**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, 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 one (Resident #21) of 23 residents reviewed for pharmacy services. The facility failed to ensure MA A administered the medication Sevelamer Carbonate (a Phosphate binding medication to control Phosphorus levels for hemodialysis patients) with a meal to Resident #21 as ordered by the resident's physician. This failure to provide medications as ordered could lead to residents not receiving the care they require to reach their highest physical, mental and emotional wellbeing. Findings included: Review of Resident #21's admission face sheet undated reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included end stage renal disease, and type 2 diabetes mellitus with diabetic chronic kidney disease. Record review of Resident # 21's quarter MDS (a standardized assessment tool used to evaluate a residents functional, medical, psychosocial and cognitive status) dated 03/18/2025 indicated a BIMS ( a brief cognitive screening that focuses on orientation and short-term word recall) score of 6 reflecting moderate cognitive impairment. The MDS indicated that Resident # 21 required set up or clean up assistance with eating. Record review of Resident #21's Care Plan, date initiated 03/10/2025, reflected the following: Focus: Resident needed hemodialysis related to renal failure Goal: Resident would have no signs or symptoms of complications from dialysis. Intervention: Monitor labs and report to doctor as needed. Record review of Resident #21's Physician's Order Summary Report active orders dated as of 05/14/2025 reflected the following orders: Sevelamer Carbonate Oral Tablet 800 MG Give 2 tablets by mouth three times a day for renal. Take with meals order dated 03/09/2025. Record review of Resident #21's MAR dated 05/01/2025-05/31/2025 revealed Sevelamer Carbonate Oral Tablet 800 MG Give 2 tablets by mouth three times a day for renal. Take with meals order dated 03/09/2025. The medication was documented as administered on 05/13/2025 at 4:00PM by MA A. An observation and interview on 05/13/2025 at 3:11 PM revealed MA A removed two tablets from the Sevelamer Carbonate medication container. Review of the medication container at this time revealed Take With Meal. As the observation continued Resident #21 was awake and alert sitting on the side of his bed. No food or snacks were observed in the resident's room. Resident #21 was administered the Sevelamer Carbonate by MA A. In an interview at that time, Resident #21 stated he ate his lunch a long time ago and dinner would not be until about 5:00 or 5:30 PM. During the medication administration, the MA did not ask Resident #21 if he had any snacks or needed something to eat. In an interview on 05/14/2025 at 4:45 PM, the facility Pharmacist stated Sevelamer Carbonate was a phosphorus binding medication. The Pharmacist stated the food was needed for the absorption of the medication. The Pharmacist stated taking the medication without food had no major risk except possibly the phosphorus level could go high . He stated the medication was often for short term use. The pharmacist stated this was not a life sustaining drug, and it was not a drug that needed to be administered at the same time. In an interview on 05/14/2025 at 5:03 PM, the HD Nurse stated Sevelamer Carbonate was a Phosphorus binder to help keep the patient's phosphorus levels within normal limits. The HD Nurse stated this medication was not a life sustaining medication. The nurse stated the medication did not need to be given at the same time daily. The risk of not giving the medication with food was absorption of the medication because food was needed for the proper absorption of the medication resulting in high phosphorus levels. In an interview on 05/14/2025 at 5:11PM, the NP stated this medication was given to help control phosphorus for hemodialysis residents. The NP stated the risk was subjective due to the levels being controlled by diet also. The food was to be given with the medication because it was needed for the absorption of the medication. In an interview on 05/15/2025 at 11:10 AM, the DON stated the medication was a phosphorus binder. The risk of not giving with food was poor absorption of the medication. When special instructions for medication administration were needed, the DON stated she expected the physician orders and medication container to be read. The DON stated she would educate on medication administration. In a phone interview on 05/15/2025 at 11:30 AM, MA A stated that she did remember she gave the medication to Resident #21. MA A stated he usually had crackers in the room. MA A stated she did not remember seeing any snacks in the room. MA A stated she did not ask the resident if he had any snacks or needed something to eat with the medication. MA A stated she normally read the medication container so she knew any special instruction for medications. MA A stated it was not done this time because she was being observed. MA A stated she would take more time to read containers before giving a medication. MA A stated she would make sure food was available or provided if needed. In an interview on 05/15/2025 at 11:59 AM, the Administrator stated she was notified of the medication error. The Administrator stated her expectations were the medications was administered following the resident rights. The Administrator stated the risk of not administering with food was absorption because the medication needed food to absorb to work. She stated to prevent this again, medication administration would be monitored, and they would in-service staff on medication administration. Record review of the facility's policy titled Administering Medications revised dated April 2020 read in part .Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed .2. Medications must be administered in accordance with the orders, including yny required time frame .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened after usage. 2. The facility failed to ensure that dietary staff did not leave a disposable plastic cup to scoop the cornmeal out of the container. These failures could place residents at risk of cross-contamination and foodborne illness. Findings included: During an observation on 05/13/2025 at 08:12 AM, an initial tour of the kitchen was conducted with the dietary manager of a walk-in dry storage area in the kitchen. Observation revealed that half of a 5-gallon bag of uncooked enriched macaroni that was open and undated. Further observation revealed a plastic cup was also left in a large container of cornmeal. During an interview on 05/15/25 at 10:18 AM, [NAME] A said all items should have dates on the items when they receive it. She also said a plastic cup should never be left in the cornmeal container because it can cause cross-contamination. [NAME] A said the staff was in-serviced 2 weeks ago on cross-contamination. During an interview on 05/15/25 at 10:21 AM, the Dietary manager said all items in the kitchen should be dated. She said the risk of leaving the cup in the cornmeal was cross contamination. During an interview on 05/15/25 at 2:00 PM, the Administrator said the dietary staff should not have had a disposable cup in the cornmeal container. She said her expectations were for staff to follow the dietary policy. She said the risk of leaving the cup in the container was an infection control concern. Record review of the Record review of the Food Receiving and Storage policy, last revised on 07/2014 revealed . Foods shall be received and stored in a manner that complies with safe food handling practices. 13. Food items and snacks kept on the nursing units must be maintained as indicated below: e. e. Other opened containers must be dated and sealed or covered during storage .

**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 one of three residents (Resident #1) reviewed for infection control. Unknown A and Unknown B failed to use proper PPE for Enhanced Barrier resident (Resident #1). The facility failed to ensure Unknown A and Unknown B wore appropriate PPE when entering Resident #1s' room on 03/13/2025 who was on Enhanced Barrier precautions while they performed direct care. These failures could place residents at risk for spread of infection. Findings included: Record review Resident #1's face sheet, dated 02/26/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Anoxic Brain Damage (Brain damage caused by complete lack of oxygen supply to the brain, leading to cell death and potential neurological impairments), Respiratory Failure (A condition where the lungs are unable to adequately perform their primary function of gas exchange, resulting in either insufficient oxygen in the blood (hypoxemia) or excessive carbon dioxide levels (hypercapnia), Type 2 Diabetes Mellitus Diabetic Hyperglycemia (A Condition where blood sugar (glucose) levels are persistently elevated), Alzheimer's Disease (A progressive brain disorder that primarily causes memory loss and cognitive decline, eventually affecting a person's ability to perform everyday tasks), Chronic Kidney Disease Stage 3 (Moderate kidney damage, meaning your kidneys are less able to filter waste and fluid from your blood), Tracheostomy Status (A person's current situation regarding having a tracheostomy), Persistent Vegetative State (A neurological condition where a person is awake but lacks awareness of a self or surrounding, with no purposeful behavior or interaction), Unspecified Dementia (A dementia diagnosis where the specific type and severity are not determined, and there are no co-occurring behavioral, psychotic, mood or anxiety symptoms), Aphasia (A language disorder that affects a person's ability to communicate). Record review of Resident #1's care plan, dated 11/06/24, reflected a focus area that Resident #1 had a tracheostomy related to acute respiratory failure Interventions: .Use Enhanced Barrier Precautions. Record review of Resident 1's quarterly MDS assessment, dated 02/12/25, reflected a BIMS score of 0, which indicated cognition was severely impaired. Section O- Respiratory Treatment- E1. Tracheostomy Care. Record review of screenshots of Resident #1's video monitoring dated 03/13/25 with a time stamps of 7:01 AM revealed Unknown A and Unknown B providing direct care to Resident #1. Unknown A did not have on a mask or gown. Unknown B did not have on a gown. During an observation on 04/03/25 at 11:28am of Resident #1's room door revealed an Enhanced Barrier Precautions signage that stated, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linen, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. During an interview on 4/03/25 at 11:32 AM, the DON stated when staff are working with a resident with contact isolation they are to DONN and DOFF PPE. She stated there was an Enhanced Barrier signage outside of the door and the PPE carrier was hanging on the doors of residents that are on Enhanced Barriers. Surveyor showed DON pictures taken from video monitoring of Resident #1's room in which staff did not have on gowns or mask while providing direct care to Resident #1 who was on Enhanced Barriers Precautions. She stated she was unsure of who the exact staff were in the pictures. She stated the staff should always have on PPE whenever providing direct care to a resident that has Enhanced barrier signage outside of the door. She stated the risk of not wearing proper PPE while providing direct care to resident who are on Enhanced Barrier Precautions could be a risk for the staff and the resident for spreading organisms. She stated she was not aware that the staff were providing care without PPE. During an interview on 04/03/25 at 11:43 AM, the ADON/IP who stated a staff member should never provide direct contrat without PPE to a resident that was on contact isolation. She stated she was not aware that staff were providing care to the resident without the proper PPE. She stated the risk of not having full PPE on while providing are to a resident that has Enhanced Barriers was transferring infection to others and cross contamination. Record review of the facility's policy on Infection Control, revised date of 03/2024, reflected, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . Procedures: 1. Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include: a. Proper selection and use of PPE such as gowns, gloves, facemasks, respirators, and eye protection i. Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). .3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities from indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: b. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: i. Dressing ii. Bathing/showering iii. Transferring iv. Providing hygiene v. Changing linens vi. Changing briefs or assisting with toileting vii. Device care or use: central vascular line (including hemodialysis catheters), indwelling urinary catheter, feeding tube, tracheostomy/ventilator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 (Resident #1) residents reviewed for care plan timeliness and accuracy in that: The facility failed to ensure Resident #1's care plan accurately addressed his facility acquired sacral wound and MASD (moisture associated skin damage) to his groin. This failure could affect residents by placing them at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male that was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of spinal stenosis (a condition in which the space inside the bones of the spine get too small), dysphagia(difficulty swallowing foods or liquids), Type 2 Diabetes (a long-term condition in which the body trouble controlling blood sugar), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and chronic kidney failure (a chronic condition that causes permanent damage to the kidneys over time. Resident was bedfast. Record review of Resident #1's discharge summary from local hospital #1 revealed: Resident #1 was discharged from the hospital and admitted to the facility on [DATE]. It was noted that Resident #1 had red area to groin or buttock both lower extremities. Record review of Resident #1's Care plan dated 4/1/2024 reflected he had bowel and bladder incontinence and at risk for skin breakdown. Goal: Resident #1 will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Check as required for incontinence. Wash, rinse and dry perineum. Change clothes PRN after incontinence episodes. Further care plan review initiated on 9/18/2024 reflected Resident #1 had a potential for pressure ulcer development to buttock r/t decreased mobility, weakness, diabetes, and neuropathy. Goal: Resident #1's skin will remain intact, free from redness, blister, or discoloration. Intervention: Administer treatments as ordered and monitor for effectiveness and weekly head to toe assessment. It did not address the sacral wound. Record review of care plan dated 11/24/2024 revealed Resident #1 had actual impairment to skin integrity r/t contact dermatitis. Goal: Resident #1 will not have a re-hospitalization within 30-days. Intervention: Monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, sign and symptoms, maceration etc. to MD. Provide wound care to site daily per WCD recommendations. Use enhanced barrier precautions, and weekly [NAME] consult with recommendations. It did not address the sacral wound. Record review of Resident #1's quarterly MDS dated [DATE] revealed: Section C500- Brief Interview of Mental Status was scored as 08, which meant moderately impaired cognition. Section GG0115- Functional Limitation in Range of Motion was coded as 2 representing upper and lower extremity impairment. Section GG0130- Functional Abilities revealed: Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene was coded as 2 (Substantial/maximum assistance). Section GG0170 revealed roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer was coded as (01)- which presented dependent- helper does all the effort. Section H0300 revealed Urinary continence was coded 3 for always incontinent (no episodes of continent voiding). Section H0400 revealed Bowel continence was codes 3 for always incontinent (no episodes of continent bowel movements). Section I- Active Diagnosis listed 1- (need for personal care assistance) Section M- Skin condition revealed Risk of pressure ulcer coded 1 was entered representing (Yes). M1040- Other uIcers, wounds and skin problems such as diabetic foot ulcers, open lesions, surgical wounds, MASD (incontinent associated dermatitis, perspiration drainage) Z. was coded which meant none of the above. Section N- Medications G. Diuretic was marked and code indicated Resident #1 was taking and here was an indication for the medication. Record review of Resident #1's Discharge return not anticipated MDS dated [DATE] did not mention wounds to the sacral area nor the MASD to the groin. It said that it was in progress. Record review of LN weekly skin evaluations for Resident #1 revealed: 10/14/2024 - Resident #1 noted with excoriation to groin region. Treatment initiated pending wound care physician evaluation. No new skin breakdown observed. Signed by LVN B 10/18/2024- Site #1 Sacrum Etiology: Trauma/Injury Measurements 3.5cm x1cm x 0.1 cm Procedure: Autolytic debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 10/22/2024- Site #1 Sacrum Measurements 3 cm x1 cm x 0.1 cm Procedure: Autolytic debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 11/1/2024 - Site #1 Sacrum Measurements 2 cm x 1 cm x 0.1 cm Procedure: Autolytic debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 11/12/2024- Site #1 Sacrum Measurements 2 cm x 1 cm x 0.1 cm Procedure: Surgical excisional debridement Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 11/22/2024 - Site #1 Sacrum Measurements 3 cm x 2 cm x 0.1 cm Procedure: Surgical excisional debridement (11/12/2024) Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Progress: Not at goal MASD to groin region treat with house barrier cream every brief change Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B 11/28/2024- Site #1 Sacrum Measurements 5 cm x 5 cm x 0.1 cm Procedure: Surgical excisional debridement (11/22/2024) Description: Light serous exudate 100% granulation Treatment: Cleanse area with NS or wound cleanser, pat dry, apply zinc ointment cover with bordered dressing daily. Progress: Not at goal MASD to groin region treat with house barrier cream every brief change. Risk factor: Immobility Interventions: 4. Offloading wound while in bed as needed /tolerated 5. Repositioning resident as needed/tolerated 6. RD to follow Signed by LVN B Record review of Resident #1's Skin IDT dated 12/11/2024 at 12:50pm, revealed Resident #1 was re-admitted to facility following a transfer to the hospital due to altered mental status. Resident has stage 2 wound to the sacrum and MASD to groin region. Prior orders from wound care physician include the application of zinc ointment and daily border dressing changes. These orders are being continued, and wound care physician scheduled to re-evaluate on tomorrow 12/12/2024. Care remained ongoing and compliant with prescribed treatment plan. Record review of Resident #1's Wound Care Doctor A assessments: 10/15/2024- Chief complaint -Wound on sacrum Etiology: Trauma/Injury Wound size: 3.5 x 1 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 30 days 2nd dressing: Gauze Island with border apply once daily for 30 days. 10/22/2024- Chief complaint wound on sacrum. Wound size: 3 x1 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 23 days 2nd dressing: Gauze Island with border apply once daily for 23 days. 10/29/2024- Chief complaint: Wound on sacrum Size 2 x 1 x not measurable due to presence of tissue overgrowth Treatment plan: Zinc ointment apply once daily for 16 days. 2nd dressing: Gauze island with border apply once daily for 16 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 10/25/2024. 11/5/2024- Sacrum wound size: 2x 0.3 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 9 days. 2nd dressing: Gauze island with border apply once daily for 9 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 10/25/2024. 11/12/2024- Sacrum wound size 1.5 x 0.3 x 0.1 cm Treatment plan: Zinc ointment apply once daily for 30 days. 2nd dressing: Gauze Island with border apply once daily for 13 days. Site 1: Surgical excisional debridement procedure Indication for procedure: Necrotic tissue and establish the margins of viable tissue. 11/19/2024- Sacrum wound: 3 x 2 x 0.1 cm Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater detail today. Reviewed offloading surfaces and discussed surfaces care plan. Considered patient behavior as factor that is complicating wound healing and discussed further with staff and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Treatment plan: Zinc ointment apply once daily for 23 days. 2nd dressing: Gauze Island with border apply once daily for 23 days. Debridement History: The most recent debridement of this wound was an excisional debridement performed on 11/12/2024. 11/26/2024- Sacrum wound size: 5 x 5 x 0.1 Granulation tissue: 60% surface area: 25.00cm Cluster wound: Open ulceration area of 15.00 cm Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater detail today. Patient not following repositioning or offloading recommendations and counseling provided. Considered patient behavior as factor that is complicating wound healing and discussed further with staff and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Treatment plan: Zinc ointment apply once daily for 16 days. 2nd dressing: Gauze Island with border apply once daily for 16 days. 12/3/2024- Sacrum wound size: 4 x 4x 0.1 cm surface area: 16.00 cm slough: 20%, granulation tissue 80% Wound progress: Not at goal Duration: 50 days Treatment plan: Zinc ointment apply once daily for 9 days. 2nd dressing: Gauze Island with border apply once daily for 9 days. Site #1 Surgical Excisional Debridement Procedure Indication: Necrotic tissue and establish the margins of viable tissue. PROCEDURE NOTE: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 3.2cm' of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percent to O percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Site 2-Unstagebale DTI of the left heel undetermined thickness wound size 2 x 2 x not measurable offloading and boot ordered. 12/12/2024 Chief complaint: Wound on sacrum; right medial thigh; left heel; scrotum. Wound size 8 x 8 x 0.1 Surface: 64.00 cm Slough: 20% ADDITIONAL WOUND DETAIL readmission from hospital DRESSING TREATMENT PLAN Primary Dressing(s) Alginate calcium apply once daily for 30 days Secondary Dressing(s) Gauze island w/ border apply once daily for 30 days PLAN OF CARE REVIEWED AND ADDRESSED Recommendations: Off-Load Wound; Reposition per facility protocol; Turn side to side in bed every 1-2 hours Site #1- Surgical excisional debridement procedure Indication: Remove necrotic tissue and establish margins of viable skin. PROCEDURE NOTE The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 12.8cm2 of devitalized tissue Including slough, biofilm and non-viable subcutaneous level tissues were removed al a depth of 0.1 cm and heallhy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percent to O percent. Homeostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the pla11 of care are documented in the Assessment and Plan section below. Record review of Resident #1's local hospital #2 record revealed: Principal problem upon admission on [DATE] was altered mental status. Assessment and Plan: Acute toxic metabolic encephalopathy -multifactorial in the setting of an acute UTI, complicated UTI, E-coli UTI General Information: Resident #1 was confused and lethargic. Wound care assessment on 12/6/2024: Sacral stage 3 pressure injury wound- size L 6.0cm x W 6.0cm x D 0.1cm - no undermining - no tunneling/induration - Wound bed is full thickness with some pink and red non granular tissue. The area is denuded most probably from incontinence - edges well defined -small to moderate serosanguinous drainage - no odor - Peri wound redness noted. Left heel DTPI wound- size L 3.0cm x W 3.0cm x D 0cm - no undermining - no tunneling/induration -Wound with purple/ maroon non blanchable intact skin - edges well defined -No drainage - no odor - Peri wound skin is intact Location: Penis, scrotum, inner thighs, groin, posterior thighs and peri area - Type: MASD/ IAD (Moisture Associated Skin Damage/ Incontinence Associated Skin Damage) Appearance: Bright red erythematous rash and inflammation with denuded skin due to: moisture trapping in skin folds and fecal/ urine incontinence. Posterior thighs are full thickness which I will recommend Zinc paste. Exudate: Clear weeping skin due to inflammation, edema, and skin erosions. Current Pressure Support Surfaces: Bed: LAL mattress; microclimate pad; glide sheet with pillows or wedges and Z flex boots. Mobility: Bed bound. Recommendations: Sacrum and left heel wounds- Cleanse with Vashe (Ref # 108824) and pat dry with gauze. Apply Cavilon skin barrier to the peri wound skin, apply Polymem (Ref# 7114) to the wound base and cover with silicone foam dressing every other day and as needed. 1. Clean penis, scrotum, inner thighs, groin and peri area with Coloplast no rinse wash cloths (Ref# 119680) and warm water 2. Pat dry with towel 3. Apply Cavilon advanced skin barrier twice a week and as needed. Goal/Treatment Plan: 1. Dressing Changes as ordered or PRN if soiled. 2. Using wedges or pillow to turn and reposition the pt every 2 hours to offload pressure to wound, even when on specialty bed. 3. Encourage lowering the head of the bed below 30 degrees is tolerable. 4. Ensure patient is on pressure redistribution and microclimate control bed is order is placed. 5. Offload pressure to patient's heels by floating with pillows or by applying specialty boots. 6. Nutritional consultation for wound healing. The following supplements to aid in wound healing are recommended, unless contraindicated: - 1000 mg Vitamin C daily - 220 mg Zinc sulfate daily - Multivitamin daily - Juven 2 times per day - Accurately monitor and document patient's PO intake, so supplements can be adjusted accordingly. 7. Skin care and skin protection from moisture damage - If possible, keep diapers off patient to reduce moisture - Consider using Pure Wick/ Condom catheter for incontinence management - Apply Cavilon Advanced to perineal and perianal area 2x weekly Photos of Resident wounds were taken at the hospital. Record review of the last IDT care plan review for Resident #1 was conducted on 9/17/2024. No wounds were discussed. No other care plan reviews were conducted after 9/17/2024. An interview on 12/11/2024 at 3:30pm with the Wound Care nurse (LVN B) revealed she had been employed at the facility for about 1 year. She stated she started wound care of Resident #1 after CNA reported observing a skin tear on his sacral area and MASD to groin sometime in October. She said she immediately followed up with the NP about the wounds and house barrier cream was ordered along with a wound doctor consultation. She said she sometimes learned about skin issues from the CNA's and from wound sweeps in which she randomly looked at different residents' skin in search of wounds/tears. She stated the Wound Care Doctor A came to the facility every week on Thursday and did measurements of wounds and debridement as needed. She said all documentation is put into PCC as a nursing note and weekly wound care assessments. She said she followed physician orders for treatment of wounds. She said Resident #1 sacral wound was getting better, but after returning from the hospital it looked bad. She denied that Resident had the buttock, thigh and gluteal wounds before leaving for the hospital stay. She said she did not know why there were no notes concerning the MASD because it was treated with barrier cream since it was brought to her attention in October. She said she did not know why there was not documentation of the MASD until 11/12/2024. She was not sure why Resident #1's care plan had not been updated. She does participate in IDT meetings in which skin condition is discussed. An interview with RP on 12/11/2024 at 8:04 p.m, revealed her to state Resident #1 was admitted to the facility in March 2024. She stated that she usually visited him after work (6pm or so) at least 3 to 4 days a week. She said she had not participated in a care plan meeting for Resident #1 in months. She said not since August or September 2024. She said wounds were not discussed or he did not have them at that time. She denied having a care plan meeting to discuss Resident #1's wounds, goals or interventions. Interview with the DON on 12/13/2024 at 11:16am she stated she had been employed for about 4 months. She said sacral wounds could come from residents' co-morbidities or could be from residents' briefs needing to be changed more often because some residents get wet more than expected. She said the consequence of having a sacral wound is discomfort and pain. She stated the MDS nurse was responsible for updating the care plans but the IDT team met also to discuss any significant changes. An interview with the Executive Director on 12/13/2024 at 11:16 a.m. reflected her to state she could not recall when she first learned about Resident #1's sacral wound. She said that the MASD in his groin area was being treated to her knowledge. She was not sure why it was not in the progress notes because the weekly skin assessment showed up on the nursing progress notes. She said the baseline care plan was to be done within 48 hours, and updated upon significant change, quarterly and annually. She was not sure why the care plan did not address the sacral wound but probably because it was not a stage 3 wound until he returned from the hospital. An interview with the SW on 12/19/2024 at 10:57 a.m., stated the last conversation he had with Resident #1's RP was concerning his wounds on last Friday (12/13/2024). He said she wanted to make sure the facility was taking care of his wounds and keeping him clean. He said Resident #1 was scheduled for a care plan meeting today (12/19/2024), however, he went back to the hospital today. He stated the last care plan meeting was on 9/19/2024. He stated care plan meetings were held quarterly unless there was a hospital stay or upon request from the family. He stated he could not recall the RP asking for a meeting or any concerns prior to last week. In a subsequent interview with the DON on 12/17/2024 at 2:55pm, she stated that all care plans should be done upon admission, significant change, re-entry from a hospital stay (if anything changed), quarterly and annually. She said she was not sure why the care plan had not been updated. She said she would have to check with the team about it. She stated all care plans should be updated as needed. All admission, re-entry or significant changes should have an update. She said if care plans are not completed timely there could be a delay in care, worsening of wounds and pain. An interview with MDS Nurse on 12/19/2024 at 1:15pm, stated baseline care plans are done within 48 hours, quarterly, annually, and upon a significant change. She stated all Residents are at a high risk for pressure wound when they have low mobility. She said Resident #1 was not walking but was alert when he was admitted . She said she was puzzled about why his assessment at the hospital was done the next day after he was admitted . She does not know how they can say the sacral wound was developed at the facility. She said this is why it was not addressed on the care plan. It was merely a skin tear as far as she was aware and that did not require an updated care plan. Record review of the facility's person-centered care plan revised on 12/2023 read in part: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 resident (CR # 212) of 6 residents reviewed for physician's orders received treatment and care in accordance with professional standards of practice . -CR #212 had an order dated 03/08/2024 for a treatment for his left heel and for heel protectors to be applied. -The facility did not transfer the order to the eTAR, resulting in the resident not receiving the treatments for three days. The deficient practice could place residents at risk for additional skin breakdown. Findings include: Record review of the admission Record for CR #212 (printed 03/13/2024) revealed he was [AGE] years old and was originally admitted to the facility on [DATE]. He was most recently readmitted to the facility on [DATE]. Diagnoses included, but were not limited to, right hip fracture, abnormalities of gait and mobility, and generalized muscle weakness. Record review of the Physician's Order dated 03/08/2024 at 3:59 p.m. revealed Claen (sic) left heel area with normal saline and apply skin prep to to left heel area and apply heel protectors. Record review of the March 2024 eTAR for CR #212 revealed the order had not been transcribed onto the eTAR. In an interview via telephone on 03/13/2024 at 2:40 p.m., a Personal Care Home representative for CR #212 said the facility had attempted to discharge the resident on 03/08/2024. She said the resident had a non-healing wound on his left heel. She said the facility had said it was a scab. She said there was no wound care order at that time. The resident was discharged on 03/11/2024. In an interview on 03/13/2024 at 4:40 p.m., ADON A said CR #212 had an issue with his heel prior to admission. She said it was scabbed over. In an interview on 03/13/2024 at 4:41 p.m. LVN B said the resident readmitted with scabs, and they were monitoring. When asked about the Physician's Order dated 03/08/2024 to clean CR #212's left heel, apply skin prep and heel protectors, LVN B said the order should have been transferred to the eTAR. In an interview on 03/13/2024 at 4:42 p.m., ADON A said the Personal Care Home had requested the order for the left heel on 03/08/2024. In an interview on 03/13/2024 at 4:43 p.m. the DON said the order was in the eTAR. At that time ADON C performed a search of CR #212's March 2024 eTAR and confirmed the order had not been transferred. The facility policy Pharmacy Services/Nursing Services Subject: Physician Orders (revised March 2023) read, in part, .6. Medication, treatment, or related orders are transcribed in the eMAR or eTAR,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 resident (Residents #90) reviewed for pharmacy services. The facility failed to ensure RN D administered Lorazepam (a controlled medication that treats anxiety) to Resident #90 in accordance with physician orders. The facility failed to ensure the reconciliation of controlled drug sheets compared to MAR for Resident #90 to ensure every controlled drug that was administered and documented as administered in the MAR reflected the correct quantity on the controlled drug/disposition form. These failures could place residents at risk of medication error and drug diversion due to not reconciling every shift nor accounting for all controlled drugs administered and/or wasted. The findings included: Record review of Resident #90's face sheet dated 03/14/24 indicated Resident #90 was a [AGE] year-old male who admitted on [DATE] with the following diagnoses: Chronic Diastolic Congestive Heart Failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), Gastro-Esophageal Reflux Disease without Esophagitis (condition in which the stomach contents move up into the esophagus), Anxiety Disorder (ongoing worry and tension may be accompanied by physical symptoms, such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping), and Essential Hypertension(When the pressure in your blood vessels is too high, 130/80 mm Hg or higher). Resident was admitted to the facility for Long Term and Hospice Care. Record review of the MDS assessment dated [DATE] revealed a BIMS summary score of 15, indicative of being cognitively intact. Record review of Telephone Order dated 03/05/24 for Lorazepam (anti-anxiety medication) oral .5mg tab by mouth every 6 hours as needed for anxiety for 14 days. Record review of the Medication Administration record from March 9 - 13, 2024, for Resident #90 revealed the following medication documentation on the MAR: *03/09/24 10:00 p.m. Lorazepam.5mg tab administered *03/10/24 1:22 a.m. Lorazepam.5mg tab administered *03/11/24 1:43 a.m. Lorazepam.5mg tab administered *03/11/24 3:19 p.m. Lorazepam.5mg tab administered *03/12/24 2:50 p.m. Lorazepam.5mg tab administered *03/13/24 7:31 a.m. Lorazepam.5mg tab administered *03/13/24 5:32 p.m. Lorazepam.5mg tab administered There was no active order for Lorazepam (Ativan) 1 mg tab by mouth every 12 hours until 03/13/24 at 10:00 p.m. However, the form titled Controlled Drug Receipt/Disposition form for Lorazepam 1mg tabs revealed: *03/09/24 10:00 p.m. Lorazepam 1mg tab administered *03/10/24 1:22 a.m. Lorazepam 1mg tab administered *03/10/24 3:54 a.m. Lorazepam 1mg tab administered *03/11/24 1:43 a.m. Lorazepam 1mg tab administered *03/11/24 3:22 p.m. Lorazepam.5mg tab administered *03/12/24 4:38 a.m. Lorazepam.5mg tab administered *03/12/24 2:55 p.m. Lorazepam.5mg tab administered *03/13/24 7:51 a.m. Lorazepam 1mg tab administered *03/13/24 5:44 p.m. Lorazepam 1mg tab administered Record review of the form titled Controlled Drug Receipt/Disposition form for Lorazepam 1mg tabs revealed missing .5 mg waste for the following dates and times: 3/9/24 at 10:00 p.m. 3/10/24 at 1:22 a.m. 3/11/24 at 1:43 a.m. 3/12/24 at 2:50 p.m. 3/13/24 at 5:32 p.m. Record review of the Progress Notes revealed additional Lorazepam medication administration did not correspond with the eMAR or Controlled drug receipt/disposition form. These dates and times include: 03/11/24 6:25 a.m. Lorazepam.5mg tab administered 03/11/24 6:14 p.m. Lorazepam.5mg tab administered 03/12/24 4:40 p.m. Lorazepam.5mg tab administered 03/13/24 1:35 a.m. Lorazepam 1mg tab administered In an interview on 03/14/24 at 10:32 a.m., the Hospice RN stated that Morphine in conjunction with Lorazepam was extremely common for residents with agitation. She said, We don't have a max dose of Lorazepam in Hospice. We give whatever it takes to make them comfortable. I was called yesterday to assess the resident, and I gave a dose of 1 mg of Ativan from the facility's med cart, and what I gave to the resident yesterday was actually a very mild dose. Morphine in conjunction with Ativan is like a standing order. The nurse was asked if she ordered the .5 mg from the pharmacy, and she stated that she did order the .5 mg Lorazepam from a pharmacy called Long Term Care or Pharma Care. In an interview on 03/14/24 at 10:37 a.m. with the Pharmacy Manager at Pharma Care (LTC Pharmacy), he stated that they never received an order for the .5 mg of Lorazepam and only received the Lorazepam 1mg order. The pharmacy distributed Lorazepam 1mg on 12/28/23 (quantity of 10 tabs) and 03/12/24 (quantity 60 tabs) in a blister pack per the physician's order. In an Interview on 03/14/24 at 2:39 p.m. with the Hospice Nurse Manager, she stated that it is common to order Ativan 1mg every hour for Hospice residents. She stated that this is a Physician order, but it's not considered a standing order. This Lorazepam order is often in combination with Morphine, and it is not uncommon because it will keep him safe, minimize his ability to hurt himself, and also relieve pain. In an interview on 3/14/24 at 2:42 p.m. with the DON, she stated that the resident has had a change of condition since being hospitalized last week and has been getting Lorazepam for agitation. He was currently on Hospice, and they prescribed the medication. She stated that there was an order for both Ativan .5mg and 1mg. She was referred to an order that showed that the Lorazepam was not ordered until 03/13/24. DON said, If we didn't have an order for 1mg of Ativan, it must be a documentation error, and this can be a concern because we are not following Doctor's Orders. The DON also said, When nursing staff administer a controlled medication, it should automatically go on the MAR, and you can put supplemental documentation in the electronic medical record when it populates. She said, Point Click Care ([electronic medical record) ] sometimes glitches, so medication administration may be in the progress notes but not on the MAR; however, she would have to find out and come back to me to see why the wasted medication is not correct. In an interview on 03/14/24 at 4:51 with the Administrator, she said, I don't know the process for wasting medications, but they do have to discard medication properly. She initially denied any problems with the electronic medical record. However, she stated that she was made aware that there were charting concerns this morning, and she reported the issue to her IT department when she was made aware of the problem. Record review of the facility policy and procedure titled Pharmacy/Nursing Service Physician Orders revealed that medications shall be administered only upon written order of a duly licensed and authorized to prescribe such drug. The Policy read, in part, .6. Medication, treatment, or related orders are transcribed in the eMAR or eTAR, Review of the policy regarding, Discarding and Destroying Medications revealed in part that medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lid were secured. This failure could place residents at risk of infection for exposure to germs and diseases carried by rodents from improperly disposed garbage. Findings included: Observation on 03/12/24 at 8:32 am, revealed the facility's dumpster area, which was in the front parking area to the right side of the facility. The dumpster on the left side: lid was wide open. Interview on 3/13/2024 at 10:33am, with the Dietary Manager, she said all the workers know they are supposed to close the dumpster sliding door and make sure the lid was closed. She said if the dumpsters were left open it would bring stray cats and animals in the area causing an infection control issue. Interview on 3/13/2024 at 1:35pm, with the Cook, she said if the lid was to remain open to the dumpster rats and stray cats would come around and create a hazard around the facility. Interview on 3/13/2024 at 2:25pm with the Executive Director, she said if the dumpster lid was left open, it can cause an infection control issue. Record review of the Facility's policy dated 2019 indicated: .Chapter 4: Sanitation Infection Control 4-28 . Procedure: 2. Trash will be deposited into a sealed container outside the premises. Record review of the Facility's Food-Related Garbage and Rubbish Disposal policy, revised April 2006 revealed . 2. All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be covered when stored or not in continuous use. 5. Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin. 7. Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure clinical records for 2 residents (CR #212 and Resident # 90) of 4 residents reviewed for clinical records were maintained in accordance with accepted professional standards and practices, were complete, and accurately documented. -CR #212 had a treatment order for staff to clean the resident's left heel and apply skin prep, then heel protectors and the treatment order was not transcribed to CR #212's eTAR. -The administration of a PRN anxiety medication to Resident #90 by not documenting Lorazepam .05mg tabs in the eMAR The deficient practice could place residents CR #212 at risk for additional skin breakdown and Resident #90 at risk for having inaccurate records and inadequate care. Findings include: CR #212 Record review of the admission Record for CR #212 (printed 03/13/2024) revealed he was [AGE] years old and was originally admitted to the facility on [DATE]. He was most recently readmitted to the facility on [DATE]. Diagnoses included, but were not limited to, right hip fracture, abnormalities of gait and mobility, and generalized muscle weakness. Record review of the Physician's Order dated 03/08/2024 at 3:59 p.m. revealed Claen (sic) left heel area with normal saline and apply skin prep to left heel area and apply heel protectors. Record review of the March 2024 eTAR for CR #212 revealed the order had not been transcribed onto the eTAR. In an interview via telephone on 03/13/2024 at 2:40 p.m., a Personal Care Home representative for CR #212 said the facility had attempted to discharge the resident on 03/08/2024. She said the resident had a non-healing wound on his left heel. She said the facility had said it was a scab. She said there was no wound care order at that time. The resident was discharged on 03/11/2024. In an interview on 03/13/2024 at 4:40 p.m., ADON A said CR #212 had an issue with his heel prior to admission. She said it was scabbed over. In an interview on 03/13/2024 at 4:41 p.m. LVN B said the resident readmitted with scabs, and they were monitoring. LVN B stated the Physician's Order dated 03/08/2024 should have been transferred to the eTAR. In an interview on 03/13/2024 at 4:42 p.m., ADON A said the Personal Care Home had requested the order for the left heel on 03/08/2024. In an observation and interview on 03/13/2024 at 4:43 p.m. the DON said the order was in the eTAR. At that time ADON C performed a search of CR #212's March 2024 eTAR and confirmed the order had not been transferred. The facility policy Pharmacy Services/Nursing Services Subject: Physician Orders (revised March 2023) read, in part, .6. Medication, treatment, or related orders are transcribed in the eMAR or eTAR, Resident #_90 Record review of Resident #90's face sheet dated 03/14/24 indicated Resident #90 was a [AGE] year-old male who admitted on [DATE] with the following diagnoses: Chronic Diastolic Congestive Heart Failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), Gastro-Esophageal Reflux Disease without Esophagitis (condition in which the stomach contents move up into the esophagus), Anxiety Disorder (ongoing worry and tension may be accompanied by physical symptoms, such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping), and Essential Hypertension(When the pressure in your blood vessels is too high, 130/80 mm Hg or higher). Resident was admitted to the facility for Long Term and Hospice Care. Record review of the MDS assessment dated [DATE] revealed a BIMS summary score of 15, indicative of being cognitively intact. Record review of Telephone Order dated 03/05/24 for Lorazepam (anti-anxiety medication) oral .5mg tab by mouth every 6 hours as needed for anxiety for 14 days. Record review of the Medication Administration record from March 9 - 13, 2024, for Resident #90 revealed the following medication documentation on the MAR: *03/09/24 10:00 p.m. Lorazepam.5mg tab administered *03/10/24 1:22 a.m. Lorazepam.5mg tab administered *03/11/24 1:43 a.m. Lorazepam.5mg tab administered *03/11/24 3:19 p.m. Lorazepam.5mg tab administered *03/12/24 2:50 p.m. Lorazepam.5mg tab administered *03/13/24 7:31 a.m. Lorazepam.5mg tab administered *03/13/24 5:32 p.m. Lorazepam.5mg tab administered There was no active order for Lorazepam (Ativan) 1 mg tab by mouth every 12 hours until 03/13/24 at 10:00 p.m. However, the form titled Controlled Drug Receipt/Disposition form for Lorazepam 1mg tabs revealed: *03/09/24 10:00 p.m. Lorazepam 1mg tab administered *03/10/24 1:22 a.m. Lorazepam 1mg tab administered *03/10/24 3:54 a.m. Lorazepam 1mg tab administered *03/11/24 1:43 a.m. Lorazepam 1mg tab administered *03/11/24 3:22 p.m. Lorazepam.5mg tab administered *03/12/24 4:38 a.m. Lorazepam.5mg tab administered *03/12/24 2:55 p.m. Lorazepam.5mg tab administered *03/13/24 7:51 a.m. Lorazepam 1mg tab administered *03/13/24 5:44 p.m. Lorazepam 1mg tab administered Record review of the form titled Controlled Drug Receipt/Disposition form for Lorazepam 1mg tabs revealed missing .5 mg waste for the following dates and times: 3/9/24 at 10:00 p.m. 3/10/24 at 1:22 a.m. 3/11/24 at 1:43 a.m. 3/12/24 at 2:50 p.m. 3/13/24 at 5:32 p.m. Record review of the Progress Notes revealed additional Lorazepam medication administration did not correspond with the eMAR or Controlled drug receipt/disposition form. These dates and times include: 03/11/24 6:25 a.m. Lorazepam.5mg tab administered 03/11/24 6:14 p.m. Lorazepam.5mg tab administered 03/12/24 4:40 p.m. Lorazepam.5mg tab administered 03/13/24 1:35 a.m. Lorazepam 1mg tab administered In an interview on 03/14/24 at 10:32 a.m., the Hospice RN stated that Morphine in conjunction with Lorazepam was extremely common for residents with agitation. She said, We don't have a max dose of Lorazepam in Hospice. We give whatever it takes to make them comfortable. I was called yesterday to assess the resident, and I gave a dose of 1 mg of Ativan from the facility's med cart, and what I gave to the resident yesterday was actually a very mild dose. Morphine in conjunction with Ativan is like a standing order. The nurse was asked if she ordered the .5 mg from the pharmacy, and she stated that she did order the .5 mg Lorazepam from a pharmacy called Long Term Care or Pharma Care. In an interview on 03/14/24 at 10:37 a.m. with the Pharmacy Manager at Pharma Care (LTC Pharmacy), he stated that they never received an order for the .5 mg of Lorazepam and only received the Lorazepam 1mg order. The pharmacy distributed Lorazepam 1mg on 12/28/23 (quantity of 10 tabs) and 03/12/24 (quantity 60 tabs) in a blister pack per the physician's order. In an Interview on 03/14/24 at 2:39 p.m. with the Hospice Nurse Manager, she stated that it is common to order Ativan 1mg every hour for Hospice residents. She stated that this is a Physician order, but it's not considered a standing order. This Lorazepam order is often in combination with Morphine, and it is not uncommon because it will keep him safe, minimize his ability to hurt himself, and also relieve pain. In an interview on 3/14/24 at 2:42 p.m. with the DON, she stated that the resident has had a change of condition since being hospitalized last week and has been getting Lorazepam for agitation. He was currently on Hospice, and they prescribed the medication. She stated that there was an order for both Ativan .5mg and 1mg. She was referred to an order that showed that the Lorazepam was not ordered until 03/13/24. DON said, If we didn't have an order for 1mg of Ativan, it must be a documentation error, and this can be a concern because we are not following Doctor's Orders. The DON also said, When nursing staff administer a controlled medication, it should automatically go on the MAR, and you can put supplemental documentation in the electronic medical record when it populates. She said, Point Click Care ([electronic medical record) ] sometimes glitches, so medication administration may be in the progress notes but not on the MAR; however, she would have to find out and come back to me to see why the wasted medication is not correct. In an interview on 03/14/24 at 4:51 with the Administrator, she said, I don't know the process for wasting medications, but they do have to discard medication properly. She initially denied any problems with the electronic medical record. However, she stated that she was made aware that there were charting concerns this morning, and she reported the issue to her IT department when she was made aware of the problem. Record review of the facility policy and procedure titled Pharmacy/Nursing Service Physician Orders revealed that medications shall be administered only upon written order of a duly licensed and authorized to prescribe such drug. The Policy read, in part, .6. Medication, treatment, or related orders are transcribed in the eMAR or eTAR, Review of the policy regarding, Discarding and Destroying Medications revealed in part that medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F609 Based on interview and record review, the facility failed to ensure all alleged violations involving injury of unknown origin, abuse, neglect, or misappropriation of resident property were reported immediately, but not later than 24 hours after the allegation was made, to the administrator of the facility and to other officials (including to the State Agency) for 2 (CR#2 and CR#4) of 12 residents reviewed for injury of unknown origin. The facility failed to immediately report within 24 hours CR#2's injury of unknown origin when he had increased pain and was diagnosed with a torn rotator cuff on 7/18/23. The facility failed to immediately report within 24 hours CR#4's, who had glaucoma and was cognitively impaired, ingesting shampoo from an unlabeled medication cup while CNA gave him a shower. Findings include: CR #2 was an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with metabolic encephalopathy, elevated white blood cell count, pure hypercholesterolemia, hypertensive heart disease, chronic atrial fibrillation, acute respiratory failure with hypoxia and hypercapnia, muscle weakness, dysphagia-oropharyngeal phase, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, systemic inflammatory response syndrome, and need for assistance with personal care. Record review of CR #2's Care Plan dated 7/5/23 revealed CR#2 was at risk for impaired thought processes r/t cognitive communication deficit with interventions to give step by step instructions one at a time as needed to support cognitive function and keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. CR#2 was found to have ADL self care performance deficit r/t limited mobility, impaired balance, pain, limited range of motion, and required assistance with bed positioning, eating and dressing. CR #2 was found to be at risk for falls r/t deconditioning, gait/balance problems, incontinence with interventions to be sure the call light is within reach and encourage to use it to call for assistance as needed and keep needed items, water, etc., in reach. CR#2 had antidepressant medication use r/t poor nutrition with interventions to educate resident, family/caregivers about risks, benefits and the side effects of medication, give anti depressant medications ordered by physician, monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations, sedation, drowsiness, blurred vision, muscle tremor, agitation, rash, weight loss or weight gain, monitor for adverse side effects of antidepressant appetite changes, blurry vision, constipation ., observe for signs and symptoms of following: confusion, mood change, change in normal behavior, hallucinations/delusions, social isolation, suicidal ideations, withdrawal, decline in ability to help with/do ADLs, continence, cognitive function, shuffle gait, rigid muscles difficult ambulation, balance problems, accidents, dizziness/vertigo, falls, movement problems, tremors .CR#2 had acute/chronic general pain with interventions as pain assessment every shift. Record review of CR #2's admission MDS dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 9 indicating moderately impaired cognition. CR#2's functional status revealed walking in room and corridor only occurred once or twice with 1 person assisting, bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene were extensive assistance with one person assisting. Record review of CR#2's Physician's Orders, dated 06/27/23, revealed monitor and assess pain level every shift using the 0-10 scale .Lidoderm Patch 5% applied topically every morning for pain .dated 07/10/23, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for pain in the lower extremities . Record review of CR#2's June-August 2023 MAR revealed, CR#2 was administered a Lidocaine Patch on his back every day from 06/27/23 to 07/31/23. Record Review of CR#2's Pain Assessment, dated 06/27/23 revealed CR#2 expressed having aching back pain daily or several times a day, worst in the early morning. Medications and non-medication interventions were discussed between MD and CR#2. Record review of CR#2's Radiology Results Report dated 7/18/23 revealed Shoulder X-ray complete 2 or more views, significant findings . No fracture or dislocation. Bony demineralization. Impression: Rotator cuff tear. Degenerative changes. Record review of Nurse note dated 7/18/23 at 6:48 p.m. written by LVN G revealed Right shoulder x-ray results sent to NP. NP informed this writer that he needs to be seen by orthopedic. This writer informed CR#2's family member via telephone. Record review of Nurse note dated 7/18/23 at 7:06 p.m. written by LVN G revealed Type Change in Condition. Change in Condition: symptoms or signs of condition change: Functional decline (worsening function and/or mobility) Other change in condition pain to right shoulder. Reported to primary care clinician: NP on 7/18/23 at 6 p.m., CR#2's family member notified 7/18/23 at 6 p.m. Record review of Nurse note dated 7/19/23 at 10:39 a.m. written by LVN G revealed Pain: Yes, Pain level 8- 7/19/23 at 10:39 a.m. pain scale numerical. Pain originates from rotator cuff tear located at right shoulder described as frequent sharp pain nonpharmaceutical interventions include being at rest .Cognition is alert, oriented x 2 no active symptoms or treatments effecting level of consciousness, cognition, sleep, mood or behavior. Cognitive symptoms described as slow to answer verbally. Occasionally forgetful. Record review of CR#2's Progress note dated 7/19/23 by NP revealed Resident (CR#2) is seen and examined in bed, he is awake alert and oriented, he denies any distress or discomfort at my time of examination. Patient had pain to right shoulder which x-ray was positive for rotator cuff tear for which Orthopedic appointment has been placed for 7/24/23. He has otherwise not had any other acute change in condition. In an interview with LVN G on 09/25/23 at 12:25 PM, she said she contacted CR#2's nurse practitioner to order an x-ray of the resident's shoulder because he was always complained about shoulder pain. She said she contacted CR#2's responsible party when the x-ray results returned diagnosing the resident with a torn rotator cuff. She said she did not remember what she told the responsible party what the reason for the x-ray was. She said a torn rotator cuff could be caused from overstraining the arm and muscle, or pushing down or applying too much weight on a surface. She said if she was notified of a resident fall, witnessed or unwitnessed, she would perform a head to toe assessment, check vital signs, document findings in a progress note or complete a change in condition assessment. She said if there were no concerns or injuries, she would still notify the resident's physician, the DON and the responsible party. She said if the resident hit their head or suffered an unwitnessed fall, she would begin doing neuro checks on the resident for 72 hours. She said if there were injuries or concerns regarding the resident, she would discuss the information with the physician and follow whatever directives were given. She said neuro checks were not completed in CR#2's Clinical records, but documented on one page sheets, turned into the ADON's and DON. In an interview on 9/14/23 at 10:15 a.m. with CR#2's family member, she said CR#2 moved into the facility in June 2023. CR#2's family member stated around mid-July 2023 (unknown date), the family member received a phone call from LVN G informing her the resident had a fractured rotator cuff. She said LVN G told her the resident was complaining of pain in his shoulder. She said after being informed about CR#2's injury, the next time she visited him, she requested a copy of the incident report. She said the facility did not have an incident report. In an interview with PT A on 09/25/23 at 1:20 PM, she said any time she became aware of an incident with a resident, she was supposed to report it to the resident's nurse immediately. She said she did not know if the nurse assessed CR#2. She said CR#2 made increasing complaints of pain in his shoulder. She said the reason an x-ray was ordered for CR#2 was due to his increasing complaints of pain. She said she did not know who ordered the x-ray to be performed on CR#2. In an interview with LVN G on 09/25/23 at 1:48 PM, she said she did not know whether CR#2 was assessed by another staff. She said she remembered having to perform neuro checks for CR#2 at some point during his stay at the facility. She said if she was notified of a resident's unwitnessed fall, she perform a head to toe assessment, check vitals, check for skin tears and any other visible injuries, document a change in condition, if necessary, call the resident's doctor, notify the DON and the responsible party. She said if a change in condition was not necessary, she would at least document what was reported to her, what she found during her assessment of the resident. She said if the resident hit their head, she would ask the doctor if the resident needed to be sent to the hospital or monitored by neuro checks. She said CR#2 complained about pain from the time he was admitted to the facility, until he was discharged . She said CR#2 suffered from chronic pain and was prescribed Tylenol as a PRN medication for pain. She said any time CR#2 complained about pain, she documented the information on CR#2's MAR progress notes at the time she administered pain medication to CR#2. She said she did not know why she could not locate any notes related to complaints of pain from CR#2 on his June, July and August 2023 MAR's. She said she was trained to document the resident's level of pain by asking the resident to identify their pain on a scale of 1-10, and whether the pain was radiating or not. She said if she performed an assessment, she would have documented it in their system. She said she contacted CR#2's NP to get an x-ray order of CR#2's left shoulder because CR#2 began making increased complaints of pain to his left shoulder after the resident's roommate said CR#2 fell. She said she probably could have documented CR#2's complaints of pain better. She said if the resident was on a coagulant they are to monitor for any signs of bleeding for a resident on anticoagulants and suffered a fall. She said this information would be documented in the resident's eMAR. She said if there is a witnessed fall and head hit, they initiate neuro checks. In an Interview with Administrator and Clinical Market Leader on 9/28/23 at 10:58 a.m. she stated CR#2's family member said the rotator cuff tear was a longstanding issue. The Administrator stated if CR#2 had an unwitnessed fall it would be reported and he stated the DON was also able to make a report to the State. In an interview on 9/28/23 at 11:20 a.m. with the DON, the Administrator and Clinical Market Leader, The DON stated in the morning meetings they discussed incidents, and allegations. The Administrator stated the allegations regarding CR#2 were not discussed in the morning meeting. Clinical Market Leader stated she would report the allegations about CR#2's to the State, and based on their own evidence she would do an investigation and an assessment. Clinical Market Leader stated a visual or staff looking at CR#2 was not appropriate to complete an assessment. The DON stated in her job she reviewed incidents/accident reports, but no one reviewed CR#2's incident/accidents. The DON stated she reviews assessments, and care plans weekly and as needed and she reviewed CR#2's Care plan but she did not recall when she did the review. The DON stated when she reviews care plans she looks for any changes residents have, ensure their initial care plan was completed, and to add anything specifically to the resident they need personalized. In an interview on 9/28/23 at 12:15 p.m. with Clinical Market Leader, she stated the staff are aware when to involve their clinical resource and the staff were aware they should have informed them when something would arise to a reportable. She stated if the staff do not know what to do, they should make a call and they also have what to include when reporting. This incident should have been reported and investigated. In an interview on 9/28/23 at 12:50 p.m. with the Administrator and DON, the Administrator stated from the time they were educated about the incident they have increased their intakes and reporting when they were not sure what happened in the incident they report, and they had 5 days to investigate it. He stated unfortunately, they cannot go back and change the past and they were trying to get better on those and it's a consistent work in progress. In an interview with ADON B on 9/29/23 at 8:55 AM, she said she was familiar with CR#2. She said CR#2 was a resident on the hall she was responsible for. She said she entered CR#2's order into his electronic health record upon his admission to the facility. She said CR#2 used his wheelchair most of the time when he was not in his bed. She said she believed LVN G completed an assessment on CR#2. She said when the resident got here, the resident had a poor appetite. She said CR#2's family member said since his other family member passed on the years before, his appetite had been poor since then. She said with regard to CR#2's increased pain, CR#2 already had pain in his shoulder. She said she could not speak to why the shoulder pain was not documented at the time of admission. ADON B said CR#2 did not want to participate in therapy. She said they spoke to the family and told CR#2 in order for him to go home, he had to complete therapy. She said CR#2 began participating in therapy and had increased pain, she said they attributed the increased pain to CR#2 now participating in therapy. ADON B said CR#2 was not doing therapy before, but now he was and they attributed the pain to increased activity via therapy. She said if CR#2's rotator cuff tear a new injury, she would report it, but the nurse practitioner said CR#2's injury was chronic. She said she spoke to the nurse practitioner. The ADON said an unwitnessed fall occurs when a staff finds a resident on the floor and no one knows how they fall, and the resident can't say how they fell. She said when a nurse was notified of an unwitnessed fall, they do neuro checks, head to toe assessments, pain assessments for 72 hours. She said if there are any abnormalities, they will notify the doctor. ADON said she did not have LVN G sign anything, or review anything after this. She said she just instructed LVN G to do an assessment on CR#2. She said she did not review LVN G's assessment or CR#2's electronic health record. The ADON said she was not aware CR#2 was prescribed and administered an anticoagulant medication. She said CR#2's care plan should have included the anticoagulant medication. She said if a resident was prescribed an anticoagulant and was reported to have an unwitnessed fall, she would treat the situation like a witnessed fall. She said the resident's doctor would need to be contacted, neuro checks and other assessments for 72 hours, and notify the RP. The ADON said a resident on anticoagulant medication not being assessed after unwitnessed fall was at risk of bleeding. The ADON said she was aware of CR#2's rotator cuff tear. She said the facility did an investigation into CR#2's injury, and according to x-ray results, the rotator cuff tear was a degenerative injury. She said they spoke to CR#2, and CR#2's family member. She said that was the investigation they did for CR#2's injury. The ADON said she did not document any of the conversations regarding the rotator cuff tear because she thought the DON had done it. She said none of the nurse's ever told the ADON CR#2 experiencing shoulder pain. She said the pain medication prescribed for CR#2 was for his hip. In an interview on 9/29/23 at 11:23 a.m. with the Orthopedic Physician he stated he saw CR#2 once on July 24, 2023 and CR#2 came in with his family member with right shoulder pain. He stated CR#2's family member told the physician CR#2 fell and had a vertebral fracture and was unable to move his wheelchair. The Physician stated the bars on his wheelchair obstructed any view of the shoulder so he could not get the x-rays. The Orthopedic physician stated CR#2 was weak on all rotator cuff testing and two days ago, the Clinical Market Leader called from the facility saying, how did you diagnose a rotator cuff tear with acute x-rays. He stated the Clinical Market Leader sent a one view x-ray and it was hard to tell anything on one view that was a one-dimensional structure. He stated he needed more info from CR#2 and additional views. The Physician stated CR#2's rotator cuff was fully torn, or he could have had 2 fibers hanging on and then it broke eventually. He stated CR#2 did not complain of an injury, just increased shoulder pain. The Orthopedic physician stated if the rotator cuff was fully torn it could not become more torn, but if CR#2 had further injury like a fall it could have completely torn. The physician stated he was unable to examine CR#2's shoulder more because of the patient's (CR#2's) condition. The physician stated CR#2 had not had the shoulder pain initially, he did not know if the patient (CR#2) fell or if transferring him or moving him improperly could have caused the rotator cuff to completely tear. He stated it was hard to say definitively the reason for the rotator cuff tear. He stated it was hard because if CR#2 had a fracture it would be healed by now, but rotator cuff's once torn completely do not just repair. The Orthopedic physician stated if CR#2 did not have issues with his shoulder before it was not all the way torn, but he could not say if it happened in the facility, or if it happened in the hospital. He stated CR#2's condition was chronic and long standing but it does not mean his symptoms were chronic and longstanding. The Physician stated if CR#2 was asymptomatic before did not mean he did not have the problem and just because the problem occurred did not mean it existed before. He stated if CR#2 did have the condition before a fall, a fall undoubtedly can reinjure and could cause significant injury. He stated it was impossible to say how long CR#2 had it and chronic was longer than 3 months. He stated the x-rays were from a while back, but it did not mean CR#2 did not injure himself due to falling, it absolutely could have happened from a fall or mistreatment. CR#4 Record review of CR #4's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. He was diagnosed with chronic obstructive pulmonary disease (constriction of airways and difficulty breathing), acute kidney failure (kidney unable to filter waste), non-St elevation (NSTEMI) myocardial infarction (partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart), atherosclerotic heart disease (narrows the arteries close to your heart), type 2 diabetes with diabetic neuropathy (high blood sugar with type of nerve damage mostly affects legs and feet), need for assistance with personal care, unsteadiness on feet, muscle weakness, lack of coordination, insomnia (difficulty sleeping), pleural effusion (water on the lungs), mild cognitive impairment, radiculopathy of cervical region (pinched nerve), major depressive disorder, anemia (low red blood cells), chronic pain syndrome, heart failure (heart muscle unable to pump blood), respiratory failure (not enough oxygen in the tissue in your body or when you have too much carbon dioxide in your blood), rectal abscess (collection of pus from an infection near the anus), gastrointestinal hemorrhage (bleeding in your digestive tract), obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), and difficulty walking. Record review of CR #4's Care Plan dated 1/16/23 revealed CR#4 was found at risk for impaired thought processes r/t mild cognitive impairment of uncertain or unknown etiology with interventions as engage in simple, structured activities that avoid overly demanding tasks, Give step by step instructions one at a time as needed to support cognitive function, Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. CR#4 also had potential for mood problem r/t mild cognitive impairment of uncertain or unknown etiology with interventions to assist to identify strengths, positive coping skills and reinforce these. CR#4 was identified for preferring to stay in room, has no interest in activities with interventions as establish and record prior level of activity involvement and interests by talking with resident, caregivers and family on admission and as necessary, explain the importance of social interaction and leisure activity time. Encourage participation by next review . Record review of CR #4's Quarterly MDS assessment dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 10 indicating moderate impaired cognition. CR#4's functional status revealed walk in room and corridor did not occur, locomotion on/off the unit only occurred once or twice with person assisting, transfer only happened once or twice with the assistance of 2 staff, bed mobility and toilet use were extensive assistance with one person assisting. Bathing self performance was found to be activity itself did not occur. CR#4 required substantial/maximal assistance for toileting, upper and lower body dressing and was dependent for shower/bathing self and putting on/taking off footwear. CR#4 was found to have occasional pain. Record review of CR#4's Nurse notes dated 7/1/23 at 6:33 p.m. by LVN I revealed, Around 5 p.m. staff reported, while bathing resident he placed a cup on table with soap in it, about 30cc. Resident drank the soap. He stated he thought it was his medicine. Resident alert and oriented x 4, no distress noted. No complaint of pain or discomfort NP was notified, monitor Patient. DON was notified by message. Call light was in reach. Record review of CR#4's Nurse Notes dated 7/2/2023 at 12:33 p.m. by LVN I revealed, Complained of upset stomach, nausea, and cannot move bowels. Alert and oriented x 4, .Called team Health, spoke with NP. Give enema, rectal, gave Zofran as ordered. Record review of CR#4's Clinical records did not reveal an incident report. Record review of CR#4's Clinical records did not reveal neuro checks. In an interview with ADON A on 09/14/23 at 12:00 PM, she said the CNA took CR#4 to take a shower and there was soap in a medication cup. She said she did not recall seeing an incident report. In an interview on 09/14/23 at 1:42 PM with the DON she stated she was aware of the incident in July 2023 with CR#4. The DON stated she was told that a CNA was giving CR#4 a shower and CR#4 drank shampoo. The DON stated she believed CR#4's nurse informed her of the incident, but she was not sure. The DON stated the CNA poured shampoo from the bottle into a medicine cup to use on CR#4 during the shower. She stated it was about 30 cc's worth of shampoo in the cup, and CR#4 drank it all. The DON stated she could not recall who the CNA was. She stated she did not report the incident to the State and she did not know why the incident was not reported. The DON stated after the incident, the CNA was in-serviced, but there was no disciplinary action as a result of the incident. She stated she would look for documents related to CR#4's incident and provide them to the State Surveyors. In an interview with the Administrator on 09/21/23 at 5:40 PM, he said he was made aware of the incident with the shampoo after being informed by the DON a few days ago. He said the facility addressed the concern at the time the incident occurred. The Administrator stated the CNA involved in the incident did receive disciplinary action as a result of the incident. He stated the CNA no longer worked at the facility. The Administrator stated after learning about the incident, he reviewed all the information and discussed the incident with the facility's Clinical Resource. He stated the incident had not been reported to HHSC. He said he was not intending to report the incident to HHSC. He said based on the feedback from the Clinical Resource, the facility determined this incident did not meet the criteria to report to HHSC. The Administrator stated he was not aware documentation regarding this incident had been requested from the DON on 09/14/23. He stated he would have the DON email all documents to the State Surveyor. In an interview with the Facility MD on 09/27/23 at 12:52 PM, she said stated the incident should have been reported to poison control and poison control would have been able to tell them what they needed to do for CR#4. The Facility MD stated gastro intestinal concerns, vomiting, and nausea may be symptoms someone could have. She stated if a resident ingested shampoo, they should contact the doctor and call poison control. In an interview on 9/28/23 at 10:58 a.m. with the Clinical Market Leader she stated she found out about CR#4 who drank shampoo recently and the facility did not report it. She stated the Administrator said notification was done to CAC and physician. The Clinical Market Leader stated they were told to continue monitoring. She stated the CNA was giving a bed bath to CR#4, and it was soap and the CNA turned away CR#4. The Clinical Market Leader stated the Nurse assessed CR#4 and contacted CR#4's physician. She stated CR#4 went to hospital on 7/2/23 related to chest pain. She stated the days following the shampoo incident CR#4 had chronic abdominal issues prior to this and they contacted CR#4's physician. The Clinical Market Leader stated the facility did not contact poison control. In an interview on 9/29/23 at 1:55 p.m. with RN B she stated she heard about CR#4 swallowing shampoo, and he was her long term care resident. She learned about CR#4's situation after he was discharged . She stated she did not know about him swallowing shampoo when it happened. In an interview on 9/29/23 at 2:22 p.m. ADON B she stated the shampoo was an unusual occurrence she would make sure the nurse documented it and she would assess the resident (CR#4) because shampoo is chemical and she would notify the DON and the Administrator and CR#4's family and the doctor. She stated she was not aware the incident happened. On Tuesday, 9/26/23 and learned State was in the building investigating shampoo on Monday, 9/25/23. She stated she was told that the CNA had shampoo on the bedside table and the CNA was giving care to CR#4 and CR#4 thought it was medicine and drank it. She stated she had no idea it happened, but if she were to be notified of an incident like that, she would expect the CNA to tell her when that happened. ADON B stated should she have been notified she would have completed an assessment, notified the Dr. and CR#4's family and the Administrator because it was an unusual occurrence. ADON B stated CR#4 should be monitored for several days after, notify the Dr. to ask what orders they want to be in place because CR#4 swallowed the shampoo, and they would have contacted poison control. Record review of Abuse: Prevention of and Prohibition Against, revealed the following: Revised on 10/22, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of Resident property, and exploitation the facility will provide oversight and monitoring to ensure that it's staff deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of Resident property, and exploitation. D. Prevention .assuring the residents are free from neglect by having the structures and processes to provide immediate care and services to all residents which includes but is not limited to the completion of a facility assessment to determine what resources are necessary to care for its residents competently

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on investigation and record review the facility failed to thoroughly investigate injury of unknown origin for 2(CR#2 and CR#4) of 12 residents reviewed for thorough investigations. CR#2 had an injury of unknown origin and the facility did not thoroughly investigate after he had increased pain and was diagnosed with a torn rotator cuff on 7/18/23. The facility failed to have evidence to demonstrate a thorough investigation after CR#4, who was cognitively impaired, ingested shampoo from a medicine cup while receiving a shower. These failures placed residents at risk of further injury, pain and potential exposure to abuse and neglect. Findings include: Record review of CR #2's face sheet was an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with metabolic encephalopathy, elevated white blood cell count, pure hypercholesterolemia, hypertensive heart disease, chronic atrial fibrillation, acute respiratory failure with hypoxia and hypercapnia, muscle weakness, dysphagia-oropharyngeal phase, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, systemic inflammatory response syndrome, and need for assistance with personal care. Record review of CR #2's Care Plan dated 7/5/23 revealed CR#2 was at risk for impaired thought processes r/t cognitive communication deficit with interventions to give step by step instructions one at a time as needed to support cognitive function and keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. CR#2 was found to have ADL self care performance deficit r/t limited mobility, impaired balance, pain, limited range of motion, and required assistance with bed positioning, eating and dressing. CR #2 was found to be at risk for falls r/t deconditioning, gait/balance problems, incontinence with interventions to be sure the call light is within reach and encourage to use it to call for assistance as needed and keep needed items, water, etc., in reach. CR#2 had antidepressant medication use r/t poor nutrition with interventions to educate resident, family/caregivers about risks, benefits and the side effects of medication, give anti depressant medications ordered by physician, monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations, sedation, drowsiness, blurred vision, muscle tremor, agitation, rash, weight loss or weight gain, monitor for adverse side effects of antidepressant appetite changes, blurry vision, constipation ., observe for signs and symptoms of following: confusion, mood change, change in normal behavior, hallucinations/delusions, social isolation, suicidal ideations, withdrawal, decline in ability to help with/do ADLs, continence, cognitive function, shuffle gait, rigid muscles difficult ambulation, balance problems, accidents, dizziness/vertigo, falls, movement problems, tremors .CR#2 had acute/chronic general pain with interventions as pain assessment every shift. Record review of CR#2's Care plan revealed no updates were made to CR#2's care plan after the discovery of his rotator cuff tear. Record review of CR #2's admission MDS assessment dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 9 indicating moderately impaired cognition. CR#2's functional status revealed walking in room and corridor only occurred once or twice in the last 7 days with 1 person assisting. Bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene were extensive assistance with one person assisting. Record review of CR#2's Radiology Results Report dated 7/18/23 revealed Shoulder X-ray complete 2 or more views, significant findings . No fracture or dislocation. Bony demineralization. Impression: Rotator cuff tear. Degenerative changes. Record review of CR#2's Psychiatric Initial assessment dated [DATE] revealed This patient (CR#2) was referred for Depression, Confusion. Today on exam:-In chair, poor eye contact, gave brief, incomplete and unreliable answers to specific questions. Record review of Nurse note dated 7/18/23 at 10:58 a.m. written by LVN G revealed Resident is alert, oriented x 2 no active symptoms or treatments effecting level of consciousness, cognition, sleep, mood or behavior. Cognitive symptoms described as slow to answer verbally. Occasionally forgetful .transfer: self-performance Limited assistance, transfer- support provided: one person physical assistance. Record review of Nurse note dated 7/18/23 at 6:48 p.m. written by LVN G revealed Right shoulder x-ray results sent to NP. NP informed this writer that he needs to be seen by orthopedic. This writer informed CR#2's family member via telephone. Record review of Nurse note dated 7/18/23 at 7:06 p.m. written by LVN G revealed Type Change in Condition. Change in Condition: symptoms or signs of condition change: Functional decline (worsening function and/or mobility) Other change in condition pain to right shoulder. Reported to primary care clinician: NP on 7/18/23 at 6 p.m., CR#2's family member notified 7/18/23 at 6 p.m. Record review of Nurse note dated 7/19/23 at 10:39 a.m. written by LVN G revealed Pain: Yes, Pain level 8- 7/19/23 at 10:39 a.m. pain scale numerical. Pain originates from rotator cuff tear located at right shoulder described as frequent sharp pain nonpharmaceutical interventions include being at rest .Cognition is alert, oriented x 2 no active symptoms or treatments effecting level of consciousness, cognition, sleep, mood or behavior. Cognitive symptoms described as slow to answer verbally. Occasionally forgetful. Record review of CR#2's Progress note dated 7/19/23 by NP revealed Resident (CR#2) is seen and examined in bed, he is awake alert and oriented, he denies any distress or discomfort at my time of examination. Patient had pain to right shoulder which x-ray was positive for rotator cuff tear for which Orthopedic appointment has been placed for 7/24/23. He has otherwise not had any other acute change in condition. Record review of CR#2's Daily Skilled Note dated 7/20/23 at 5:34 p.m. written by LVN B revealed Musculoskeletal: Observations of ROM, ADL care, locomotion, assistive device use are weak &limited ROM, 1 person assist for ADL care, wheelchair for locomotion when out of bed. No musculoskeletal changes observed . In an interview with LVN G on 09/25/23 at 12:25 PM, she said she contacted CR#2's nurse practitioner to order an x-ray of the resident's shoulder because he was always complained about shoulder pain. She said she contacted CR#2's responsible party when the x-ray results returned diagnosing the resident with a torn rotator cuff. She said she did not remember what she told the responsible party what the reason for the x-ray was. She said a torn rotator cuff could be caused from overstraining the arm and muscle, or pushing down or applying too much weight on a surface. She said if she was notified of a resident fall, witnessed or unwitnessed, she would perform a head to toe assessment, check vital signs, document findings in a progress note or complete a change in condition assessment. She said if there were no concerns or injuries, she would still notify the resident's physician, the DON and the responsible party. She said if the resident hit their head or suffered an unwitnessed fall, she would begin doing neuro checks on the resident for 72 hours. She said if there were injuries or concerns regarding the resident, she would discuss the information with the physician and follow whatever directives were given. She said neuro checks were not completed in CR#2's Clinical records, but documented on one page sheets, turned into the ADON's and DON. In an interview on 9/14/23 at 10:15 a.m. with CR#2's family member, she said CR#2 moved into the facility in June 2023. CR#2's family member stated around mid-July 2023 (unknown date), the family member received a phone call from LVN G informing her the resident had a fractured rotator cuff. She said LVN G told her the resident was complaining of pain in his shoulder. She said after being informed about CR#2's injury, the next time she visited him, she requested a copy of the incident report. She said the facility did not have an incident report. In an interview with PT A on 09/25/23 at 1:20 PM, she said any time she became aware of an incident with a resident, she was supposed to report it to the resident's nurse immediately. She said she did not know if the nurse assessed CR#2. She said CR#2 made increasing complaints of pain in his shoulder. She said the reason an x-ray was ordered for CR#2 was due to his increasing complaints of pain. She said she did not know who ordered the x-ray to be performed on CR#2. In an interview with LVN G on 09/25/23 at 1:48 PM, she said she did not know whether CR#2 was assessed by another staff. She said she remembered having to perform neuro checks for CR#2 at some point during his stay at the facility. She said if she was notified of a resident's unwitnessed fall, she perform a head to toe assessment, check vitals, check for skin tears and any other visible injuries, document a change in condition, if necessary, call the resident's doctor, notify the DON and the responsible party. She said if a change in condition was not necessary, she would at least document what was reported to her, what she found during her assessment of the resident. She said if the resident hit their head, she would ask the doctor if the resident needed to be sent to the hospital or monitored by neuro checks. She said CR#2 complained about pain from the time he was admitted to the facility, until he was discharged . She said CR#2 suffered from chronic pain and was prescribed Tylenol as a PRN medication for pain. She said any time CR#2 complained about pain, she documented the information on CR#2's MAR progress notes at the time she administered pain medication to CR#2. She said she did not know why she could not locate any notes related to complaints of pain from CR#2 on his June, July and August 2023 MAR's. She said she was trained to document the resident's level of pain by asking the resident to identify their pain on a scale of 1-10, and whether the pain was radiating or not. She said if she performed an assessment, she would have documented it in their system. She said she contacted CR#2's NP to get an x-ray order of CR#2's left shoulder because CR#2 began making increased complaints of pain to his left shoulder after the resident's roommate said CR#2 fell. She said she probably could have documented CR#2's complaints of pain better. She said if the resident was on a coagulant they are to monitor for any signs of bleeding for a resident on anticoagulants and suffered a fall. She said this information would be documented in the resident's eMAR. She said if there is a witnessed fall and head hit, they initiate neuro checks. In an interview with the Facility MD on 09/27/23 at 12:52 PM, she said she was familiar with CR#2. She said the first time she assessed CR#2 was on 06/28/23. She said she saw CR#2 on 07/13/23 and CR#2 was not able to ambulate using his walker. She said she could not remember whether she noted whether CR#2 was able to ambulate. She said she noted CR#2 to be a minimum assist in bed and CR#2 could only take 10 steps with his walker. She said she never received any alerts from staff regarding pain to the shoulder. She said CR#2 was receiving skilled nursing services, so she was seeing him every week. She said CR#2 complained about pain every time she saw him. She said she decided to order the xray because CR#2 was complaining about shoulder pain. The MD said CR#2's x-ray results show a torn rotator cuff. The MD stated most rotator cuff injuries were more common in painters and tennis players. She said a rotator cuff tear was not typically an injury that could be sustained from one single movement. She said rotator cuff tears were the result of repeated motion of the arms. She said the reason she did not get a full history on CR#2, in regard to how he could've sustained the rotator cuff tear was because he was at the facility for skilled nursing. She said while CR #2 was under her care, she was seeing him on a weekly basis because he was receiving skilled nursing services. She said she prescribed the Voltaren Gel on 8/10/23 after CR#2 complained of pain in his shoulder and hands during her weekly assessment. She said she preferred not to prescribe narcotic medication for pain when it was possible. In an interview with the MDS Nurse on 09/27/23 at 1:50 PM, she said when she completed CR#2's care plan, she goes over ever complete diagnoses, psychotropics. She said she was not sure as to why there was a breakdown in the system in having the resident's care plan updated. She said she did not remember hearing anything about CR#2 having a rotator cuff tear in the staff morning meetings. She said if the issue was acute or had to do with a medication, the nurse would be responsible for updating the care plan. She said she is typically swamped, so the nurse would assist. The MDS nurse said the RN F was responsible for psychotropics, the treatment nurse does wounds and anything triggered for ADL, hydration, constipation, incontinence she does and the DON does the falls. In an interview on 9/26/23 at 1:30 p.m. with the DON, she said she was aware of the shoulder injury to CR#2. He has a chronic issue of shoulder pain, and she said he came from a different facility and had a fall at that facility. CR#2 also had a fall at home prior to that. He was complaining of pain in the shoulder and the x-ray showed rotator cuff injury. He was sent to ortho and ortho said it was chronic. She stated the CR#2 was admitted with the injury. She referred to miscellaneous documents in the electronic file. Surveyor and DON looked together and there was no mention of the injury in the documents DON stated was there. CR#2 was on pain management already. Surveyor and DON reviewed the clinical file and discovered the pain management was for his back. She stated that she found out about the injury after admission. He was given x ray order for shoulder pain. He was complaining more of shoulder pain. DON stated that just because he had increased shoulder pain did not mean this was an injury of unknown origin or was a new injury. She stated that her and the NP had a discussion about situation (injury). She said NP was within the same group as the other facility, possibly. DON stated that she does not know for sure but believes NP was seeing CR#2 before. DON confirmed with surveyor that CR#2 was not care planned for rotator cuff injury and that CR#2 was a fall risk upon admission. She doesn't recall looking at assessments, She did not assess CR#2. She said based on the policy she supposes it would be an injury of unknown origin. The Administrator is aware at this point. But at the time of incident it was talked about in the morning meeting. She said she is capable of reporting incidents. If another staff came to her about a resident having a fall the expectation is to assess the resident. Nueros would be initiated for unwitnessed falls. It would be herself or the ADON who are on the hall to oversee the documentation and ensure it was done. Care plan should be updated. Interventions he had were working, he would put the light on and they would check on him. In an Interview with Administrator and Clinical Market Leader on 9/28/23 at 10:58 a.m. she stated they recently looked at CR#2's previous hospital records before coming to their facility and found CR#2 had arm swelling, but it did not say right or left and the hospital completed a doppler for DVT (Deep vein thrombosis) and it was ruled out. She stated CR#2 had a fall prior to being discharged going to another Nursing facility CR#2 went home and went to a hospital. She stated the facility did not have hospital records that show CR#2 had rotator cuff injury and the facility did not have any other records. The Administrator stated the facility did reach out to CR#2's previous Nursing facility to get CR#2's paperwork and they did speak with the NP and that is when x-ray was done. The Administrator stated CR#2's family member said the rotator cuff tear was a longstanding issue. The Administrator stated when the NP gave CR#2 the order for an x-ray he was not aware that CR#2 had increased pain. She stated CR#2 came into the facility with right shoulder pain, but the facility assumed therapy would help but it did not help it. She stated CR#2 started not participating in therapy so NP gave order to give CR#2 an x-ray. In an interview on 9/28/23 at 11:20 a.m. with the DON, the Administrator and Clinical Market Leader she stated she would report the allegations about CR#2's injury of unknown origin to the State, and based on their own evidence she would do an investigation and an assessment. Clinical Market Leader stated a visual or staff looking at CR#2 was not appropriate to complete an assessment. The DON stated in her job she reviewed incidents/accident reports, but no one reviewed CR#2's incident/accidents. The DON stated she reviews assessments, and care plans weekly and as needed. She reviewed CR#2's Care plan but she did not recall when she did the review. The DON stated when she reviews care plans she looks for any changes residents have, ensure their initial care plan was completed, and add anything a specific resident needed personalized. In an interview on 9/28/23 at 12:15 p.m. with Clinical Market Leader she stated the IDT team looks at incidents/accidents but if CR#2 was not documented it would not have triggered. She stated someone should have reported the incidents to them. She stated the staff should have told them about the Shampoo incident and that she had no clue. She stated the staff are aware when to involve their clinical resource and the staff were aware they should have informed them when something would arise to a reportable. She stated if the staff do not know what to do, they should make a phone call and they also have what to include when reporting. Clinical Market Leader said she has been getting the same things the State Surveyors have been getting where the facility staff were not giving her all the information and they have been giving 1 piece here and 1 piece there. In an interview on 9/28/23 at 12:50 p.m. with the Administrator and DON, the Administrator stated they educated themselves and they were looking at how can they do a thorough investigation, and what questions they need to ask. In an interview with ADON B on 9/29/23 at 8:55 AM, she said she was familiar with CR#2. She said CR#2 was a resident on the hall she was responsible for. She said she entered CR#2's order into his electronic health record upon his admission to the facility. She said CR#2 used his wheelchair most of the time when he was not in his bed. She said she believed LVN G completed an assessment on CR#2. She said when the resident got here, the resident had a poor appetite. She said CR#2's family member said since his other family member passed on the years before, his appetite had been poor since then. She said with regard to CR#2's increased pain, CR#2 already had pain in his shoulder. She said she could not speak to why the shoulder pain was not documented at the time of admission. ADON B said CR#2 did not want to participate in therapy. She said they spoke to the family and told CR#2 in order for him to go home, he had to complete therapy. She said CR#2 began participating in therapy and had increased pain, she said they attributed the increased pain to CR#2 now participating in therapy. ADON B said CR#2 was not doing therapy before, but now he was and they attributed the pain to increased activity via therapy. She said if CR#2's rotator cuff tear a new injury, she would report it, but the nurse practitioner said CR#2's injury was chronic. She said she spoke to the nurse practitioner. The ADON said an unwitnessed fall occurs when a staff finds a resident on the floor and no one knows how they fall, and the resident can't say how they fell. She said when a nurse was notified of an unwitnessed fall, they do neuro checks, head to toe assessments, pain assessments for 72 hours. She said if there are any abnormalities, they will notify the doctor. ADON said she did not have LVN G sign anything, or review anything after this. She said she just instructed LVN G to do an assessment on CR#2. She said she did not review LVN G's assessment or CR#2's electronic health record. The ADON said she was not aware CR#2 was prescribed and administered an anticoagulant medication. She said CR#2's care plan should have included the anticoagulant medication. She said if a resident was prescribed an anticoagulant and was reported to have an unwitnessed fall, she would treat the situation like a witnessed fall. She said the resident's doctor would need to be contacted, neuro checks and other assessments for 72 hours, and notify the RP. The ADON said a resident on anticoagulant medication not being assessed after unwitnessed fall was at risk of bleeding. The ADON said she was aware of CR#2's rotator cuff tear. She said the facility did an investigation into CR#2's injury, and according to x-ray results, the rotator cuff tear was a degenerative injury. She said they spoke to CR#2, and CR#2's family member. She said that was the investigation they did for CR#2's injury. The ADON said she did not document any of the conversations regarding the rotator cuff tear because she thought the DON had done it. She said none of the nurse's ever told the ADON CR#2 experiencing shoulder pain. She said the pain medication prescribed for CR#2 was for his hip. In an interview on 9/29/23 at 11:23 a.m. with the Orthopedic Physician he stated he saw CR#2 once on July 24, 2023 and CR#2 came in with his family member with right shoulder pain. He stated CR#2's family member told the physician CR#2 fell and had a vertebral fracture and was unable to move his wheelchair. The Physician stated the bars on his wheelchair obstructed any view of the shoulder so he could not get the x-rays. The Orthopedic physician stated CR#2 was weak on all rotator cuff testing and two days ago, the Clinical Market Leader called from the facility saying, how did you diagnose a rotator cuff tear with acute x-rays. He stated the Clinical Market Leader sent a one view x-ray and it was hard to tell anything on one view that was a one-dimensional structure. He stated he needed more info from CR#2 and additional views. The Physician stated CR#2's rotator cuff was fully torn, or he could have had 2 fibers hanging on and then it broke eventually. He stated CR#2 did not complain of an injury, just increased shoulder pain. The Orthopedic physician stated if the rotator cuff was fully torn it could not become more torn, but if CR#2 had further injury like a fall it could have completely torn. The physician stated he was unable to examine CR#2's shoulder more because of the patient's (CR#2's) condition. The physician stated CR#2 had not had the shoulder pain initially, he did not know if the patient (CR#2) fell or if transferring him or moving him improperly could have caused the rotator cuff to completely tear. He stated it was hard to say definitively the reason for the rotator cuff tear. He stated it was hard because if CR#2 had a fracture it would be healed by now, but rotator cuff's once torn completely do not just repair. The Orthopedic physician stated if CR#2 did not have issues with his shoulder before it was not all the way torn, but he could not say if it happened in the facility, or if it happened in the hospital. He stated CR#2's condition was chronic and long standing but it does not mean his symptoms were chronic and longstanding. The Physician stated if CR#2 was asymptomatic before did not mean he did not have the problem and just because the problem occurred did not mean it existed before. He stated if CR#2 did have the condition before a fall, a fall undoubtedly can reinjure and could cause significant injury. He stated it was impossible to say how long CR#2 had it and chronic was longer than 3 months. He stated the x-rays were from a while back, but it did not mean CR#2 did not injure himself due to falling, it absolutely could have happened from a fall or mistreatment. CR#4 Record review of CR #4's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. He was diagnosed with chronic obstructive pulmonary disease (constriction of airways and difficulty breathing), acute kidney failure (kidney unable to filter waste), non-St elevation (NSTEMI) myocardial infarction (partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart), atherosclerotic heart disease (narrows the arteries close to your heart), type 2 diabetes with diabetic neuropathy (high blood sugar with type of nerve damage mostly affects legs and feet), need for assistance with personal care, unsteadiness on feet, muscle weakness, lack of coordination, insomnia (difficulty sleeping), pleural effusion (water on the lungs), mild cognitive impairment, radiculopathy of cervical region (pinched nerve), major depressive disorder, anemia (low red blood cells), chronic pain syndrome, heart failure (heart muscle unable to pump blood), respiratory failure (not enough oxygen in the tissue in your body or when you have too much carbon dioxide in your blood), rectal abscess (collection of pus from an infection near the anus), gastrointestinal hemorrhage (bleeding in your digestive tract), obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), and difficulty walking. Record review of CR #4's Care Plan dated 1/16/23 revealed CR#4 was found at risk for impaired thought processes r/t mild cognitive impairment of uncertain or unknown etiology with interventions as engage in simple, structured activities that avoid overly demanding tasks, Give step by step instructions one at a time as needed to support cognitive function, Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. CR#4 also had potential for mood problem r/t mild cognitive impairment of uncertain or unknown etiology with interventions to assist to identify strengths, positive coping skills and reinforce these. CR#4 was identified for preferring to stay in room, has no interest in activities with interventions as establish and record prior level of activity involvement and interests by talking with resident, caregivers and family on admission and as necessary, explain the importance of social interaction and leisure activity time. Encourage participation by next review. CR#4 was also found to be at risk for impaired visiual function related to glaucoma . Record review of CR #4's Quarterly MDS assessment dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 10 indicating moderate impaired cognition. CR#4's functional status revealed walk in room and corridor did not occur, locomotion on/off the unit only occurred once or twice with person assisting, transfer only happened once or twice with the assistance of 2 staff, bed mobility and toilet use were extensive assistance with one person assisting. Bathing self performance was found to be activity itself did not occur. CR#4 required substantial/maximal assistance for toileting, upper and lower body dressing and was dependent for shower/bathing self and putting on/taking off footwear. CR#4 was found to have occasional pain. Record review of CR#4's Nurse notes dated 7/1/23 at 6:33 p.m. by LVN I revealed, Around 5 p.m. staff reported, while bathing resident he placed a cup on table with soap in it, about 30cc. Resident drank the soap. He stated he thought it was his medicine. Resident alert and oriented x 4, no distress noted. No complaint of pain or discomfort NP was notified, monitor Patient. DON was notified by message. Call light was in reach. Record review of CR#4's Nurse Notes dated 7/2/2023 at 12:33 p.m. by LVN I revealed, Complained of upset stomach, nausea, and cannot move bowels. Alert and oriented x 4, .Called team Health, spoke with NP. Give enema, rectal, gave Zofran as ordered. Record review of CR#4's Clinical records did not reveal an incident report. Record review of CR#4's Clinical records did not reveal neuro checks. In an interview with ADON A on 09/14/23 at 12:00 PM, she said the CNA took CR#4 to take a shower and there was soap in a medication cup. She said she did not recall seeing an incident report. In an interview on 09/14/23 at 1:42 PM with the DON she stated she was aware of the incident in July 2023 with CR#4. The DON stated she was told that a CNA was giving CR#4 a shower and CR#4 drank shampoo. The DON stated she believed CR#4's nurse informed her of the incident, but she was not sure. The DON stated the CNA poured shampoo from the bottle into a medicine cup to use on CR#4 during the shower. She stated it was about 30 cc's worth of shampoo in the cup, and CR#4 drank it all. The DON stated she could not recall who the CNA was. She stated she did not report the incident to the State and she did not know why the incident was not reported. The DON stated after the incident, the CNA was in-serviced, but there was no disciplinary action as a result of the incident. She stated she would look for documents related to CR#4's incident and provide them to the State Surveyors. In an interview with the Administrator on 09/21/23 at 5:40 PM, he said he was made aware of the incident with the shampoo after being informed by the DON a few days ago. He said the facility addressed the concern at the time the incident occurred. The Administrator stated the CNA involved in the incident did receive disciplinary action as a result of the incident. He stated the CNA no longer worked at the facility. The Administrator stated after learning about the incident, he reviewed all the information and discussed the incident with the facility's Clinical Resource. He stated the incident had not been reported to HHSC. He said he was not intending to report the incident to HHSC. He said based on the feedback from the Clinical Resource, the facility determined this incident did not meet the criteria to report to HHSC. The Administrator stated he was not aware documentation regarding this incident had been requested from the DON on 09/14/23. He stated he would have the DON email all documents to the State Surveyor. In an interview with the Facility MD on 09/27/23 at 12:52 PM, she said stated the incident should have been reported to poison control and poison control would have been able to tell them what they needed to do for CR#4. The Facility MD stated gastro intestinal concerns, vomiting, and nausea may be symptoms someone could have. She stated if a resident ingested shampoo, they should contact the doctor and call poison control. In an interview on 9/28/23 at 10:58 a.m. with the Clinical Market Leader she stated she found out about CR#4 who drank shampoo recently and the facility did not report it. She stated the Administrator said notification was done to CAC and physician. The Clinical Market Leader stated they were told to continue monitoring. She stated the CNA was giving a bed bath to CR#4, and it was soap and the CNA turned away CR#4. The Clinical Market Leader stated the Nurse assessed CR#4 and contacted CR#4's physician. She stated CR#4 went to hospital on 7/2/23 related to chest pain. She stated the days following the shampoo incident CR#4 had chronic abdominal issues prior to this and they contacted CR#4's physician. The Clinical Market Leader stated the facility did not contact poison control. In an interview on 9/29/23 at 1:55 p.m. with RN B she stated she heard about CR#4 swallowing shampoo, and he was her long term care resident. She learned about CR#4's situation after he was discharged . She stated she did not know about him swallowing shampoo when it happened. In an interview on 9/29/23 at 2:22 p.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 resident (CR#2) of 12 residents reviewed for quality of care. The facility failed update CR #2's comprehensive care plan after CR#2 was diagnosed with torn rotator cuff. This failure placed residents at risk of not receiving needed care and services to meet the resident's physical, mental, and psychosocial needs. Findings include: Record review of CR #2's face sheet was an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with metabolic encephalopathy, elevated white blood cell count, pure hypercholesterolemia, hypertensive heart disease, chronic atrial fibrillation, acute respiratory failure with hypoxia and hypercapnia, muscle weakness, dysphagia-oropharyngeal phase, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, systemic inflammatory response syndrome, and need for assistance with personal care. Record review of CR #2's Care Plan dated 7/5/23 revealed CR#2 was at risk for impaired thought processes r/t cognitive communication deficit with interventions to give step by step instructions one at a time as needed to support cognitive function and keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. CR#2 was found to have ADL self care performance deficit r/t limited mobility, impaired balance, pain, limited range of motion, and required assistance with bed positioning, eating and dressing. CR #2 was found to be at risk for falls r/t deconditioning, gait/balance problems, incontinence with interventions to be sure the call light is within reach and encourage to use it to call for assistance as needed and keep needed items, water, etc., in reach. CR#2 had antidepressant medication use r/t poor nutrition with interventions to educate resident, family/caregivers about risks, benefits and the side effects of medication, give anti depressant medications ordered by physician, monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations, sedation, drowsiness, blurred vision, muscle tremor, agitation, rash, weight loss or weight gain, monitor for adverse side effects of antidepressant appetite changes, blurry vision, constipation ., observe for signs and symptoms of following: confusion, mood change, change in normal behavior, hallucinations/delusions, social isolation, suicidal ideations, withdrawal, decline in ability to help with/do ADLs, continence, cognitive function, shuffle gait, rigid muscles difficult ambulation, balance problems, accidents, dizziness/vertigo, falls, movement problems, tremors .CR#2 had acute/chronic general pain with interventions as pain assessment every shift. Record review of CR#2's Care plan revealed no updates were made to CR#2's care plan after the discovery of his rotator cuff tear. Record review of CR #2's admission MDS assessment dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 9 indicating moderately impaired cognition. CR#2's functional status revealed walking in room and corridor only occurred once or twice in the last 7 days with 1 person assisting. Bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene were extensive assistance with one person assisting. Record of CR#2's physician orders revealed: Date 7/11/23 X-ray of Thoracic Spine to rule out osteomyelitis Date 7/11/23 Blood Cultures x2 sets Date 6/29/23 CBC, BMP, UA C&S one time only for 1 day Date 6/30/23 Chest x-ray 2 views one time only for 1 day Date 7/18/23 Right shoulder x-ray one time only for 1 day Date 7/10/23 UACnS, CBC/BMP order status discontinued Date 8/2/23 Blood sugar checks every 12 hours for diabetes mellitus. Date 8/22/23 Discharge to Hospital Date 8/17/23 May use ¼ bed side rails for positioning and ease in mobility as an enabler Date 6/27/23 Monitor & assess level of pain using the 0-10 scale: 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain every sift for monitoring. Date 6/27/23 Monitor and report to MD immediately any signs and symptoms of unusual bleeding, pale skin, weakness, black/tarry stools, head injury r/t fall/trauma as needed. Date 6/27/23 O.T. to evaluate and Treat as indicated. Date 6/27/23 P.T. to evaluate and treat as indicated. Date 7/27/23 Perform head to toe skin check, assess all areas of skin every week on Thursday day shift every day shift Thursday, document under assessment tab in residents chart (LN-skin evaluation) Date 7/18/23 Refer to orthopedic. Date 7/19/23Orthopedic appointment on 7/24/23 @ 1:45 p.m. (please print x-ray results to go with appt) one time only for 1 day Date 6/27/23 Acetylcysteine Inhalation Solution 20 % (Acetylcysteine) 4 milliliter inhale orally two times a day for cough Date 6/27/23 Albuterol Sulfate Nebulization Solution 2.5 MG/0.5ML 3 ml inhale orally via nebulizer every 6 hours as needed for Wheezing Date 6/27/23 Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure Hold if HR < 60bpm. Date 6/27/23 Docusate Sodium Capsule 100 MG Give 1 capsule by mouth two times a day for bowel care Date 6/27/23 Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for ANTICOAGULANTS. Date 6/27/23 Humalog Kwik Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 200 - 250 = 2; 251 - 300 = 4; 301 - 350 = 6; 351 - 400 = 8, subcutaneously before meals for diabetes Date 8/2/23 Humalog Kwik Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 200 - 250 = 2; 251 - 300 = 4; 301 - 350= 6; 351 - 400 = 8, subcutaneously every 12 hours for diabetes Date 7/10/23 Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Pain in the lower extremities Date 6/27/23 Lidoderm Patch 5 % (Lidocaine) Apply to per additional directions topically in the morning for Pain and remove per schedule Date 7/7/23 Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for Appetite Loss Date 6/27/23 Naphazoline-Pheniramine Ophthalmic Solution 0.025-0.3 % (Naphazoline w/ Pheniramine) Instill 1 drop in both eyes every 24 hours as needed for allergy Date 6/27/23 Ondansetron HCl Tablet 4 MG Give 1 tablet by mouth every 8 hours as needed for Nausea and Vomiting Date 6/27/23 Thiamine Mononitrate Oral Tablet 100 MG (Thiamine Mononitrate) Give 1 tablet by mouth one time a day for supplement. Date 6/29/23 Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain. Date 8/10/23 Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) Apply to hands and shoulder topically every 6 hours as needed for pain. Record review of CR #2's Fall Risk Evaluation dated on 6/27/23 by RN C revealed CR#2 was disoriented x 1, no falls in past 3 months, regularly incontinent, vision status was adequate, balance problem while standing/walking, no noted drop in systolic blood pressure between lying and standing and CR#2 had taken 1-2 of the following types of medications within last 7 days: Anesthetics, Antihistamines, Antihypertensive, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemic, Narcotics, Psychoactive Meds, Sedatives /Hypnotics. Record review of CR#2's Medication Administration Record for June 2023 revealed: Monitor & Assess level of pain using the 0-10 SCALE: 0=NO PAIN, 1-3=MILD PAIN, 4-6=MODERATE PAIN, 7-10=SEVERE PAIN every shift for monitoring the pain was 0 on 6/28/23, 6/29/23, 6/30/23 for both shifts. MONITOR and REPORT TO MD IMMEDIATELY ANY S/S OF UNUSUAL BLEEDING, PALE SKIN, WEAKNESS, BLACK/TARRY STOOLS, HEAD INJURY R/T FALL/TRAUMA as needed was left blank on 6/27/23-6/30/23. Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain revealed on 6/29/23 was left blank and 6/30/23 the pain was at level 4 and medication was administered. Eliquis Oral tablet 5 mg (Apixaban) give 1 tablet by mouth two times a day for anticoagulants was administered. Record review of CR#2's Medication Administration Record for July 2023 revealed: Lidoderm Patch 5% (Lidocaine) apply to per additional directions topically in the morning for pain and remove per schedule revealed CR#2 had pain on 7/1/23 at level 1, 7/19/23 at level 1, 7/20/23 at level 1 and 7/28/23 at level 1. Medication was administered. Eliquis Oral tablet 5 mg (Apixaban) give 1 tablet by mouth two times a day for anticoagulants was administered. Monitor & Assess level of pain using the 0-10 SCALE: 0=NO PAIN, 1-3=MILD PAIN, 4-6=MODERATE PAIN, 7-10=SEVERE PAIN every shift for monitoring the pain was 0 on 6/28/23, 6/29/23, 6/30/23 for both shifts revealed CR#2 had pain level of 4 on 7/11/23 on the evening shift, level 4 on 7/14/23 on the evening shift, level 2 on 7/17/23 on the morning shift, level 3 on 7/18/23 on the morning shift, level 2 on 7/19/23 on the morning shift, level 6 on 7/26/23 on the morning shift. Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain revealed on 7/4/23 the pain level was 7, on 7/17/23 the pain level was 8, on 7/19/23 the pain level was 8, on 7/23/23 the pain level was 6, on 7/25/23 the pain level was 4 and 7/26/23 the pain level was 6. Record review of CR#2's Pulmonary Consult Note dated 6/28/23 by physician revealed CR#2 had generalized weakness, no abdominal pain .alert, lethargic, follows commands .no distress . Record review of CR#2's Progress note dated 6/29/23 by NP revealed On examination this morning, seen and examined seated in chair awake alert and oriented, he denies any distress or discomfort although minimally verbal. Labs noted to have leukocytosis of seventeen thousand for which UA C&S, CBC and chest x-ray have been ordered and he has been empirically placed on ceftriaxone pending current interventions .Weakness generalized: Patient to participate in PT/OT. Fall precautions. Record review of CR#2's NP Progress note dated 7/3/23 revealed Today patient (CR#2) is seen and examined in chair seated awake alert and oriented, he denies any distress or discomfort at my time of examination Record review of CR#2's Physician Progress note dated 7/13/23 revealed He (CR#2) is seen in his room today, he is well-appearing, he denies pain. He has had weight loss over the past month and has lost about 5%. Per speech therapy he is contact-guard assist for feeding and is on a mechanical soft diet. He continues to do well with therapy, minimal assist for bed mobility, moderate assist for transfers unable to ambulate with his walker .Max assist with toileting, able to ambulate 10 feet with 2 wheeled walker. Record review of CR#2's Progress notes dated 7/15/23 at 9:56 a.m. written by LVN H revealed Resident (CR#2) is alert, oriented x 2 no active symptoms or treatments effecting level of consciousness, cognition, sleep, mood, or behavior. Cognitive symptoms described as weak & limited range of motion, 1 person assist for ADL care, wheelchair for locomotion when out of bed. Record review of CR#2's Progress notes dated 7/16/23 at 11:32 a.m. written by LVN H revealed Resident (CR#2) is alert, oriented x 2 no active symptoms or treatments effecting level of consciousness, cognition, sleep, mood, or behavior. Cognitive symptoms described as alert, oriented to person, sometimes needs cues, staff to anticipate needs at times. Musculoskeletal: Observations of ROM, ADL care, locomotion, assistive device use are weak & limited ROM, 1 person assist for ADL care, wheelchair for locomotion when out of bed. No musculoskeletal changes observed. Skilled rehab services: Physical therapy Skilled rehab services: Occupational Therapy other observations and interventions include currently working with therapy to progress to goals. Record review of CR#2's Radiology Results Report dated 7/18/23 revealed Shoulder X-ray complete 2 or more views, significant findings No fracture or dislocation. Impression: Rotator cuff tear. Degenerative changes. Record review of CR#2's Psychiatric Initial assessment dated [DATE] revealed This patient (CR#2) was referred for Depression, Confusion. Today on exam:-In chair, poor eye contact, gave brief, incomplete and unreliable answers to specific questions. Record review of Nurse note dated 7/18/23 at 10:58 a.m. written by LVN G revealed Resident is alert, oriented x 2 no active symptoms or treatments effecting level of consciousness, cognition, sleep, mood or behavior. Cognitive symptoms described as slow to answer verbally. Occasionally forgetful .transfer: self-performance Limited assistance, transfer- support provided: one person physical assistance. Record review of Nurse note dated 7/18/23 at 6:48 p.m. written by LVN G revealed Right shoulder x-ray results sent to NP. NP informed this writer that he needs to be seen by orthopedic. This writer informed CR#2's family member via telephone. Record review of Nurse note dated 7/18/23 at 7:06 p.m. written by LVN G revealed Type Change in Condition. Change in Condition: symptoms or signs of condition change: Functional decline (worsening function and/or mobility) Other change in condition pain to right shoulder. Reported to primary care clinician: NP on 7/18/23 at 6 p.m., CR#2's family member notified 7/18/23 at 6 p.m. Record review of Nurse note dated 7/19/23 at 10:39 a.m. written by LVN G revealed Pain: Yes, Pain level 8- 7/19/23 at 10:39 a.m. pain scale numerical. Pain originates from rotator cuff tear located at right shoulder described as frequent sharp pain nonpharmaceutical interventions include being at rest .Cognition is alert, oriented x 2 no active symptoms or treatments effecting level of consciousness, cognition, sleep, mood or behavior. Cognitive symptoms described as slow to answer verbally. Occasionally forgetful. Record review of CR#2's Progress note dated 7/19/23 by NP revealed Resident (CR#2) is seen and examined in bed, he is awake alert and oriented, he denies any distress or discomfort at my time of examination. Patient had pain to right shoulder which x-ray was positive for rotator cuff tear for which Orthopedic appointment has been placed for 7/24/23. He has otherwise not had any other acute change in condition. Record review of CR#2's Daily Skilled Note dated 7/20/23 at 5:34 p.m. written by LVN B revealed Musculoskeletal: Observations of ROM, ADL care, locomotion, assistive device use are weak &limited ROM, 1 person assist for ADL care, wheelchair for locomotion when out of bed. No musculoskeletal changes observed . In an interview with LVN G on 09/25/23 at 12:25 PM, she said she contacted CR#2's nurse practitioner to order an x-ray of the resident's shoulder because he was always complained about shoulder pain. She said she contacted CR#2's responsible party when the x-ray results returned diagnosing the resident with a torn rotator cuff. She said she did not remember what she told the responsible party what the reason for the x-ray was. She said a torn rotator cuff could be caused from overstraining the arm and muscle, or pushing down or applying too much weight on a surface. In an interview on 9/14/23 at 10:15 a.m. with CR#2's family member, she said CR#2 moved into the facility in June 2023. CR#2's family member stated around mid-July 2023 (unknown date), the family member received a phone call from LVN G informing her the resident had a fractured rotator cuff. She said LVN G told her the resident was complaining of pain in his shoulder. In an interview with PT A on 09/25/23 at 1:20 PM, she said any time she became aware of an incident with a resident, she was supposed to report it to the resident's nurse immediately. She said she did not know if the nurse assessed CR#2. She said CR#2 made increasing complaints of pain in his shoulder. She said the reason an x-ray was ordered for CR#2 was due to his increasing complaints of pain. She said she did not know who ordered the x-ray to be performed on CR#2. In an interview with LVN G on 09/25/23 at 1:48 PM, she said she did not know whether CR#2 was assessed by another staff. She said CR#2 complained about pain from the time he was admitted to the facility, until he was discharged . She said CR#2 suffered from chronic pain and was prescribed Tylenol as a PRN medication for pain. She said any time CR#2 complained about pain, she documented the information on CR#2's MAR progress notes at the time she administered pain medication to CR#2. She said she did not know why she could not locate any notes related to complaints of pain from CR#2 on his June, July and August 2023 MAR's. She said she was trained to document the resident's level of pain by asking the resident to identify their pain on a scale of 1-10, and whether the pain was radiating or not. She said if she performed an assessment, she would have documented it in their system. She said she contacted CR#2's NP to get an x-ray order of CR#2's left shoulder because CR#2 began making increased complaints of pain to his left shoulder. She said she probably could have documented CR#2's complaints of pain better. In an interview with the Facility MD on 09/27/23 at 12:52 PM, she said she was familiar with CR#2. She said the first time she assessed CR#2 was on 06/28/23. She said she saw CR#2 on 07/13/23 and CR#2 was not able to ambulate using his walker. She said she could not remember whether she noted whether CR#2 was able to ambulate. She said she noted CR#2 to be a minimum assist in bed and CR#2 could only take 10 steps with his walker. She said she never received any alerts from staff regarding pain to the shoulder. She said CR#2 was receiving skilled nursing services, so she was seeing him every week. She said CR#2 complained about pain every time she saw him. She said she decided to order the xray because CR#2 was complaining about shoulder pain. The MD said CR#2's x-ray results show a torn rotator cuff. The MD stated most rotator cuff injuries were more common in painters and tennis players. She said a rotator cuff tear was not typically an injury that could be sustained from one single movement. She said rotator cuff tears were the result of repeated motion of the arms. She said the reason she did not get a full history on CR#2, in regard to how he could've sustained the rotator cuff tear was because he was at the facility for skilled nursing. She said while CR #2 was under her care, she was seeing him on a weekly basis because he was receiving skilled nursing services. She said she prescribed the Voltaren Gel on 8/10/23 after CR#2 complained of pain in his shoulder and hands during her weekly assessment. She said she preferred not to prescribe narcotic medication for pain when it was possible. In an interview with the MDS Nurse on 09/27/23 at 1:50 PM, she said when she completed CR#2's care plan, she goes over ever complete diagnoses, psychotropics. She said she was not sure as to why there was a breakdown in the system in having the resident's care plan updated. She said she did not remember hearing anything about CR#2 having a rotator cuff tear in the staff morning meetings. She said if the issue was acute or had to do with a medication, the nurse would be responsible for updating the care plan. She said she is typically swamped, so the nurse would assist. The MDS nurse said the RN F was responsible for psychotropics, the treatment nurse does wounds and anything triggered for ADL, hydration, constipation, incontinence she does and the DON does the falls. In an interview on 9/26/23 at 1:30 p.m. with the DON, she said she was aware of the shoulder injury to CR#2. He has a chronic issue of shoulder pain, and she said he came from a different facility and had a fall at that facility. CR#2 also had a fall at home prior to that. He was complaining of pain in the shoulder and the x-ray showed rotator cuff injury. He was sent to ortho and ortho said it was chronic. She stated the CR#2 was admitted with the injury. She referred to miscellaneous documents in the electronic file. Surveyor and DON looked together and there was no mention of the injury in the documents DON stated was there. CR#2 was on pain management already. Surveyor and DON reviewed the clinical file and discovered the pain management was for his back. She stated that she found out about the injury after admission. He was given x ray order for shoulder pain. He was complaining more of shoulder pain. DON stated that just because he had increased shoulder pain did not mean this was an injury of unknown origin or was a new injury. She stated that her and the NP had a discussion about situation (injury). She said NP was within the same group as the other facility, possibly. DON stated that she does not know for sure but believes NP was seeing CR#2 before. DON confirmed with surveyor that CR#2 was not care planned for rotator cuff injury and that CR#2 was a fall risk upon admission. She doesn't recall looking at assessments, She did not assess CR#2. She said based on the policy she supposes it would be an injury of unknown origin. The Administrator is aware at this point. But at the time of incident it was talked about in the morning meeting. She said she is capable of reporting incidents. If another staff came to her about a resident having a fall the expectation is to assess the resident. Nueros would be initiated for unwitnessed falls. It would be herself or the ADON who are on the hall to oversee the documentation and ensure it was done. Care plan should be updated. Interventions he had were working, he would put the light on and they would check on him. In an Interview with Administrator and Clinical Market Leader on 9/28/23 at 10:58 a.m. she stated they recently looked at CR#2's previous hospital records before coming to their facility and found CR#2 had arm swelling, but it did not say right or left and the hospital completed a doppler for DVT (Deep vein thrombosis) and it was ruled out. She stated CR#2 had a fall prior to being discharged going to another Nursing facility CR#2 went home and went to a hospital. She stated the facility did not have hospital records that show CR#2 had rotator cuff injury and the facility did not have any other records. The Administrator stated the facility did reach out to CR#2's previous Nursing facility to get CR#2's paperwork and they did speak with the NP and that is when x-ray was done. The Administrator stated CR#2's family member said the rotator cuff tear was a longstanding issue. The Administrator stated when the NP gave CR#2 the order for an x-ray he was not aware that CR#2 had increased pain. She stated CR#2 came into the facility with right shoulder pain, but the facility assumed therapy would help but it did not help it. She stated CR#2 started not participating in therapy so NP gave order to give CR#2 an x-ray. In an interview on 9/28/23 at 11:20 a.m. with the DON, the Administrator and Clinical Market Leader she stated she would report the allegations about CR#2's injury of unknown origin to the State, and based on their own evidence she would do an investigation and an assessment. Clinical Market Leader stated a visual or staff looking at CR#2 was not appropriate to complete an assessment. The DON stated in her job she reviewed incidents/accident reports, but no one reviewed CR#2's incident/accidents. The DON stated she reviews assessments, and care plans weekly and as needed. She reviewed CR#2's Care plan but she did not recall when she did the review. The DON stated when she reviews care plans she looks for any changes residents have, ensure their initial care plan was completed, and add anything a specific resident needed personalized. In an interview with ADON B on 9/29/23 at 8:55 AM, she said she was familiar with CR#2. She said CR#2 was a resident on the hall she was responsible for. She said she entered CR#2's order into his electronic health record upon his admission to the facility. She said CR#2 used his wheelchair most of the time when he was not in his bed. She said she believed LVN G completed an assessment on CR#2. She said when the resident got here, the resident had a poor appetite. She said CR#2's family member said since his other family member passed on the years before, his appetite had been poor since then. She said with regard to CR#2's increased pain, CR#2 already had pain in his shoulder. She said she could not speak to why the shoulder pain was not documented at the time of admission. ADON B said CR#2 did not want to participate in therapy. She said they spoke to the family and told CR#2 in order for him to go home, he had to complete therapy. She said CR#2 began participating in therapy and had increased pain, she said they attributed the increased pain to CR#2 now participating in therapy. ADON B said CR#2 was not doing therapy before, but now he was and they attributed the pain to increased activity via therapy. She said if CR#2's rotator cuff tear a new injury, she would report it, but the nurse practitioner said CR#2's injury was chronic. She said she spoke to the nurse practitioner. The ADON said she was aware of CR#2's rotator cuff tear. She said the facility did an investigation into CR#2's injury, and according to x-ray results, the rotator cuff tear was a degenerative injury. She said they spoke to CR#2, and CR#2's family member. The ADON said she did not document any of the conversations regarding the rotator cuff tear because she thought the DON had done it. She said none of the nurse's ever told the ADON CR#2 experiencing shoulder pain. She said the pain medication prescribed for CR#2 was for his hip. In an interview on 9/29/23 at 11:23 a.m. with the Orthopedic Physician he stated he saw CR#2 once on July 24, 2023 and CR#2 came in with his family member with right shoulder pain. He stated CR#2's family member told the physician CR#2 fell and had a vertebral fracture and was unable to move his wheelchair. The Physician stated the bars on his wheelchair obstructed any view of the shoulder so he could not get the x-rays. The Orthopedic physician stated CR#2 was weak on all rotator cuff testing and two days ago, the Clinical Market Leader called from the facility saying, how did you diagnose a rotator cuff tear with acute x-rays. He stated the Clinical Market Leader sent a one view x-ray and it was hard to tell anything on one view that was a one-dimensional structure. He stated he needed more info from CR#2 and additional views. The Physician stated CR#2's rotator cuff was fully torn, or he could have had 2 fibers hanging on and then it broke eventually. He stated CR#2 did not complain of an injury, just increased shoulder pain. The Orthopedic physician stated if the rotator cuff was fully torn it could not become more torn, but if CR#2 had further injury like a fall it could have completely torn. The physician stated he was unable to examine CR#2's shoulder more because of the patient's (CR#2's) condition. The physician stated CR#2 had not had the shoulder pain initially, he did not know if the patient (CR#2) fell or if transferring him or moving him improperly could have caused the rotator cuff to completely tear. He stated it was hard to say definitively the reason for the rotator cuff tear. He stated it was hard because if CR#2 had a fracture it would be healed by now, but rotator cuff's once torn completely do not just repair. The Orthopedic physician stated if CR#2 did not have issues with his shoulder before it was not all the way torn, but he could not say if it happened in the facility, or if it happened in the hospital. He stated CR#2's condition was chronic and long standing but it does not mean his symptoms were chronic and longstanding. The Physician stated if CR#2 was asymptomatic before did not mean he did not have the problem and just because the problem occurred did not mean it existed before. He stated if CR#2 did have the condition before a fall, a fall undoubtedly can reinjure and could cause significant injury. He stated it was impossible to say how long CR#2 had it and chronic was longer than 3 months. He stated the x-rays were from a while back, but it did not mean CR#2 did not injure himself due to falling, it absolutely could have happened from a fall or mistreatment. Record review of Facility Policy on Significant Change in Condition, Response under Quality of Care revised on 1/2022 revealed, It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): .Change in ability to or decline in physical function .Fall or other related incident, New complaints of pain or worsening pain .The Nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. The resident will then be placed on the 24 Hour Report and Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions Record review of Abuse: Prevention of and Prohibition Against, revealed the following: Revised on 10/22, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of Resident property, and exploitation the facility will provide oversight and monitoring to ensure that it's staff deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of Resident property, and exploitation. D. Prevention .assuring the residents are free from neglect by having the structures and processes to provide immediate care and services to all residents which includes but is not limited to the completion of a facility assessment to determine what resources are necessary to care for its residents competently

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (CR#4) of 12 residents reviewed for accidents, hazards, and supervision. The facility failed to adequately supervise CR#4 while giving him a shower using shampoo in an unlabeled medication cup. The facility failed to contact the physician after CR#4 drank shampoo The facility failed to contact poison control after drinking shampoo Findings include: Record review of CR #4's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. He was diagnosed with chronic obstructive pulmonary disease (constriction of airways and difficulty breathing), acute kidney failure (kidney unable to filter waste), non-St elevation (NSTEMI) myocardial infarction (partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart), atherosclerotic heart disease (narrows the arteries close to your heart), type 2 diabetes with diabetic neuropathy (high blood sugar with type of nerve damage mostly affects legs and feet), need for assistance with personal care, unsteadiness on feet, muscle weakness, lack of coordination, insomnia (difficulty sleeping), pleural effusion (water on the lungs), mild cognitive impairment, radiculopathy of cervical region (pinched nerve), major depressive disorder, anemia (low red blood cells), chronic pain syndrome, heart failure (heart muscle unable to pump blood), respiratory failure (not enough oxygen in the tissue in your body or when you have too much carbon dioxide in your blood), rectal abscess (collection of pus from an infection near the anus), gastrointestinal hemorrhage (bleeding in your digestive tract), obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), and difficulty walking. Record review of CR #4's Care Plan dated 1/16/23 revealed CR#4 was found at risk for impaired thought processes r/t mild cognitive impairment of uncertain or unknown etiology with interventions as engage in simple, structured activities that avoid overly demanding tasks, Give step by step instructions one at a time as needed to support cognitive function, Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. CR#4 also had potential for mood problem r/t mild cognitive impairment of uncertain or unknown etiology with interventions to assist to identify strengths, positive coping skills and reinforce these. CR#4 was identified for preferring to stay in room, has no interest in activities with interventions as establish and record prior level of activity involvement and interests by talking with resident, caregivers and family on admission and as necessary, explain the importance of social interaction and leisure activity time. Encourage participation by next review . Record review of CR #4's Quarterly MDS assessment dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 10 indicating moderate impaired cognition. CR#4's functional status revealed walk in room and corridor did not occur, locomotion on/off the unit only occurred once or twice with person assisting, transfer only happened once or twice with the assistance of 2 staff, bed mobility and toilet use were extensive assistance with one person assisting. Bathing self performance was found to be activity itself did not occur. CR#4 required substantial/maximal assistance for toileting, upper and lower body dressing and was dependent for shower/bathing self and putting on/taking off footwear. CR#4 was found to have occasional pain. Record review of CR#4's Nurse notes dated 7/1/23 at 6:33 p.m. by LVN I revealed, Around 5 p.m. staff reported, while bathing resident he placed a cup on table with soap in it, about 30cc. Resident drank the soap. He stated he thought it was his medicine. Resident alert and oriented x 4, no distress noted. No complaint of pain or discomfort NP was notified, monitor Patient. DON was notified by message. Call light was in reach. Record review of CR#4's Nurse Notes dated 7/2/2023 at 12:33 p.m. by LVN I revealed, Complained of upset stomach, nausea, and cannot move bowels. Alert and oriented x 4, .Called team Health, spoke with NP. Give enema, rectal, gave Zofran as ordered. Record review of CR#4's Clinical records did not reveal an incident report. Record review of CR#4's Clinical records did not reveal neuro checks. In an interview with ADON A on 09/14/23 at 12:00 PM, she said the CNA took CR#4 to take a shower and there was soap in a medication cup. She said she did not recall seeing an incident report. In an interview on 09/14/23 at 1:42 PM with the DON she stated she was aware of the incident in July 2023 with CR#4. The DON stated she was told that a CNA was giving CR#4 a shower and CR#4 drank shampoo. The DON stated she believed CR#4's nurse informed her of the incident, but she was not sure. The DON stated the CNA poured shampoo from the bottle into a medicine cup to use on CR#4 during the shower. She stated it was about 30 cc's worth of shampoo in the cup, and CR#4 drank it all. The DON stated she could not recall who the CNA was. She stated she did not report the incident to the State and she did not know why the incident was not reported. The DON stated after the incident, the CNA was in-serviced, but there was no disciplinary action as a result of the incident. She stated she would look for documents related to CR#4's incident and provide them to the State Surveyors. In an interview with the Administrator on 09/21/23 at 5:40 PM, he said he was made aware of the incident with the shampoo after being informed by the DON a few days ago. He said the facility addressed the concern at the time the incident occurred. The Administrator stated the CNA involved in the incident did receive disciplinary action as a result of the incident. He stated the CNA no longer worked at the facility. The Administrator stated after learning about the incident, he reviewed all the information and discussed the incident with the facility's Clinical Resource. He stated the incident had not been reported to HHSC. The Administrator stated he was not aware documentation regarding this incident had been requested from the DON on 09/14/23. He stated he would have the DON email all documents to the State Surveyor. In an interview with the Facility MD on 09/27/23 at 12:52 PM, she said stated the incident should have been reported to poison control and Poison control would have been able to tell them what they needed to do for CR#4. The Facility MD stated gastro intestinal concerns, vomiting, and nausea may be symptoms someone could have. She stated if a resident ingested shampoo, they should contact the doctor and call poison control. In an interview on 9/28/23 at 10:58 a.m. with the Clinical Market Leader she stated she found out about CR#4 who drank shampoo recently and the facility did not report it. She stated the Administrator said notification was done to CAC and physician. The Clinical Market Leader stated they were told to continue monitoring. She stated the CNA was giving a bed bath to CR#4, and it was soap and the CNA turned away CR#4. The Clinical Market Leader stated the Nurse assessed CR#4 and contacted CR#4's physician. She stated CR#4 went to hospital on 7/2/23 related to chest pain. She stated the days following the shampoo incident CR#4 had chronic abdominal issues prior to this and they contacted CR#4's physician. The Clinical Market Leader stated the facility did not contact poison control. In an interview on 9/29/23 at 1:55 p.m. with RN B she stated she heard about CR#4 swallowing shampoo, and he was her long term care resident She learned about CR#4's situation after he was discharged . She stated she did not know about him swallowing shampoo when it happened. In an interview on 9/29/23 at 2:22 p.m. ADON B she stated the shampoo was an unusual occurrence she would make sure the nurse documented it and she would assess the resident (CR#4) because shampoo is chemical and she would notify the DON and the Administrator and CR#4's family and the doctor. She stated she was not aware the incident happened. On Tuesday, 9/26/23 and learned State was in the building investigating shampoo on Monday, 9/25/23. She stated she was told that the CNA had shampoo on the bedside table and the CNA was giving care to CR#4 and CR#4 thought it was medicine and drank it. She stated she had no idea it happened, but if she were to be notified of an incident like that, she would expect the CNA to tell her when that happened. ADON B stated should she have been notified she would have completed an assessment, notified the Dr. and CR#4's family and the Administrator because it was an unusual occurrence. ADON B stated CR#4 should be monitored for several days after, notify the Dr. to ask what orders they want to be in place because CR#4 swallowed the shampoo, and they would have contacted poison control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to make prompt efforts to resolve grievances the resident may have for 1 (Resident #9) of 9 residents reviewed for grievances. The facility failed to - investigate Resident #9's claim of a missing $20 bill and a missing pajama set that was never returned from the laundry room. This failure could place residents at risk of unresolved grievances and diminished resident's quality of life. Findings included: Record review of Resident #9's face sheet dated 1/20/2023 revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included type 2 diabetes (condition where blood glucose levels are too high), hyperlipidemia (high blood cholesterol), and mood disorder (general emotional state or mood is disturbed or inconsistent with your circumstances and interferes with the ability to function). Record review of Resident #9's Comprehensive MDS dated [DATE] revealed Resident #9 had a BIMs score of 12 out of 15 indicating the resident's cognition was moderately impaired. The resident required extensive assistance with one-person physical assist with bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident required supervision to walk in room, to walk in corridor, and locomotion on unit. Record Review of Resident #9's Grievance Resolution Form dated 12/19/2022 reflected, R.P. stated the resident was missing her new eyeglasses. A search was done in the room; however, her eyeglasses could not be found. A new order for eyeglasses was placed by the facility from the store, recommended by the R.P. Observation and interview on 1/22/2023 at 10:28 a.m. revealed Resident #9 lying in bed. She said she was missing two new pair of pajamas that she sent to the laundry. She said they returned one pair of pajamas, but the other one was missing. She said they had been missing for two weeks. She said her eyeglasses and eyeglass case went missing on 12/19/22. She said she had $20.00 in her eyeglass case when her eyeglass case went missing. She said her eyeglasses and eyeglass case were returned, but the $20.00 bill was no longer in the eyeglass case. In a follow-up interview on 1/24/2023 at 1:00 p.m. with Resident #9, she said she went to the doctor's office and got a new pair of eyeglasses. She said the doctor gave her back the case. She said the maintenance man and a CNA were in her room the day her items went missing, and she believed one of them took her $20 bill. She said she had two pajama sets with her name written on the inside and one pair was found on another resident and they were returned to her. She said the other pair of pajamas were still missing. Interview on 1/24/2023 at 1:15 p.m. with MD2, he said he was aware of the incident and was in the room the day Resident #9 said her $20 bill went missing. He said he was in the room for about 10-12 minutes to fix a tube light on the B-side bed area. He said he was not on Resident #9's side of the room. MD2 denied touching Resident #9's eyeglass case. Interview on 1/24/2023 at 1:17 p.m. with SW, she said she had a grievance form concerning a pair of eyeglasses that were reported missing. She said there was nothing reported or investigated regarding Resident #9's missing $20 bill. She said the grievance regarding the missing eyeglasses was reported on 12/19/2022. Interview on 1/24/2023 at 1:23 p.m. with the LVN supervisor, she said whatever Resident #9's family reported that the day of the incident of the missing glasses, is what she put on the grievance form. She said if Resident #9's family complained about money missing then it wasn't on the same day. She said today is the first time hearing about the money not being handled. She said she heard staff talking about the missing twenty-dollar bill it a week ago. She said the Social Worker was responsible for investigating the incident. In a follow-up Interview on 1/24/2023 at 2:07 p.m. with SW, she said nothing was reported to her regarding Resident #9's missing pajamas. She said she received a report about a few dresses that went missing, and the facility replaced those dresses. She said the CNA's, residents, and their family's reported issues and problems to her, and she was responsible for investigating those issues. She said the facility reimbursed Resident #9 for her missing $20.00 bill today. She said she notified Resident #9's family member regarding the reimbursement of Resident #9's missing $20 bill. In a follow-up interview on 1/24/2023 at 2:20 p.m. with Resident #9, she said her pajamas went missing on 12/16/22. She said she reported the incident to the CNA, and the CNA reported it to another staff member. She said she was missing a pair of paints and a grey shirt with white sleeves. Interview on 1/24/2023 at 2:25 p.m. with the LVN supervisor, he said today was the first time hearing about Resident #9 missing pajamas. She said the CNA reported the incidents to the charge nurse. Record Review of the facility's policy titled Grievances revised on 11/23/2016 read in part . it is the policy of this facility to establish a grievance process to make prompt efforts to resolve grievances the resident may have. The facility's grievance official is responsible for overseeing the grievance process receiving and tracking grievances; leading necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested; and coordinating with state and federal agencies if necessary. Grievance official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property to the administrator; and as required by State law .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility for one resident (Resident #1) of four residents reviewed for discharge. -The facility documented intent to discharge Resident #1 to a women's shelter that did not provide the assistance the resident required. -Although Resident #1 was not yet discharged due to a pending appeal decision, the facility documentation reflected the resident would be discharged to the shelter if the RP lost the appeal. The deficient practice placed the resident at risk for not receiving basic care required for her healthcare needs. Findings include: Record review of the admission Record dated 01/04/2023 revealed Resident #1 was an [AGE] year old female and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, fracture of left femur (upper leg bone), cognitive communication deficit, muscle weakness, and lack of coordination. Record review of the MDS dated [DATE] for Resident #1 revealed she scored 3 of 15 on the BIMS, indicative of severely impaired cognition. The MDS reflected the resident required extensive assistance from one person for bed mobility, transfers, dressing, and personal hygiene. She was not able to walk. The MDS reflected the resident was at risk for developing pressure ulcers. The resident was incontinent of bowel and bladder. Record review of the Care Plan for Resident #1 (revised 04/18/2022) revealed the resident required staff assistance with toilet use, repositioning in bed, bathing, bed mobility, personal hygiene, eating, and transferring. Record review of the Care Plan for Resident #1 (revised 07/06/2022) revealed the resident wished to return to her home upon discharge. An intervention was Make arrangements with required community resources to support independence post-discharge (SPECIFY: homes [sic] care, PT, OT, MD, Wound Nurse). Record review of the Notice of Proposed Transfer/discharge date d 10/25/2022 for Resident #1 revealed the resident was going to be discharged to a women's shelter. The Notice was signed by the facility's Executive Director. Record review of the Physician's Order dated 11/29/2022 at 9:58 a.m. revealed Resident #1 was to be discharged home. The order did not reflect the resident was to be discharged to a shelter. Interview on 01/04/2023 at 8:52 a.m. with the Ombudsman revealed an appeal hearing was conducted on 12/28/2022 , and all parties were awaiting a decision. Observation on 01/04/2023 at 10:00 a.m. revealed Resident #1 was in her room. She was sitting in a wheelchair. She responded to a verbal greeting but did not answer any questions. Interview on 01/04/2023 at 11:09 a.m. with BOM A revealed she said the 30-day discharge letter was a form letter that the facility filled in the resident's name and RP information, as well as a discharge to address. She said if there's no discharge address available, the address on the letter would be the nearest shelter receiving admissions. She said she had been in communication with Resident #1's RP but had not been provided an address for discharge. Interview on 01/04/2023 at 1:45 p.m. with BOM A revealed she again said the address on the 30-day discharge letter was a women's shelter. She said the shelter was chosen because the RP did not provide an address. She did not provide documentation to support the facility asked for an address prior to issuing the 30-day discharge letter on 10/25/2022. She said the criteria used to select the shelter was that it provided meals, shelter, and it was physically located near the RP. Interview on 01/04/2023 at 2:36 p.m. with SW B revealed she said the facility BOM had asked for an address from the RP but had not received one . She said when that happened, the facility looked for the closest shelter to discharge the resident to. She said there was an IDT meeting and that the physician knew. The SW was asked for documentation to reflect the IDT meeting occurred and of the physician's notification. No such documentation was provided prior to exit. SW B was asked if she thought it was safe to discharge a resident who required extensive assistance with transfers and eating to a shelter. She answered, No. On 01/04/2023 at 4:23 p.m. the surveyor attempted to contact the physician. The telephone number reflected on Resident #1's admission Record revealed an answering service told the surveyor they did not have a physician by that name. On 01/04/2023 at 4:33 p.m. revealed an internet search provided a different number for the physician. The office said they did have a physician by that name. The person who answered the phone attempted to locate Resident #1's chart on her computer. She was not able to locate a chart. She attempted to call the physician but the phone kept ringing and did not go to voicemail. Record review of the facility policy Criteria for Transfer and Discharge (revised January 2022) revealed it did not address the criteria for the receiving facility.