety and comfort. The temperatures were taken with a laser thermometer.<BR/>This failure could place residents at risk of being/feeling uncomfortable due to the air temperatures.<BR/>Findings included:<BR/>Observation on 06/27/23 at 1:34 pm the temperature in room [ROOM NUMBER] revealed a temperature of 84 degrees Fahrenheit (F).<BR/>Observation on 06/27/23 at 2:09 pm of the front lobby area of the facility revealed two residents seated in chairs. The temperatures taken next to the residents revealed a temperature of 88 degrees to the left where the resident sat and a temperature of 84 degrees to the right side of the lobby where the resident sat. <BR/>A review of accuweather.com on 06/27/23 at 2:15 pm revealed an outside temperature of 101 degrees.<BR/>An interview on 06/27/23 with the residents in room [ROOM NUMBER] on 06/27/23 at 1:45 pm revealed the resident did not have any concerns about being too hot or uncomfortable. The residents revealed they had been provided an air conditioning unit on 06/23/23. The central air conditioner had not been working well since 06/23/23. Each of the residents in the room had no complaints about the temperature .<BR/>An interview on 06/27/23 at 2:15pm with both of the residents located in the lobby area of the facility. Both residents stated they were not hot or uncomfortable . <BR/>An interview on 06/27/23 at 2:33 pm with the Maintenance Director revealed the facility had identified issues with the central A/C unit 2 weeks prior. On 06/23/23 he was informed the units were not cooling the facility properly . Some of the residents were provided window A/C units. The Maintenance Director revealed a company was scheduled to repair the Central units, but had not arrived, and had rescheduled for 06/28/23. The Maintenance Director revealed the Lobby area central A/C had been removed by the previous ownership company, and the facility had not replaced the unit. <BR/>An interview with the ADM on 06/27/23 at 2:47 pm revealed the facility had some issues with the central AC unit the following week . The resident's rooms that were identified were provided window AC units . The facility staff received education on 06/19/23 regarding resident hydration. She had not been aware of any residents reporting issues with being too hot in the facility. The resident with rooms above 81 degrees would be moved to another hallway with comfortable temperatures. <BR/>A review of an in-service education dated 06/19/23 regarding Resident hydration was completed and signed by staff members. <BR/>A review of the facility's Resident Rights policy last revised on 11/28/16 revealed The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide 6. Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 degrees to 81 degrees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. <BR/>CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. <BR/>CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). <BR/>These failures could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. <BR/>Findings include:<BR/> A record review of Resident #1's electronic face sheet, dated 02/09/23, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included muscle weakness, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one?sided weakness) following intracerebral hemorrhage (bleeding into the brain tissue) affecting right dominant side, muscle wasting and atrophy, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS of 15, which indicated the resident's cognition was intact. Resident #1's MDS revealed she required extensive assistance with two-persons physical assistance for the following ADLs: bed mobility, transfers, and toilet use. <BR/>A record review of Resident #1's Care Plan dated 10/13/22 revealed Resident #1 had an ADL self-care performance deficit related to weakness on right side upper and lower extremities with history of CVA impaired mobility for bed mobility, toilet use, transfers. The interventions included the following: Toilet Use: The resident requires Extensive Assist x2 providers; Transfer: Requires Extensive Assist x2 providers.<BR/>A record review of Resident #1's Progress Notes by LVN C, dated 01/15/23, revealed Resident was being transferred to bed by agency CNA when she became weak, and CNA lowered her slowly to the floor with no complications. Resident noted stable denied no pain or any discomfort at this time. Resident was alert and oriented x4 with all upper and lower extremity functioning. Resident able to explain that she was assisted to sit on the floor by CNA since she could not bear weight. All vital signs within reach b/p 127/66, pulse 64, temp 98. Resident successfully assisted to bed using Hoyer lift.<BR/>A record review of Resident #1's Progress Notes by LVN D, dated 01/18/23, revealed At approximately 0700 Aide called stating that resident was on floor. Writer went to room resident was sitting on floor head leaning to assigned aides leg, who was standing beside resident's bed. Vitals remain within normal limit. No temperature noted. Resident complain of pain to right shoulder and arm. Assessment completed mild inflammation noted on site and painful to touch. Staff instructed to immobilize arm (not to move arm). MD notified. New order received to send resident to the ER for further evaluation. Medication audited noted administration of Tylenol 3 at 0600. Schedule gabapentin of 600 mg administered at this time. 911 call at approximately 0715 and resident was sent out to the ER [hospital] at 0725. RP Notified and aware of hospital of choice. <BR/>A record review of Resident #1's hospital paperwork, dated 01/19/23, revealed she was admitted to the hospital on [DATE] at 7:58 AM due to right shoulder pain from a fall. The hospital record revealed x-rays were completed on Resident #1's right shoulder and she was diagnosed with a closed fracture of neck of right humerus, initial encounter.<BR/>An observation and an interview on 02/09/23 at 10:19 AM, revealed Resident #1's right arm was in a sling. Resident #1 stated she had fall a couple of times in the facility, but she did not recall the details or the dates of the falls. Resident #1 stated in the last fall she was sent to the hospital and her arm was broken. She stated her arm was very sore. Resident #1 stated each time she fell it was while she was being transferred in and out of bed. She stated in the last fall she was being put in the bed and her paralyzed leg (right side) got stuck while she was being turned towards the bed. Resident #1 stated the CNA could not hold her up and they slid to the floor. She stated there was only one CNA transferring her in or out of bed each time she fell. <BR/>In an interview on 02/09/23 at 12:23 PM, the ADMN and DON, the ADMN stated Resident #1 was a 2-persons assist and after the fall on 01/18/23, she was changed to Hoyer lift for transfers. The ADMN stated both falls were with agency staff, but their facility staff all knew Resident #1 was a 2-person assist. The DON stated staff were in-serviced after each fall. The ADMN stated when agency staff worked at the facility, they were supposed to round with a facility staff member at the beginning of their shift. The ADMN stated the facility staff were supposed to go over the resident's needs, such as transfer status during the rounds. <BR/>In an interview on 02/09/23 at 1:14 PM, the Nurse Manager stated she was aware of the falls from 01/15/23 and 01/18/23. She stated she in-serviced staff about falls and transfers after each incident. The Nurse Manager stated when agency staff arrived, they were supposed to check in with the charge nurse and they would receive their assignment. She stated whoever the agency staff was relieving they were supposed to round with them, and discuss resident's needs, such as transfers. The Nurse Manager stated they had started using more agency around the times of the incidents, so she did an in-service about rounding. The Nurse Manager stated CNA B was assigned to round with CNA E. She stated she did not know about CNA A because this happened in the evening after she left for the day. <BR/>In an interview on 02/09/23 at 1:46 PM, CNA E stated she worked on 01/18/23 and was assigned to do rounds with CNA B. She stated she provided CNA B with a cheat sheet, which had info about the residents, which included who was incontinent, who needed help with feeding, and transfer requirements, such as who needed a Hoyer lift. CNA E stated Resident #1 was a two-persons transfer and when they rounded, she told the agency CNA B to let her know when she needed help with transfers. She said Resident #1 is a larger lady, so she doesn't know why CNA B would try to transfer her by herself. CNA E stated facility staff always used two people. <BR/>In a phone interview on 02/10/23 at 2:48 PM, LVN C stated on 01/15/23, he was called into Resident #1's room by CNA A. He stated CNA A said she was getting Resident #1 out of her wheelchair to put her in the bed. LVN C stated CNA A said she could not hold resident up by herself and so they slide down to the floor. LVN C stated Resident #1 was a 2-persons assist. He stated he had always observed facility staff using two CNAs when transferring Resident #1 to and from bed, but CNA A was agency. <BR/>LVN C stated he asked CNA A why she attempted to transfer Resident #1 by herself, without asking for help. He stated CNA A said she told Resident #1 she was going to get help and Resident #1 told her she was able to stand by herself and only needed one aide to help her. LVN C stated CNA A said she believed what the resident said, so she attempted to transfer her. LVN C stated Resident #1 is a larger lady and CNA A said she could not hold her weight, when Resident #1 stood out of the wheelchair, so they slide to the ground. LVN C stated agency staff are usually paired with a facility staff to do rounds, but he was not sure if she completed rounds because he worked a 12 hr. shift on the weekends and CNA A had already started her shift before he arrived. <BR/>On 02/13/23 at 2:10 PM, the Administrator communicated she had attempted to get CNA A's phone number from the staffing agency via email and by phone and was unable to get her number. <BR/>In a phone interview on 02/09/23 at 5:49 PM, LVN D stated on 01/18/23 she was called to Resident #1's room by CNA B, who told her she was transferring Resident #1 from the bed and could not hold her up, so she lowered Resident #1 to the floor. LVN D stated Resident #1 was a 2-persons transfer and maybe because CNA B was agency she did not know. LVN D stated she had never seen facility CNAs transferring the resident by themselves. She stated when agency CNAs checked in, she was supposed to pair them with a facility CNA to do rounds. LVN D stated during rounds, the facility CNA was supposed to educate the agency CNAs on the resident's needs, such as how they were transferred. LVN D stated she did pair CNA B with a facility CNA. She stated she did not recall who she was paired with, but she was sure she paired her. <BR/>In a phone interview on 02/10/23 at 10:41 AM, CNA B stated she was agency staff and she had worked at the facility twice before 01/18/23. CNA B stated she was not sure if Resident #1 was a 2-persons assist for transfers. CNA B stated when she had worked with Resident #1 before, she had transferred her by herself, and she was able to pivot her good side to help with transfer. She stated Resident #1 was ready to get up and into her wheelchair so she could go smoke. CNA B stated she was changing Resident #1's brief and stood her up to pull up the brief. CNA B stated she had a weak side that she could not really move, so she was holding her up under her arm on the weak side, which was her right side. She stated Resident #1 was standing and as she pulled her brief up, and suddenly Resident #1 started screaming that her arm was hurting, and she could not hold on. CNA B stated she lowered Resident #1 to the floor to ensure she doesn't hit her head. She stated she did not move resident and called for a nurse. CNA B stated she was in-serviced on falls and transfers after the incident. She stated she did do rounds with another CNA (doesn't recall her name) at the beginning of her shift. CNA B stated when she rounded with the CNA, she was telling her who required Hoyer lift and what the resident needed help with. She stated the CNA did not provide a paper with the resident's needs. CNA B stated when she was rounding with the CNA and they got to Resident #1's room, the CNA told her to start with Resident #1 first because if she missed her first smoke break then she would get upset. CNA B stated the CNA never told her Resident #1 required two people to transfer her, but she did tell her if she needed help with Resident #1, then let her know.<BR/>A record review of the facility's in-services revealed staff were in-serviced on falls and transfers on 01/16/23 and 01/18/23. A further review revealed staff were in-serviced on 01/12/23 on Rounding oncoming shift: CNAs round with CNAs and Nurses round with Nurses. <BR/>A record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, dated 2003, revealed Purpose: The purposes of this procedure are to allow the resident to bout of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure: Note: This procedure may require two (2) persons. H. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, the facility failed to review and revise care plans for 2 (Residents #1 and #2) of 5 residents reviewed for care plan revision.<BR/>The facility failed to revise Resident #1 and #2's care plans to reflect their need for direct supervision while smoking. <BR/>This failure could place the residents at risk of harm to themselves or other residents<BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included paralysis, seizures, stroke affecting left side, and cardiac pacemaker.<BR/>Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating she was cognitively intact. Her Functional Status indicated she required a wheelchair for mobility, and limited assistance with her ADLs. <BR/>Review of Resident #1's care plan revealed she did not have a focus area on smoking and/or smoking with supervision.<BR/>Review of Resident #1's monthly Safe Smoking Assessment, dated 04/20/24, reflected: This resident requires direct supervision while smoking .All smoking materials will be kept at the nurses station. <BR/>Observation and interview on 04/20/24 at 3:20 PM revealed Resident #1 was in the smoking area with a lit cigarette and smoking with no staff present to monitor. Resident #1 extinguished the cigarette when the DON and the surveyor approached her. Resident #1 denied smoking. Ash from a cigarette was observed on her pants leg, and a suspected cigarette burn hole in her pants was near the same spot. The DON brushed away the ash and asked Resident #1 when the burn in her pants had occurred. Resident #1 stated it had happened about a month ago. <BR/>Review of Resident #2's undated admission Record revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included diabetes, history of falls, heart failure, and amputation of the left leg above the knee. <BR/>Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 15 indicating she was cognitively intact. Her Functional Status indicated she required minimal assistance for her ADLs. <BR/>Review of Resident #2's care plan, dated 03/19/24, revealed she did not have a focus area on smoking with supervision. <BR/>Review of Resident #2's Safe Smoking Assessment, dated 04/20/24 reflected This resident requires direct supervision while smoking All smoking materials will be kept at the nurses station. <BR/>Observation and interview on 04/20/24 at 3:20 PM revealed Resident #2 was in the smoking area with a lit cigarette and no staff supervision. Resident #2 continued to smoke when the DON and the surveyor approached her. The DON advised the resident that it was not a designated smoke time and asked who had lit her cigarette. Resident #2 refused to answer the DON. Resident #2 had no obvious burns to her hands or her clothing. <BR/>Interview on 04/20/24 at 3:30 PM the DON stated residents were only allowed to smoke at designated times when staff were present to monitor them. Resident smoke times began at 7:30 AM and were every other hour throughout the day. The DON stated CNAs rotate the monitoring of smoke times throughout the day. The DON stated it was hard to keep the residents from smoking on the off times because they sneak cigarettes from outside the facility, and smoke any time t hey wanted to. The DON stated the risk of residents smoking unsupervised were they could harm themselves or another resident with a lit cigarette. <BR/>Review of the facility's undated policy Comprehensive Care Planning, reflected:<BR/>The resident's care plan will be reviewed after each Admission, Quarterly, Annually and/or Significant Change MDS assessment, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one (secure unit hall) of three halls reviewed for environment.<BR/>The facility failed to ensure a safe, functional, sanitary and comfortable environment for residents staff and the public.<BR/>The facility failed to ensure the secure unit did not have a strong urine odor.<BR/>This failure could place residents at risk for a diminished quality of life.<BR/>Findings included:<BR/>Observation on 11/12/2023 at 10:13 a.m., upon entrance to the secure unit, the hallway near the entrance and towards the middle of the hallway had a urine odor. The floors appeared clean. Residents appeared well groomed and dressed and no residents appeared soiled.<BR/>Observation and interview on 11/14/2023 at 1:14 p.m., revealed a strong urine odor at the entrance of the secure unit, down the hallway and near the dining room. CNA A stated she noticed the odor and stated residents go to the bathroom anywhere. She stated the rooms and hallway are clean, the residents are changed, but there was still an odor.<BR/>Observation and interview on 11/14/2023 at 2:06 p.m., the DON revealed a strong urine smell. The DON stated the urine smell was mild and the first 2 rooms on the hallway (near the entrance) are quad rooms with all male residents. He stated sometimes they do not go to the bathroom in the commode and housekeeping was always cleaning. The DON stated they have tried to wax the floor with bleach, and he said he was going to bring it up to corporate about ripping up the floor if that would get rid of the odor. <BR/>Record review of facility policy titled Deep cleaning process - Resident Room dated 2015, reflected in part, Follow the cleaning procedures I the Housekeeping Training Manual for using appropriate products can help you keep the room as sanitary as possible .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 4 residents (Residents #1 and Resident #2) reviewed for abuse.<BR/>The facility failed to report a resident-to-resident altercation that occurred on 02/18/24 between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of being notified.<BR/>This failure could place residents at risk for abuse. <BR/>Findings include:<BR/>Resident #1<BR/>A record review of Resident #1's electronic face sheet, dated 02/21/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses which included dementia , abnormalities of gait (a change to your walking pattern) and mobility, and muscle weakness. <BR/>A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was able to complete a BIMS assessment and had a BIMS score of 0, which indicated his cognition was severely impaired. <BR/>A record review of Resident #1's Care Plan, revised 12/21/23, reflected Resident #1 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included Administer meds as ordered, Communicate with the resident/family/caregivers regarding residents capabilities and needs encourage therapeutic conversation as able. The Care Plan reflected Resident #1 had the potential to demonstrate physical behaviors. The interventions included . Communication provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately .Monitor/document/report to MD of danger to self and others . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. <BR/>Resident #2<BR/>A record review of Resident #2's electronic face sheet, dated 02/21/24, reflected Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective disorder bipolar type (experience psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - bipolar type (episodes of mania and sometimes depression)), psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), abnormalities of gait (a change to your walking pattern) and mobility, and altered mental status. <BR/>A record review of Resident #2's Optional State Assessment MDS, dated [DATE], reflected Resident #2 was able to complete a BIMS assessment and had a BIMS score of 3, which indicated his cognition was severely impaired. <BR/>A record review of Resident #2's Care Plan, revised 12/22/23, reflected Resident #2 had impaired cognitive function and thought process due to dementia. The Care Plan interventions included . Communication: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV , radio, close door etc . The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. The Care Plan reflected Resident #2 had a potential to demonstrate physical/verbal behaviors due to poor impulse control and adjusting to facility. The interventions included Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . Notify the charge nurse of any physically abusive behaviors . Re-educate staff on redirection of aggressor, Relocate other residents as needed to prevent re-altercations.<BR/>A record review of the facility documents titled Even Nurses' Note- Behavior, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #1 had a resident-to-resident altercation in the dining room. The document indicated there were no injuries to Resident #1 when he was assessed, yet the document reflected LVN A notified the facility MD and Resident #1's family on 02/18/24 at 2:30 PM. <BR/>A record review of the facility documents titled Behavior Nurses Note 8 hr, dated 02/20/24 and completed by LVN A, reflected on 02/18/24 Resident #2 had an argument with another resident and there were no changes to Resident #2 that required physician notification.<BR/>In an interview on 02/20/24 at 1:54 PM, LVN A stated she was PRN at the facility and worked on Sunday 02/18/24 in the MC unit. LVN A stated Resident #1 and Resident #2 got into an argument and fight. She stated she did not witness the incident. LVN A stated she was called to the dining room by a CNA (did not recall her name). She stated the CNA told her Resident #1 and Resident #2 were arguing and fighting and she had just broken them up. LVN A stated the CNA said the residents were fighting because one resident said the other stole from him. LVN A stated Resident #1 had a scratch above his eye and Resident #2 had no injuries. LVN A stated she assessed Resident #1's eye and contacted the MD and residents' family. LVN A stated the MD did not give her any new orders. She stated she notified the DON and the Administrator. LVN A stated the Administrator told her because she did not witness the incident, to hold off on doing the incident report, because she wanted to do an investigation. LVN A stated she did not complete the incident report and did not know if the Administrator completed the report. <BR/>In a phone interview on 02/21/24 at 10:28 AM, CNA B stated she worked in the MC unit on 02/18/24 from 6AM to 2PM. CNA B stated there was a verbal altercation between Resident #1 and Resident #2. She stated Resident #2 accused Resident #1 of stealing his truck, so they started arguing. CNA B stated she split the residents up and got them to calm down. She stated later when the residents were going outside to smoke, Resident #2 bumped Resident #1, but Resident #1 did not fall nor was he injured. CNA B stated she never witnessed a physical altercation between the residents on her shift. She stated she worked the following day on 02/19/24 and saw the scratch on Resident #1's eye. CNA B stated the scratch was not on Resident #1's eye on 02/18/24. CNA B stated she did not ask what happened to his eye nor did anyone tell her how he got the scratch. She stated she did not know if something happened after her shift ended at 2:00 PM . <BR/>An observation and interview on 02/21/24 at 11:03 AM revealed Resident #1 had a scratch approximately 1 inch in length, above his right eye. When Resident #1 was asked how he got the scratch on his eye, he appeared confused and said he did not know. Resident #1 was asked if he had gotten into any arguments or fights in the facility, he said no and he could not remember. <BR/>In an interview on 02/21/24 at 11:06 AM, Resident #2 stated he did not believe he hit anyone at the facility, but he sometimes could not remember things. He stated he did not get into any fights or arguments with other residents because he liked everyone at the facility. <BR/>In a phone interview on 02/21/24 at 12:16 PM, CNA C stated she worked on 02/18/24 and was scheduled for the 2-10 PM shift. CNA C stated she arrived to work late about 3/3:30 PM and things seemed crazy. She stated one of the residents told her Resident #1 and Resident #2 had a fight, but the resident often got confused so she did not know if it was true. CNA C stated she worked with CNA D and LVN A and neither of them mentioned there was an altercation between Resident #1 and Resident #2. CNA C stated she did see LVN A looking at Resident #1's eye and she took a picture of it. She stated she did see the scratch above Resident #1's eye. CNA C stated the scratch was not bleeding but it looked like a fresh scratch. CNA C stated she did not ask CNA D or LVN A how Resident #1 received the scratch .<BR/>In an interview on 02/21/24 at 12:26 PM, the Administrator stated LVN A called her on 02/18/24 and said she was called into the dining room by an aide because there was an argument between Resident #1 and Resident #2. The Administrator stated LVN A said the altercation happened during shift change and she did not witness the incident. The Administrator stated because LVN A did not witness the incident, she told her to hold off on completing an incident report because she wanted to investigate the situation. She stated she told her to make an event note in PCC. She stated she contacted CNA B, who was working 6-2PM. She stated CNA B told her she was in the dining room when Resident #1 and Resident #2 were arguing about a truck. She stated CNA B told her that nothing was physical, and they were only arguing, which she split them up. The Administrator stated LVN A and CNA B did not report to her that Resident #1 had a scratch above his eye. She stated she did not ask LVN A if she assessed the resident for any injuries. The Administrator stated she did observe the scratch above Resident #1's eye today. She stated she did not complete a report to the state because she was told it did not get physical and was only a verbal altercation. The Administrator stated she did investigate the situation by talking to all the staff who worked on Sunday and everyone she spoke to stated they did not witness anything physical. She stated she did not have any documentation of the investigation.<BR/>In a follow up interview on 02/21/24 at 1:23 PM, LVN A stated she did notify the Administrator that even though she did not witness the incident, she believed there was a physical altercation because Resident #1 had a scratch above his eye. She stated she did not know why the Administrator would say she did not notify her of the scratch above Resident #1's eye. She stated she told the Administrator she contacted the MD about the scratch on Resident #1's eye. LVN A stated she had the text message feed that she contacted the MD and would provide it.<BR/>A record review of LVN A's text feed reflected on Sunday (02/18/24) at 2:18 LVN A texted the MD and stated the following Good afternoon [Resident #1] and [Resident #2] got into a physical altercation. [Resident #2] being the aggressor. [Resident #1] has a laceration to his top left eye otherwise no c/o pain. The text revealed the MD responded Ok; does it need steri [stupa] . strips. LVN A responded to the MD with the following No Strips needed. They are both [are] up and ambulating throughout the unit. Will keep them separated and monitored. <BR/>In a phone interview on 02/21/24 at 1:54 PM, CNA D stated there was a physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch above his eye. CNA D stated she did not witness the incident. She stated she the worked 2-10 PM shift on 02/18/24. CNA D stated she heard screaming coming from the dining area and headed that way. She stated the altercation happened during the shift change, so everything was out of order. CNA D stated when she entered the dining room, CNA B and LVN A were in there and had broken them apart. CNA D stated Resident #1 had a scratch above his eye and the area looked a bit red. She stated she did see LVN A assessing and treating the scratch .<BR/>In a confidential interview, the facility staff member stated they were aware of the physical altercation between Resident #1 and Resident #2 and Resident #1 had a scratch on his eye because the facility had a group chat and LVN A notified everyone via the group chat. The facility staff member read the text message aloud, which said Resident #1 had a scratch above his eye. The facility staff member stated the Administrator was included on the facility's group chat. <BR/>A record review of the facility's policy titled Abuse/Neglect, dated 03/29/18, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse . E. Reporting: 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 . a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation . Resident to Resident: The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 3 residents reviewed for infection control. <BR/>1. The Treatment Nurse failed to discard contaminated gauze after performing wound care on Resident #2 on 05/07/25. <BR/>This failure could put residents at risk of infection from cross contamination.<BR/>Findings included:<BR/>Record review of Resident #2's face sheet dated 05/08/25, reflected a [AGE] year-old female, with an admission date of 05/05/25. Resident #2 had diagnoses of Chronic Venous Hypertension with Ulcer of Bilateral Lower Extremity (damaged leg veins that causes blood pressure build up and skin breakdown), and Type 2 Diabetes with foot ulcer (body cannot regulate blood sugar levels). <BR/>In an observation and interview on 05/08/25 starting at 8:40 AM, the Treatment Nurse was observed as she provided wound care to the toes and heel of Resident #2. The Treatment nursed wiped the toes of Resident #2, put her gloved hand into the package of clean gauze, took a few out, wiped the toes of Resident #2, then put her gloved hand back into the package of clean gauze to get a few more out. The Treatment Nurse was observed as she closed the package of remaining gauze and placed the package back in the drawer of the treatment cart and locked it. The Treatment Nurse stated she had a few more residents to treat on 05/08/25. <BR/>In an interview on 05/08/25 at 11:39 AM, the Treatment Nurse stated she was not aware she put the gauze back on the treatment cart after she put her gloved hand into the package. The Treatment Nurse stated that was something she would not normally do. The Treatment Nurse stated the risk of putting her gloved hand into the package after touching Resident #2's wounds, then putting the gauze back on the treatment cart was infection. <BR/>In an interview on 05/08/25 at 2:30 PM, the DON stated all employees were trained on infection control, but the staff get nervous when The State is in the building. She stated the Treatment Nurse was probably nervous during the observation. The DON stated the Treatment Nurse putting a contaminated hand in the gauze package and placing the gauze back on the treatment cart was contamination and infection. <BR/>In an interview on 05/08/25 at 2:40 PM, the Administrator stated the risk of the Treatment Nurse putting her gloved hand into the gauze package during wound care was infection being spread to other residents. She stated all employees were trained on infection control. <BR/>Record review of the facility's policy titled, Infection Control Plan: Overview, dated 03/2024, reflected the following:<BR/>Infection Control<BR/>The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 3 residents reviewed for infection control. <BR/>1. The Treatment Nurse failed to discard contaminated gauze after performing wound care on Resident #2 on 05/07/25. <BR/>This failure could put residents at risk of infection from cross contamination.<BR/>Findings included:<BR/>Record review of Resident #2's face sheet dated 05/08/25, reflected a [AGE] year-old female, with an admission date of 05/05/25. Resident #2 had diagnoses of Chronic Venous Hypertension with Ulcer of Bilateral Lower Extremity (damaged leg veins that causes blood pressure build up and skin breakdown), and Type 2 Diabetes with foot ulcer (body cannot regulate blood sugar levels). <BR/>In an observation and interview on 05/08/25 starting at 8:40 AM, the Treatment Nurse was observed as she provided wound care to the toes and heel of Resident #2. The Treatment nursed wiped the toes of Resident #2, put her gloved hand into the package of clean gauze, took a few out, wiped the toes of Resident #2, then put her gloved hand back into the package of clean gauze to get a few more out. The Treatment Nurse was observed as she closed the package of remaining gauze and placed the package back in the drawer of the treatment cart and locked it. The Treatment Nurse stated she had a few more residents to treat on 05/08/25. <BR/>In an interview on 05/08/25 at 11:39 AM, the Treatment Nurse stated she was not aware she put the gauze back on the treatment cart after she put her gloved hand into the package. The Treatment Nurse stated that was something she would not normally do. The Treatment Nurse stated the risk of putting her gloved hand into the package after touching Resident #2's wounds, then putting the gauze back on the treatment cart was infection. <BR/>In an interview on 05/08/25 at 2:30 PM, the DON stated all employees were trained on infection control, but the staff get nervous when The State is in the building. She stated the Treatment Nurse was probably nervous during the observation. The DON stated the Treatment Nurse putting a contaminated hand in the gauze package and placing the gauze back on the treatment cart was contamination and infection. <BR/>In an interview on 05/08/25 at 2:40 PM, the Administrator stated the risk of the Treatment Nurse putting her gloved hand into the gauze package during wound care was infection being spread to other residents. She stated all employees were trained on infection control. <BR/>Record review of the facility's policy titled, Infection Control Plan: Overview, dated 03/2024, reflected the following:<BR/>Infection Control<BR/>The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.<BR/>

Based on observation, interview, and record review, the facility failed to keep garbage storage receptacles in a sanitary condition according to professional standards for 1 of 1 kitchen for kitchen sanitation. <BR/>The facility failed to keep garbage receptacles covered with lids, in the kitchen area, while food was being prepared. <BR/>This failure could place residents at risk for contracting food-borne illness. <BR/>Findings included:<BR/>During an observation on 11-12-2023, at 9:45am, a large trash can was observed to have a liner, with trash contents, in the kitchen area, without a lid or covering. The trash can was not currently in use. <BR/>During an interview with the Dietary Manager, on 11-12-2023, at 9:55am, she stated the trash can should have a lid on it. The Dietary Manager then kicked the trash can into another room but still did not put a lid on the receptacle. <BR/>During an interview with the Administrator on 11-14-2023, at 2:00pm she stated that her expectation is that trash receptacles, in the kitchen area, be always covered with a lid. <BR/>Review of the facility's Kitchen Waste Control and Disposal Policy, on 11-14-2023, at 3:00pm, stated:<BR/>a. <BR/>Trash cans must be always covered, except during use. <BR/>b. <BR/>Trash can must have non-permeable plastic liners and should be cleaned daily. <BR/>Review of the U.S. Public Health Service Food Code, dated 2022, reflected: .5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and (B) With tight- <BR/>fitting lids or doors if kept outside the food establishment .