Every finding on record at Amarillo Medical Lodge

Based on observations, interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 4 (Resident #40, Resident #76, Resident #86, and Resident #97) of 19 residents reviewed for baseline care planning.1. The facility failed to include dialysis in Resident #40's baseline care plan.2. The facility failed to include a central line in Resident #76's baseline care plan.3. The facility failed to include a central line and a life vest in Resident #86's baseline care plan.4. The facility failed to include a PICC line in Resident #97's baseline care plan.These failures could place newly admitted residents at risk of not receiving safe, effective, person-centered care.Findings Included:1. Record review of Resident #40's admission record dated 03/11/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, end stage renal disease (kidney failure) and dependence on renal dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally).Record review of Resident #40's EHR under the MDS tab revealed an admission MDS assessment with an ARD of 02/27/26 that was labelled export ready. Resident #40 had a BIMS score of 13 which indicated intact cognition.Record review of Resident #40's baseline care plan initiated on 02/23/26 revealed no mention of dialysis except in the list of diagnoses at the bottom of the care plan where she was noted to have dependence on renal dialysis. The care plan included the following focus area: [Resident #40] Has nutritional problem or potential nutritional problem r/t . ESRD My current diet is LIBERALIZED RENAL diet .Record review of Resident #40's order summary report dated 03/11/26 revealed the following orders with corresponding order dates:02/23/26 LIBERALIZED RENAL diet.02/23/26 DIALYSIS COMMUNICATION FOMR TO BE COMPLETED AND FILED/SCANNED IN CHART ON DIALYSIS DAYS02/24/26 [Name address and phone number of dialysis clinic]02/23/26 HEMODIALYSIS 3X/WEEK EVERY T-TH-SAT @12PM.Record review of Resident #40's progress notes dated 02/09/26-03/12/26 revealed the following notes with corresponding dates and times:02/23/26 at 05:45 PM .Genitourinary: Dialysis - while a Resident.02/24/26 at 04:41 PM Res was taken to Dialysis, no new issues noted.During an observation and interview on 03/10/26 at 09:34 AM Resident #40 was seated in her wheelchair in her room. Her left upper wrist had what appeared to be lumpy bruising. When asked about the bruising, she stated, That is where I get dialysis. Resident #40 stated she went for dialysis three times a week on Tuesdays, Thursdays, and Saturdays.2. Record review of Resident #76's admission record dated 03/11/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic osteomyelitis with draining sinus right ankle and foot (persistent bone infection that often requires surgical intervention and long-term antibiotic therapy), type 2 diabetes mellitus with foot ulcer (insufficient production of insulin, causing high blood sugar with a foot ulcer caused by nerve damage, poor circulation and high blood sugar), and non-pressure chronic ulcer of other part of right foot with unspecified severity (an ulcer on the right foot not caused by pressure).Record review of Resident #76's EHR under the MDS tab revealed an admission MDS assessment with an ARD of 03/03/26 that was labelled In Progress. Resident #76 had a BIMS score of 15 which indicated intact cognition.Record review of Resident #76's baseline care plan initiated on 02/26/26 revealed no mention of a central line or IV medication administration.Record review of Resident #76's order summary report dated 03/11/26 revealed the following orders with corresponding order dates:02/26/26 CENTRAL LINE - CHANGE DRESSING prn IF WET, SOILED, SATURATED OR LOOSE as needed02/26/26 CENTRAL LINE CARE: CHANGE CENTRAL LINE DRESSING Q 7 DAYS.02/26/26 CENTRAL LINE FLUSHING: FLUSH WITH 5 cc 0.9% NS IV SOLUTION BEFORE AND AFTER EACH MED ADMINISTRATION every 4 hours02/26/26 CHANGE INTRAVENOUS TUBING EVERY 24HOURS [sic] every day shift02/26/26 Enhanced Barrier Precautions: PPE required or high resident contact care activities. Indication: IMPLANTED IV ACCESS AND WOUNDS every shift03/06/26 Nafcillin Sodium Injection Solution Reconstituted 2 GM . Use 2 grams intravenously every 4 hours related to CHRONIC OSTEOMYELITIS WITH DRAINING SINUS, RIGHT ANKLE AND FOOT . UNTIL 04/07/26 .Record review of Resident #76's MAR for February 2026 revealed the following order with a start date of 02/26/26 and end date of 03/06/26: Nafcillin Sodium Injection Solution Reconstituted 2 GM . Use 2 grams intravenously every 4 hours related to CHRONIC OSTEOMYELITIS WITH DRAINING SINUS, RIGHT ANKLE AND FOOT .During an observation and interview on 03/12/26 at 08:43 AM Resident #76's central line was observed to be on his chest. It was a right upper subclavian (the artery or vein which serves the neck and arm on the left or right side of the body) central line. The dressing on the central line was dated 03/10/26. Resident #76 stated staff changed the dressing every 3 days.3. Resident #86 was a closed record review. Record review of Resident #86's admission record dated 03/11/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to osteomyelitis (infection of the bone), non-st elevation myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blockages of the arteries), acute on chronic systolic congestive heart failure (the sudden exacerbation of a lifelong condition that affects the left ventricle. It occurs when the heart muscle is weak and the ventricle can't contract normally. Symptoms include shortness of breath, fatigue, leg swelling, and increased risk of arrhythmias and organ failure), and presence of aortocoronary bypass graft (an indication of heart surgery to restore blood flow to the heart due to blocked arteries). Resident #86 was discharged from the facility on 02/07/26.Record review of Resident #86's EHR under the MDS tab revealed an admission MDS was not started for Resident #86 prior to his Discharge Return Anticipated on 02/07/26.Record review of Resident #86's baseline care plan initiated on 02/03/26 revealed no mention of a central line or a life vest (a wearable vest designed to protect individuals at risk of sudden cardiac arrest by continuously monitoring the heart and delivering a life-saving shock if a dangerous heart rhythm is detected).Record review of Resident #86's MAR for February 2026 revealed the following orders with corresponding start dates:02/04/26 CENTRAL LINE/MID LINE FLUSHING: FLUSH WITH 5 CC 0.9% NS IV SOLUTIONBEFORE AND AFTER EACH MED ADMINISTRATION02/03/26 ceFAZolin Sodium Injection Solution Reconstituted 2 GM . Use 2 gram intravenously every 8 hours related to OSTEOMYELITIS .Record review of Resident #86's order summary report for active orders as of 02/03/26 revealed the following order and corresponding start date: 02/06/26 RESIDENT TO WEAR LIFE VEST AT ALL TIMES . REMOVE FOR SHOWERS ONLY4. Record review of Resident #97's admission record dated 03/12/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), heart failure (heart muscle fails to pump blood as it should), and cirrhosis of liver (impaired liver function caused by the formation of scar tissue). Resident #97 was discharged from the facility on 03/11/26.Record review of Resident #97's EHR under the MDS tab revealed no admission MDS assessment was started.Record review of Resident #97's baseline care plan revealed no mention of a central line.Record review of Resident #97's order summary report dated 03/12/26 revealed the following order with corresponding start date: 03/09/26 ceftriaxone Sodium Intravenous Solution Reconstituted 1 GM . Use 1 gram intravenously every 24 hours for Infection for 5 DaysRecord review of Resident #97's MAR for March of 2026 revealed the following orders with corresponding start dates:03/07/26 ceftriaxone Sodium Intravenous Solution Reconstituted 1 GM . Use 1 gram intravenously every 24 hours for infection . D/C Date- 03/09/202603/07/26 May insert PICC d/t IV ABT therapy one time only for PICC placement for 1 Day .During an observation and interview on 03/10/26 at 02:49 PM Resident #97 was sitting up in his bed. His nurse stated Resident #97 received IV antibiotics.During an interview on 03/12/26 at 08:45 AM RN A stated the purpose of a baseline care plan was to provide quality care, and make sure there is a treatment plan, and we are hitting all of our goals. She stated central and PICC lines should be included in baseline care plans due to cleaning, flushing, and dressing changes. RN A stated a life vest, and dialysis should both be included in baseline care plans. She stated not have this information in a baseline care plan could negatively impact a resident if a baby nurse or an inexperienced nurse was assigned to provide care to the resident.During an interview on 03/12/26 at 08:52 AM ADON B stated baseline care plans were completed by herself, DON, ADON C, and MDS LVN. She stated the purpose of a baseline care plan was to outline how the facility was going to take care of the resident. She stated central lines, PICC lines, dialysis, and life vests should be included in baseline care plans. She stated she did not know why they were not included in the baseline care plans of Residents #40, #76, #86, and #97 unless it was because some of the residents were not here (in facility) very long. ADON B stated leaving the above mentioned information out of a baseline care plan could potentially negatively impact a resident if someone is new to taking care of them (residents) and doesn't know what is going on with them (residents).During an interview on 03/12/26 at 09:21 AM DON stated ADON B and MDS LVN were responsible for completing baseline care plans. She stated the purpose of the baseline care plan was to have the base of patient care. DON stated of central lines and PICC lines, It should be included on there (baseline care plan) just because that (central and PICC lines) is something that we are monitoring. She stated she did not know why they were not included in Residents #76, #86, and #97's baseline care plans, but she would ensure they were added. DON stated a life vest should be included in the baseline care plan. She stated she did not know why it was not included in Resident #97's baseline care plan. DON stated dialysis should be included in a baseline care plan. DON stated an incomplete or inaccurate baseline care plan would not affect the resident's care because nurses followed physician orders and the care plan was just our goals that we set.Record review of an undated facility policy titled, Baseline Care Plan Policy revealed the following: .The purpose of this policy is to ensure that every resident admitted to the facility receives a timely, person-centered baseline care plan that addresses immediate needs and supports safe, effective care during the initial admission period. The facility will develop and implement a baseline care plan within 48 hours of a resident's admission. The plan will include essential information needed to provide safe and appropriate care until the comprehensive care plan is completed. Timing The baseline care plan must be completed within 48 hours of the resident's admission.

Based on observation, interview, and record review, the facility failed to ensure that residents who required respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #46) of 18 residents reviewed for quality of care.Resident #46 was left on 03/10/26 unsupervised by LVN E during breathing treatment.This failure had the potential to place residents at risk for respiratory compromise due to incomplete administration of ordered respiratory treatments and lack of monitoring, which could result in shortness of breath, confusion, respiratory failure, infection, and exacerbation of their conditionFindings included:Record review of Resident #46's face sheet, dated 03/10/26, revealed a 67- year-old female admitted to the facility on [DATE] with diagnoses which included: chronic obstructive pulmonary disease (progressive, long-term long disease that makes it difficult to breathe due to damaged, inflamed airways and destroyed air sacs), pleural effusion (abnormal accumulation of fluid in the thin membrane that covers the lungs), pulmonary hypertension (increased blood pressure in the arteries of the lungs), Non-ST elevation myocardial infarction (NSTEMI) (heart attack), and heart failure.Record review of Resident #46's quarterly MDS resident assessment, dated 12/15/2026 revealed she had a BIMS score of 13 indicating her cognition was intact.Record review of Resident #46's care plan with admission date, 04/25/25, revealed the resident had COPD with interventions/tasks including: give aerosol or bronchodilators as ordered, monitor/document any side effects and effectiveness, monitor for difficulty breathing on exertion, and monitor for s/sx of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest, cyanosis (change of tissue color to a bluish-purple hue as a result of decrease of oxygen), somnolence (sleepiness/drowsiness for unusually long periods of time). Record review of Resident # 46's active order summary report revealed the following order: Monitor for s/sx of shortness of breath when resident attempted to lie flat and/or resident avoided lying flat due to shortness of breath. Albuterol Sulfate Nebulization Solution (2.5 mg/3 ml) 0.083% 3 ml inhale orally via nebulizer every 6 hours for shortness of breath. During an interview on 03/10/26 at 10:15 a.m., Resident #46 stated she administered nebulizer treatments herself frequently and staff were never present during those treatments. Resident #46 stated they filled the nebulizer mask with medication and left the room. The resident stated this occurred every day. During an observation on 03/10/26 at 11:52 a.m., a medication cart was observed outside the resident's room with no nurse present. Resident #46 was observed sitting on her bed with the head of bed elevated and a nebulizer mask in place with medication visible in the bottom of the mask. The resident was alone in the room.During an observation on 03/10/26 at 11:58 a.m., Resident #46 remained alone in the room with the nebulizer mask in place. The medication cart remained outside the room and no nurse was observed in the area.During an observation on 03/10/26 at 12:05 p.m., Resident #46 continued to be alone in the room with nebulizer mask in place. The medication cart remained outside of Resident #46's room and no nurse was observed in the area. During an observation on 03/10/26 at 12:14 p.m., LVN E and ADON C were observed entering Resident #46's room and were heard asking the resident if she had completed her breathing treatment. Resident #46 was heard answering yes to staff and no vitals observed being taken. During an interview on 03/10/26 at 12:17 p.m., LVN E stated she worked at the facility for 1 1/2 years. When asked how she knew Resident #46 received the full breathing treatment medication, she stated that she returned to the room to check and the medication was gone from the mask. LVN E stated she stood outside the door and monitored Resident #46 during the treatment, and that was the expectation from management. LVN E stated a possible negative outcome of a resident not being monitored or staff not knowing if the resident had completed the treatment could be an adverse reaction.During an interview on 03/10/26 at 12:24 p.m., the surveyor stated she observed ADON C and LVN E enter Resident #46's room after the breathing treatment. ADON C stated that during breathing treatments, the expectation of staff was that they should be outside the door and monitor the resident during the entire treatment. The surveyor stated she observed several instances where LVN E was not present outside the resident's room during the breathing treatment. ADON C stated that was incorrect practice. ADON C stated a negative outcome of residents not being monitored during breathing treatments could be that the residents may not receive medication correctly. During an interview on 03/11/26 at 11:28 a.m., CNA F stated she worked at the facility for 3 years and observed nurses remain with residents during breathing treatments until they were completed. She stated she believed that was the expected practice. During an observation and interview on 03/12/26 at 9:44 a.m., Resident #46 was observed with an empty nebulizer mask on the bedside table. The resident stated she completed her first breathing treatment of the day at approximately 9:15 a.m. and no staff were with her during the treatment. Resident #46 stated the night-shift nurse left the medication in the mask and she administered it herself after waking up. Resident #46 stated that if she experienced shortness of breath during a breathing treatment, she would place her oxygen on and attempt to relax. She stated staff were not present and she had to manage the situation herself. Resident #46 stated that she believed she was stable, but felt she should be monitored during treatments because anything could happen. The resident further stated nurses had never taken her vital signs after breathing treatments. During an interview on 03/12/26 at 9:54 a.m., RN A stated she had worked at the facility for about 13 months and worked on the hallway where Resident #46 resided. RN A stated that the policy of the facility, during breathing treatments, was to remain within line of sight of the resident. If the resident was stable, staff could leave the room, but vital signs were to be taken before and after treatment. RN A stated she was not aware Resident #46 administered a breathing treatment at 9:15 AM because she did not administer the medication. RN A stated a potential negative outcome of not monitoring a resident during a breathing treatment could include adverse reactions, heart palpitations, and increased heart rate. RN A stated if a breathing treatment medication was prepared at 5:00 AM but not administered until 9:00 a.m., it could pose a safety concern because another resident could access the medication. During an interview on 03/12/26 at 10:03 a.m., the DON stated staff were expected to ensure breathing treatments were administered correctly. She stated, for stable residents, staff should ensure the breathing treatment was running and check on residents before, during, and after treatment. The DON stated vital signs were to be taken before and after treatment, and staff were expected to remain in the hallway during the treatment. She stated a possible negative outcome of a resident not being monitored could be that a resident may not receive their full breathing treatment. Review of the undated facility's policy, Oxygen Therapy Policy, revealed the following: Purpose: This policy establishes procedures for the safe and effective administration, monitoring and documentation of oxygen therapy in accordance with Texas Health and Human Services Minimum Licensing Standards, CMS Requirements of Participation and accepted clinical practice. 6. Administration Procedures Set up oxygen equipment and/or nebulizer according to manufacturer instructions. Ensure correct flow rate, medication and delivery device.Frequently monitor the resident based on clinical stability.Document assessments and resident response.Educate the resident and family on oxygen safety. 7. Monitoring and DocumentationNursing staff will frequently monitor the resident based on clinical stability, provider orders, and changes in condition. Monitoring includes oxygen saturation levels, respiratory assessment, resident tolerance, equipment function, adverse reactions, and interventions or notifications. Residents requiring continuous oxygen or those with unstable respiratory status will receive more frequent monitoring, with documentation reflecting the resident's condition and clinical judgement. 10. Care planningThe resident's care plan will include diagnosis requiring oxygen, flow rate, delivery method, safety needs, monitoring frequency, and resident preferences or goals.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #42 and Resident #73) of 18 residents reviewed for accuracy of assessment. 1. The facility coded Resident #42 as not using tobacco when he was a smoker.2. The facility coded Resident #73 as not using tobacco when he was a smoker. These failures to accurately assess residents could result in residents not receiving correct care and services. Findings Included: Resident #42 Record review of Resident #42's admission record dated 03/10/26 revealed a [AGE] year-old male most recently admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), muscle weakness (a lack of muscle strength), and shortness of breath. Record review of Resident #42's admission MDS assessment completed 12/27/25 revealed a BIMS score of 12 which indicated moderate cognitive impairment, Resident #42 was independent with most of his ADLs, and was listed as not using tobacco at this time. Record review of Resident #42's care plan completed on 12/23/25 revealed the following focus areas with corresponding initiation dates:12/23/25 [Resident #42] has potential for injury r/t Smoking d/t impaired vision.Record review of Resident #42's Smoking Evaluation dated 12/23/25 revealed he smoked 6 times a day.Record review of Resident 42's Activity - admission Evaluation dated 12/26/25 revealed Smoking - Current. Description - resident attends smoke breaks that are monitored by staff. During an observation and interview on 03/10/2026 at 8:47 AM Resident #42 was observed in bed dressed well and in the process of transferring to his wheelchair. Resident #42 reported he was transferring to his wheelchair because the next smoke break was at 9:00 AM and he did not want to miss it. Resident #73 Record review of Resident #73's admission record dated 03/11/26 revealed a [AGE] year-old male most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, impulsiveness, need for assistance with personal care, lack of coordination, and muscle weakness. Record review of Resident #73's quarterly MDS completed 12/22/25 revealed a BIMS score of 13 which indicated intact cognition. Resident #73 required set up/clean up assistance to supervision/touching assistance across all ADLs. (This MDS assessment does not require the facility to address the residents use of tobacco) Record review of Resident #73's EHR under the MDS tab revealed an admission MDS with ARD of 08/09/25. Record review of Resident #73's admission MDS completed 08/12/25 revealed he was not coded as using tobacco. Record review of Resident #73's care plan completed on 12/22/25 revealed the following focus areas with corresponding initiation dates:08/07/25 [Resident #73] Has Oxygen Therapy r/t Ineffective gas exchange and Smoking08/14/25 [Resident #73] has potential for injury r/t Smoking d/t impaired vision and cognitive deficit. Record review of Resident #73's Smoking Evaluation dated 05/21/25 revealed he smoked 6 times a day.Record review of Resident #73's Smoking Evaluation dated 08/14/25 revealed he smoked 5 times a day. During an observation on 03/10/26 at 11:10 AM Resident #73 placed a finished cigarette into a lidded ashcan offered to him by staff member. Staff member then handed him a new cigarette and lit the cigarette for him. Resident #73 proceeded to smoke the new cigarette. During an interview on 03/11/26 at 09:40 AM Resident #73 stated he started smoking when he was [AGE] years old and had been an active smoker the whole time he had been in the facility. During an interview on 03/12/26 at 08:45 AM RN A stated tobacco use should absolutely be included in comprehensive MDS assessments. She stated not including tobacco use in the MDS assessment could place residents at risk of injury.During an interview on 03/12/26 at 08:52 AM ADON B stated MDS LVN was responsible for completing MDS assessments. She stated tobacco use should be included in comprehensive MDS assessments. She stated if a new staff member was not aware a resident smoked the resident would be at risk of burns. During an interview on 03/12/26 at 09:21 AM the DON stated MDS LVN was responsible for completing MDS assessments. She stated tobacco use should be included in comprehensive MDS assessments. She stated the only negative outcome of an inaccurate MDS assessment was the effect it could have on reimbursement. She stated funding effects would not negatively impact resident care. During an interview on 03/12/2026 at 9:33 AM the MDS LVN reported he based the tobacco part of the MDS assessment on the activity admission assessment completed at admission. The MDS LVN reviewed the activity admission assessment and found Resident #42 was marked for smoking and stated, I just missed that. The MDS LVN reported tobacco use should have been marked on the MDS assessment. The MDS LVN stated, other than accuracy, I do not think the inaccuracy of the MDS assessment will affect a residents care and it will not affect the reimbursement. During an interview on 03/12/26 at 09:41 AM the MDS LVN stated he was responsible for completing MDS assessments. He stated he utilized the RAI as his policy when completing MDS assessments. MDS LVN stated he was not sure why Resident #73 was not coded as using tobacco, but he knew he (the MDS LVN) had a new partner working with him at the time of Resident #73's comprehensive assessment. He stated residents could be negatively impacted by inaccurate MDS assessments but did not elaborate on how. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.11, dated October 2025 (RAI Manual) revealed the following: SECTION J: HEALTH CONDITIONS-J1300: Current Tobacco Use Steps for Assessment Ask the resident if they used tobacco in any form during the 7-day look-back period.If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes.If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Coding Instructions Code 0, no: if there are no indications that the resident used any form of tobacco.Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #42) of 18 Residents reviewed for comprehensive care plans. -The facility failed to address the use of a catheter in Resident #42's care plans. This failure could result in residents not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being.Findings include: Record review of Resident #42's admission record dated 03/10/26 revealed a [AGE] year-old male most recently admitted to the facility on [DATE] with diagnoses to include neuromuscular dysfunction of the bladder (the nerves and muscles of the bladder do not work well resulting in the bladder not filling or emptying well), and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland that commonly affects men as they age, often causing bothersome urinary symptoms). Record review of Resident #42's admission MDS completed 12/27/25 revealed a BIMS score of 12 which indicated moderate cognitive impairment, Resident #42 required supervision/touch assistance with his toileting hygiene, and was listed as having an Indwelling catheter. Record review of Resident #42's care plan created on 12/23/25 revealed Resident #42 had no care plans for his catheter and catheter care. Record review of Resident #42's Order Summary with Active Orders As of 3/10/26 revealed the following order:- CHANGE FOLEY CATHETER MONTHLY ON 17 DAY OF EACH MONTH. REINSERT PRN FOR ACCIDENTAL REMOVAL, DISLODGEMENT, OBSTRUCTION OF URINE FLOW one time a day starting on the 17th and ending on the 17th every month Phone Active 12/23/2025. During an observation on 03/10/2026 at 8:47 AM Resident #42 was observed in bed dressed well and in the process of transferring to his wheelchair. Resident #42 had a catheter bag present on his bed that had dark urine in the bag. Resident #42 reported he was having some trouble with bleeding from his bladder and the facility was keeping an eye on it. Resident #42 reported the facility does a good job of taking care of all his catheter needs. During an interview on 03/12/2026 at 8:54 AM the DON reviewed Resident #42's chart and reported Resident #42 did have a catheter, and he was admitted with the catheter. The DON reviewed Resident #42's care plan and reported he had a care plan for urinary retention but no care plan to address his catheter or his catheter needs. The DON reported the catheter does need to be care plan, but she did not feel it would affect his care with it missing from the care plan since they usually address that and Resident #42 has orders for his catheter care so his catheter care would have been provided. The DON reported the MDS Coordinator was responsible for completing the care plans. During an interview on 03/12/2026 at 9:37 AM the MDS LVN reported he completes portions of the care plans and verified that if a catheter was marked on an MDS then he would complete that on the care plan. The MDS LVN reviewed Resident #42's admission MDS and reported Resident #42 was marked as having a catheter. The MDS LVN then reviewed Resident #42 care plan and reported he did not include the catheter in his care plan and should have. The MDS LVN stated, It would be ideal for the catheter to be in his care plan, but we did have his orders, so his care was still provided, and nothing was missed. The MDS LVN stated, We have his orders and as long as we follow his orders, I do not think his care would be affected. During an interview on 03/12/2026 at 10:19 AM LVN D (the nurse responsible for Resident #42 this shift) reported she did not review the residents care plans, but she felt all aspects of their care to include a catheter should be covered in the care plan. LVN D stated, I know management monitored all the care plan information and passes anything we need to know to use and vice versa. If we see something that changes or needs to be included, we let them know. LVN D reported that if the care plan did not address the residents' care and needs then care might not be monitored and they might not know when a resident's condition changes. During an interview on 03/12/2026 at 10:08 AM the DON stated they did not have a policy specific to comprehensive care plans. The DON stated she asked the ADM and he told her the only care plan policy they had was the baseline care plan policy because they add to the baseline care plan and it becomes the comprehensive care plan. Record review of the facility provided policy titled Baseline Care Plan Policy undated, revealed the following: 3. Comprehensive Care Plan: A detailed, interdisciplinary plan developed after completion of the full MDS assessment.7. Transition to Comprehensive Care Plan: The comprehensive care plan must be completed withing 7 days after completion of the MDS assessment.All relevant information for the baseline plan must be incorporated into the comprehensive plan.

Based on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and a diminished quality of life. Findings included: On [DATE] at 8:11AM an initial tour of the kitchen was conducted and revealed the following: Facility Refrigerator: (1) 2-quart bag of strawberries with an expiration date of [DATE]. 15 sausage patties with no date opened and open to air. (1) 40 count cartons of chocolate milk with no date received. (7) 40 count cartons of white milk with no date received. Facility Freezer: (1) 5-pound bag of frozen strawberries with no date received and open to air. (1) 2-pound bag of frozen green beans with no date received and open to air. 11 frozen hashbrown patties with an expiration date of [DATE]. 15 frozen eggrolls with no date received and open to air. (1) 10-pound bag of frozen corn with no date received and open to air. 80 count frozen hamburger patties with no date received and open to air. Facility Dry Pantry: (1) 1.57-pound bag of cream soup base with an expiration date of [DATE]. An interview with the Dietary Manager on [DATE] at 10:30AM revealed the negative outcome of serving foods which were not properly dated and/or expired would be residents could become sick from a food-borne illness, which could reduce their quality of life. Record Review of the undated facility policy for Food Storage revealed the following: Refrigerated food storage: (f) All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Frozen food storage: (c) All food should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. There was no food storage policy regarding expiration dates or discard by dates, for the dry pantry. Record Review of FDA Food Code dated 2022 revealed the following: ,d+[DATE] Labeling ,d+[DATE].11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; ,d+[DATE].12 Other Forms of Information. (B) FOOD ESTABLISHMENT or manufacturers' dating information on FOODS may not be concealed or altered.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA A) of 5 staff observed for resident care CNA A did not wear the proper PPE when assisting with wound care per Enhanced Barrier Precautions, increasing the risk of MDRO contamination. This deficient practice could place residents at risk of cross-contamination and infections. Findings include: Record review of Resident #155's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (a chemical imbalance in the blood that causes problems in the brain), obesity (a disorder involving excessive body fat that increase the risk of health problems), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and muscle weakness (a lack of muscle strength). Record review of Resident #155's clinical record revealed her last MDS was an admission completed 12-17-2024 listing her with a BIMS of 11 indicating she had a moderately impaired cognitive function, and she has a functionality of requiring supervision or touching assistance with most of her activities of daily living. Record review of Resident #155's care plan with admitted [DATE] revealed the following: Focus: Resident has a pressure ulcer r/t decreased mobility-right buttocks stage 3-date initiated 12-17-2024 Interventions: Use Enhanced Barrier Precautions-date initiated 1-2-2025 During an observation on 01-08-2025 at 11:06 AM LVN B was performing wound care for Resident #155's Stage 3 pressure ulcer with the assistance of CNA A. LVN B donned a gown and gloves for the procedure. CNA A was only wearing gloves. CNA A did not don a gown. CNA A rolled the resident on her right side after removing the resident's covers and pulling the residents brief to her knees to expose the wound area for care. CNA A assisted the resident to maintain this position for the entire wound care procedure, then returned the resident to her back, put her brief back in place, and pulled her covers back up. During an interview on 01-08-2025 at 02:37 PM CNA A verified that he did not wear a gown during the wound care provided for Resident #155's Stage 3 pressure ulcer and reported that he did not think that he was supposed to because he was not touching the wound. CNA A verified that he performed incontinent care on the resident with the Stage 3 pressure ulcer prior to the wound care because the resident was incontinent and that he had removed the residents covers and pulled down her brief to prepare for her wound care all without wearing a gown because he did not touch the wound. During an interview on 01-08-2025 at 11:44 AM LVN B stated Resident #155 (that she had performed wound care with the assistance of CNA A) was on EBP for a Stage 3 pressure ulcer and that CNA A did not don a gown for the procedure. LVN B stated not following EBP could result in the spread of infection and result in negative effects for residents such as infections and cross-contamination. During an interview on 01-08-2025 at 02:25 PM the DON reported that a staff member such as a CNA assisting with care on a resident that had a wound or catheter, may use their discretion if they feel they will not have direct contact with the wound or catheter, especially if the residents did not have an MDRO. The DON reported that only if they are going to touch the wound then they need to use EBP. The DON reported that education for staff, visitor, and family would have been done by posting signage on the resident's door if they required EBP. Also gloves, gowns, and isolation boxes for disposal of used PPE would have been placed in the resident's room. The DON reported that currently the facility had no residents that required EBP precautions because no residents were currently positive for MDRO infections. During an interview and record review on 1-9-2025 at 08:57 the DON reported they provide signage for a resident's doorway when the resident was placed on EBP, and the DON provided the signage that revealed the following: Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities: .Providing Hygiene Changing Briefs or assisting with toileting Device care of use: Central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Record review of the facility provided policy titled, Infection Prevention and Control Program Revised July 2022, revealed the following: 3. Enhanced Barrier Precautions (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRSs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization of MDROs. 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 resident with: i. Wounds and/or indwelling medical devices regardless of MDRA colonization resident, for staff performing care. ii MDRO infection or colonization. c. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: iv. Providing Hygiene vi. Changing briefs . vii. Device care or use: central vascular line (including hemodialysis catheters), indwelling urinary catheters, feeding tube, . viii. Wound care: any skin opening requiring a dressing.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #14) of 6 residents reviewed for respiratory care. The facility failed to ensure Resident #14's nasal cannula was stored properly. This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Record review of Resident #14's clinical record revealed a [AGE] year-old male resident admitted to the facility originally on 4-22-2019 and readmitted on [DATE] with diagnosis to include chronic pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath). Record review of Resident #14's clinical record revealed his last MDS was a quarterly completed 11-30-2024 listing him with a BIMS of 04 indicating he was severely cognitively impaired, he had a functionality of substantial/maximal assistance to supervision/touching assistance with most of his activities of daily living, and he was listed as having oxygen therapy on admission and while a resident. Record review of Resident #14's Order Summary Report with Active Orders as of 1-8-2025 revealed the following order: -MAY USE O2 VIA NASAL CANNULA @ 1-5 LPM FOR O2 SATS BELOW 90 PRN EVERY SHIFT-PRN every 24 hours as needed for shortness of breath. Verbal Active 11/26/2024. Record review of Resident #14's clinical record revealed a care plan with the admitted [DATE] revealed the following: Focus: Resident has oxygen therapy r/t periods of dyspnea (difficulty breathing). - Date initiated 4-11-2022. Revision 3-2-2023. -No procedures were listed with care of any respiratory equipment to include nasal cannula or tubing. During an observation on 01-07-2025 at 10:21 AM Resident #14 was not in his room. Resident #14's roommate reported that Resident #14 was at dialysis. Resident #14 had an O2 concentrator next to the left side of his bed with the O2 tubing dated 1-6-2025. Observed was the nasal cannula hanging off the back of Resident #14's concentrator on the floor with the nasal prongs facing upward. During an observation on 01-07-2025 at 11:02 AM Resident #14's O2 concentrator was at his bedside with the nasal cannula on the floor behind the machine with the nasal prongs facing upward. During an observation on 01-07-2025 at 02:02 PM Resident #14's O2 concentrator was at his bedside with the nasal cannula on the floor behind the machine with the nasal prongs facing upward. Resident #14's room was observed to have been cleaned and his bed had been made. During an observation and interview on 01-07-2025 at 03:38 PM Resident #14 was in his room lying on his bed. Resident #14 was difficult to understand, appeared to be confused, and did not respond effectively to questions. Resident #14's O2 concentrator was at his bedside with the nasal cannula on the floor behind the machine with the nasal prongs facing upward. During an observation on 01-08-2025 at 07:45 AM Resident #14's O2 tubing (dated 1-6-2025) and nasal cannula was observed stored in a bag laying on the floor behind his O2 concentrator. During an observation on 01-09-2025 at 08:02 AM Resident #14's O2 concentrator was at his bedside with the nasal cannula on the floor to the right side of the concentrator behind the machine on the floor with the nasal prongs facing upward. During an interview on 01-09-2025 at 08:05 AM the DON reported that floor staff are to make rounds on resident every 2 hours. The DON reported that floor staff where to check the residents for incontinence or of they had any other needs. The DON verified that the staff were to check on the resident's equipment to include the respiratory equipment. The DON reported that if a nasal cannula was found on the floor then the nasal cannula would need to be changed because the nasal canula would be exposed to the floor and who knows what is on that floor. The DON reported that the floor could be dirty with any substance and if the resident was immunocompromised then they would be at even more risk. The DON reported that she would immediately start an in-service to correct the issue. During an interview on 01-09-2025 at 08:36 AM the DON reported that the facility did not have a policy on employee round responsibilities, and they were looking for a policy on respiratory tubing care. During an interview on 01-09-2025 at 08:57 AM the DON reported that the facility did not have a policy on respiratory tubing care.

Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #2) of 7 residents observed. During initial rounds of facility, Resident #2's urinal was observed on his bedside table after resident was finished using it. These failures could place residents at risk of infection and cross-contamination with food and fluids. The findings included: During an observation and interview on 05/07/2024 at 8:42am revealed Resident #2's rolling bedside table with a used dirty urinal sitting on rolling bedside table and was touching a water cup that the resident was using. Resident #2 did state that he had just used the urinal to relieve his bladder. During an interview on 05/07/2024 at 9:22am with DON regarding urinal on Resident #2's bedside table. DON stated that Men are just gross and did not state what the negative outcome would be. During an observation on 05/07/2024 at 9:35am, DON was observed giving an unidentified CNA an in-service (training) in the hallway regarding urinals on bedside tables. DON stated to CNA that the urinals should be anywhere else besides the bedside tables. During an observation on 05/07/2024 at 1:52pm revealed Resident #2 was resting with eyes closed and his empty, clean urinal was placed on the repositioning bar of his bed. Record review of facility provided policy named Infection Prevention and Control program, dated 06/2021, revealed the following: Goals Decrease the risk of infection to residents and personnel. . Identify and correct problems relating to infection control. Ensure compliance with state and federal regulations related to infection control Promote individual resident rights and well-being while trying to prevent and control the spread of infection.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (Resident #1) of 7 residents. -1 nasal medication and 2 eye drop medications were discovered on bedside table for Resident #1 The facility's failure could place all residents at risk for obtaining medications that could cause adverse reactions. Findings included: Observation/Interview on 05/07/2024 at 8:57am revealed three medications (Fluticasone (nasal spray for allergies, Therea Tears (eye drops for dry eye), and Alaway (eye drops for dry eye) were on Resident #1's bedside table. Resident #1 was asked if she could administer medications to herself, she stated that she could, but she had not used these medications this morning yet. Resident #1 was asked if these medications are supposed to be provided by nurse. Resident#1 pointed to the Fluticasone nasal spray and stated, this one is usually put up. Record review of Resident #1's face sheet, dated 05/07/2024, revealed that Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE], with the following diagnoses: Type 2 diabetes mellitus without complications (high blood sugar), hypothyroidism (thyroid underperforming), muscle weakness, cognitive communication deficit (impaired thought processes), other lack of coordination, history of falling. Record review of Resident #1's active physicians orders, dated 05/07/2024 revealed no order for the Fluticasone, Therea Tears, and Alaway medications. Record review of Resident #1's MDS assessment, dated 03/13/2024, revealed that Resident #1 has a BIMS (Brief Interview for Mental status) of 10, and functionality of performing oral hygiene, upper body dressing and personal hygiene at a level of set-up or independent. Toileting hygiene, shower/bathing/lower body dressing, and putting on/taking off footwear Resident #1 is dependent on staff to perform these types of ADLs. Record review of Resident #1's care plan with a revision date of 03/15/2024, revealed no information regarding having medications at bedside or self-administration of medications. In an interview on 05/07/2024 9:22am with DON stated that the facility was not allowed to go through resident's personal items upon entering the facility. DON stated that if the resident had medications in their possession, the staff wouldn't know unless the resident tells them. No negative outcome was provided during this interview. During an observation on 05/07/2024 at 9:35am revealed DON giving an unidentified CNA an in-service in the hallway regarding medications being left at bedside. During an observation on 05/07/2024 at 9:47am revealed LVN B asking unidentified resident Do you have any meds out? Upon entering the room there were was no observation of medicaitons in room of resident. In an interview on 05/07/2024 at 9:48am LVN B stated that if the resident has the order to have medications at bedside they can have them. LVN B was asked, So, the medications should be locked up and then when it is time for the meds to be given you bring them to the resident, and they can give it to themselves? LVN B stated No they can have them on their bedside table. LVN B stated that if the resident has the order for bedside meds that they can be on the bedside, most of those types of medications are creams. No negative outcome was provided by LVN B during this interview. In an interview on 05/07/2024 1:28pm LVN E stated that the meds were not on beside of Resident #1 this morning during med pass. LVN E stated that when LVN E went into resident's room to ask resident about meds. Resident #1 stated that she had them in her black bag. LVN E stated that she educated the resident on medications and that they could not be left out. LVN E stated that she would have to obtain an order for the medications and an order for resident to keep medications at bedside and that they would have to be in a cabinet or in her bag. LVN was asked what a negative outcome would be for having medications out and not put away, LVN E stated, it could lead to a write up. LVN E stated when she asked the Resident #1 if there any other medications in the resident's room, Resident #1 pulled out a white bag that contained Stool softener, Biofreeze, Biotin, and Melatonin in it. LVN E took medications and placed them in the medication cart and was getting orders for the medication, along with the Flonase and eye drops that were discovered earlier in the day. In an interview on 05/07/2024 at 1:49pm Resident #1 was asked if she had taken any of the medications that were found in her room. Resident #1 stated that she had only used the Biofreeze for her hands one night because her arthritis was acting up. No other medications had been taken by resident, per Resident #1. Record review of policy provided by facility named Medication Storing and Controlling Medications, undated, revealed the following: Policy: It is the policy of this Facility to: 1. Store medications safely, securely, and properly following manufacturer's recommendations or those of the supplier, and in accordance with federal and state laws and regulations. The medication supply is accessible only to authorized personnel. 2. Ensure maximum safety for residents. Procedure: 4. medication of those residents who do not self-administer, will be stored in a locked cabinet (such as a medication cart). Only authorized personnel will have a key/access to the locked cabinet .

Based on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented for 1 of 17 residents (Resident #57) reviewed for accurate medical records. The facility failed to ensure Resident #57's physician's order for oxygen was documented in the resident's clinical record. This failure could place residents at risk of not receiving needed care or treatments or duplication of care or treatment by misleading care providers regarding what care or treatments residents have or have not received. Findings included: Record Review of Resident #57's face sheet dated 12/04/2023 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included, but were not limited to, Acute Respiratory Failure with Hypoxia(life threatening condition where the lungs cannot provide enough oxygen to the blood and organs), Unspecified congestive heart failure, pneumonia (infection in lungs)-unspecified, klebsiella pneumoniae(causes bacterial pneumonia or infection in lungs). Record Review of Resident #57's Admission MDS dated [DATE], revealed a BIMS score of 13 of 15 which indicated her cognition was intact. In the MDS assessment section J1100 indicated that the resident has shortness of breath with exertion and when lying flat. In the MDS assessment section O0110 indicated that Resident #57 was receiving continuous Oxygen therapy on Admission. The MDS assessment also indicated that Resident #57 was receiving Oxygen therapy while a resident in the facility. Record Review of Resident #57's care plan dated 11/10/2023 revealed there was no documentation focusing on oxygen therapy and no goal or interventions documented relating to oxygen therapy. The care plan was updated on 12/4/2023 that indicated that Resident #57 had an altered respiratory status related to diagnosis of pneumonia, klebsiella pneumonia with an intervention to provide oxygen as ordered. Record Review of Resident #57's clinical record revealed no active orders for oxygen. Record Review of Resident #57's progress note dated 12/3/2023 indicated the resident received continuous oxygen. Record Review of Resident #57's Medication Administration Record for November 2023 indicated that Resident #57's oxygen saturation for the month of November ranged from 92-97%. During an observation/interview on 12/04/2023 at 9:35 AM, revealed Resident #57's was sitting up in her bed. The resident was receiving oxygen via nasal cannula at 3 liters per minute. The resident stated she was supposed to be receiving oxygen daily via nasal cannula at 1 liter per minute. During an observation on 12/5/2023 at 9:00 AM revealed Resident #57 sleeping in her bed, she was receiving oxygen via nasal cannula at 3 liters per minute. During an interview on 12/6/2023 at 8:37 AM, LVN A stated she knew what level to set the O2 on the concentrators by looking at the physician's orders. LVN A stated the possible negative outcome for setting a higher LPM than ordered would be that if the resident had COPD, it could cause their O2 saturations to be lower. During an observation on 12/6/2023 at 8:40 AM revealed Resident #57 sleeping in her bed. She was receiving oxygen via nasal cannula at 1.5 liters per minute. During an interview on 12/6/2023 at 8:45AM, the ADON stated that she, the DON or Admission Nurse were responsible for putting physician's orders in the EHR system. The ADON stated that the facility meets each morning and that any missed orders would be addressed at the meeting, and it would be caught before anything happened. ADON stated that a possible negative outcome for missed orders would be that a resident would not get their medication. During an interview on 12/6/2023 at 8:47AM, the ADON stated that the physician orders indicate what LPM on the O2 concentrator are set at. ADON stated the possible negative outcome for receiving O2 at a higher LPM than ordered or receiving O2 without orders would be that they wouldn't know the resident's history. During observation/interview on 12/06/2023 at 8:50 AM, the Admission Nurse stated she was responsible for putting physician's orders in the system on weekdays and the charge nurse on the weekends. Observation of Admission Nurse looking up Resident #57's physician's orders via the EHR system revealed Admission Nurse stated that she could not find any orders for oxygen for Resident #57. Admission Nurse stated that a possible negative outcome for missed orders would that the staff would not know what the saturation of oxygen should be at for the resident. During an interview on 12/6/2023 at 8:57 AM, the DON stated that it is not normal for the resident to receive O2 continuously without physician's orders. During an observation/interview on 12/06/2023 at 9:00 AM, the DON stated that she and the Admission Nurse were responsible for putting physician's orders in the resident's chart. DON stated that they have a lot of checks and balances and wouldn't miss orders. DON was observed looking at Resident #57's admission record and physician's orders and stated that the resident was on oxygen at the hospital. DON could not think of a negative outcome for a resident receiving oxygen without physician orders. During an interview on on 12/6/2023 at 9:50AM, the DON stated she would get the policy regarding medical records. Record Review of Off-site Storage of Records (no date on the policy) revealed that the facility maintain clinical records for each resident that are complete, accurately documented and readily accessible and systematically organized.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #5 and Resident #57) of 17 residents reviewed for respiratory care. 1. Resident #5 had a physician's order for continuous oxygen via nasal cannula at 2-4 lpm and was receiving oxygen therapy at higher concentrations. 2. Resident #57 had no physician's orders for oxygen and was receiving oxygen via nasal cannula on a continuous basis. These failures could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: 1. Record review of Resident #5's Admission Record dated 12/04/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diastolic heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), fatty liver (fat build up in the liver resulting in damage and possible scarring to the liver), and hypertension (high blood pressure). Record review of Resident #5's Quarterly MDS with an ARD date of 11/17/23 revealed a BIMS of 14 which indicated intact cognition. Section O of the MDS revealed Resident #5 received oxygen therapy while a resident. Record review of Resident #5 Care Plan dated 11/01/23 revealed Resident #5 had Oxygen Therapy r/t Ineffective gas exchange. Record review of Resident #5's active orders dated 12/04/23 revealed the following order with a start date of 07/08/23: O2 AT 2-4 L/MIN CONTINUOUS PER NC every shift. Record review of Resident #5's oxygen saturation summary revealed 36 entries. 28 of the entries were from July 2023 with two entries for August, September, October, and November 2023. Of the 36 entries 4 were on Room Air and the remaining 32 were on Oxygen via Nasal Cannula. Resident #5's oxygen saturation percentages ranged from 90-99% according to the summary. 2. Record review of Resident #57's Admission Record dated 12/05/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (a condition resulting from not enough oxygen in the tissues of the body), diastolic heart failure (a condition resulting from not enough oxygen in the tissues of the body), hypertension (high blood pressure), and pneumonia (lung infection characterized by cough with phlegm, fever, chills, and difficulty breathing). The Admission Record featured a picture of Resident #57 wearing oxygen tubing with nasal cannula. Record review of Resident #57's Admission MDS with an ARD date of 11/03/23 revealed a BIMS of 13 which indicated intact cognition. Section I of the MDS indicated Debility, Cardiorespiratory Conditions as Resident #57's primary medical condition category and Respiratory Failure was checked under the section titled, Pulmonary. Section J of the MDS indicated Resident #57 had shortness of breath or trouble breathing with exertion and when lying flat. Section O of the MDS revealed Resident #57 received oxygen therapy On Admission and While a Resident. Under the On Admission section Continuous was checked. Record review of Resident #57's care plan dated 11/10/23 revealed no mention of oxygen therapy. An update to Resident #57's care plan dated 12/04/23 revealed a new focus area of [Resident #57] has altered respiratory status related to diagnosis of pneumonia . One of the interventions for this focus area was, Provide oxygen as ordered. Record review of Resident #57's active orders dated 12/05/23 revealed no order for oxygen therapy. Record review of Resident #57's November 2023 MAR revealed her oxygen saturation percentages for the month of November ranged from 92-97%. Record review of Resident #57's oxygen saturation summary revealed 54 entries. 9 of the entries were on Room Air and the remaining entries were on Oxygen via Nasal Cannula. The summary revealed Resident #57 received O2 via nasal cannula for 30 of the 37 days she had been in the facility. Of the 36 days represented by the summary Resident #57 was on room air and receiving oxygen on 3 of the days and on room air only for 6 of the days. Over the course of the 36 days represented by the summary Resident #57's oxygen saturation percentages ranged from 90-99%. Her oxygen saturation percentage was 90% two times in 36 days and both times she was receiving oxygen via nasal cannula. During an observation and on 12/04/23 at 08:53 AM Resident #5 was seated in her recliner in her room watching TV and receiving O2 via nasal cannula at 5 lpm. During an observation and interview on 12/04/23 at 09:45 AM Resident #57 was receiving O2 via nasal cannula while on her back in bed. She stated she was on 1 liter of O2. An observation of her O2 concentrator revealed it to be set on 3 lpm. During an observation on 12/04/23 at 02:06 PM Resident #57 was in her bed receiving O2 via nasal cannula. During an observation on 12/05/23 at 09:00 AM Resident #57 was asleep in her bed receiving O2 via nasal cannula at 3 lpm. During an observation and interview on 12/05/23 at 09:23 AM Resident #5 was seated in her recliner watching TV and receiving O2 at 5 lpm. She stated she had been receiving O2 continuously via nasal cannula since last year when she had COVID pneumonia. She said her O2 concentrator at home was set to 3 lpm. Resident #5 stated she thought her O2 concentrator in the facility was set to 3 lpm. During an observation on 12/05/23 at 11:25 AM Resident #57 was seated in her w/c in the dining room playing dominoes and receiving O2 via nasal cannula from the O2 tank attached to her w/c. During an observation on 12/05/23 at 02:11 PM Resident #57 was asleep on her bed receiving O2 at 2 lpm via nasal cannula. During an observation on 12/05/23 at 03:12 PM Resident #57 was asleep on her back in her bed receiving O2 via nasal cannula at 2 lpm. During an observation on 12/06/23 at 08:14 AM Resident #5 was seated in her recliner receiving O2 at 5 lpm. During an interview on 12/06/23 at 8:37 AM LVN A, who was working in Resident #57's hall for the day, stated nurses were responsible to set the lpm on O2 concentrators for residents receiving O2. She stated nurses knew what lpm to set the concentrator to by looking at the doctor's orders. When asked if there was a possible negative outcome of a resident receiving O2 without orders or O2 at higher lpm than ordered, LVN A stated, Oh yes, especially if they have COPD. If you crank it [O2] up it can lower their O2 sats [saturation percentages]. During an observation on 12/06/23 at 08:40 AM Resident #57 was observed in her bed receiving O2 via nasal cannula at 1.5 lpm. During an interview on 12/06/23 at 08:47 AM ADON, who was working on Resident #5's hallway for the day, stated nurses were responsible for setting lpm levels on O2 concentrators. He stated CNAs could set the levels if a nurse directed them to do so. When asked how nurses knew what lpm to set the concentrator to, ADON stated, Orders tell them. He said a possible negative outcome of a resident receiving O2 at a higher lpm than ordered or without any orders was, We don't know their history. During an interview on 12/06/23 at 08:50 AM LVN B stated CNAs or nurses were responsible for setting O2 levels on O2 concentrators. She said they knew what lpm to set the concentrators to by looking in the resident's care plan or orders. When asked if there was a possible negative outcome of receiving O2 at higher rates than ordered she stated, There can be, sometimes, it depends on their [the resident's] diagnosis. When asked if there was a possible negative outcome of receiving O2 without orders, she replied, Only if you don't know the correct level. We do have standing orders [from MD] that if O2 is below a certain level you have the option to get 1 to 3 liters. During an interview on 12/06/23 at 08:57 AM DON stated nurses were responsible for setting O2 levels on the concentrators, but CNAs could do it if directed to do so by a nurse. She said nurses knew what level to set the concentrators to whatever the physician starts it at. She stated MD had standing orders for the facility to use O2 at 1-5 lpm to keep O2 saturation percentages greater than 90%. When asked for a possible negative outcome of a resident receiving O2 at higher lpm than ordered she replied, It depends on what their O2 saturation is. She stated she could not think of a possible negative outcome of a resident receiving O2 continuously without physician's orders. When asked if it was normal for a resident to receive O2 continuously without physician's orders DON stated, No, we would have put the orders in. DON attempted to find physician's orders for O2 for Resident #57 in the EHR but could not find them. During an interview on 12/06/23 at 09:25 AM MD stated he had facility-wide standing orders for O2 from 1-3 lpm to be used to maintain O2 saturation percentages above 90%. He stated he believed he changed the standing order to O2 from 1-5 lpm at the beginning of 2023 but was not sure of the date. When asked if there was a possible negative outcome for a resident to receive O2 at a higher level than ordered or without orders he stated, Folks with COPD, we have to watch for CO2 retention. Record review of facility document titled [Title of medical practice of MD] Long-Term Care Standing Orders [Name of Facility] and dated 03/01/23 revealed in part: . Respiratory If Spo2 <90% Apply NC at 2-3 L to maintain >90% . Record review of an undated facility policy titled Policy / Procedure - Nursing Clinical with the subject of Oxygen Administration (Mask, Cannula, Catheter) revealed in part: It is the policy of the facility that oxygen is administered, as ordered by the physician or as an emergency measure until the order can be obtained. May use standing orders for oxygen for residents without orders in PCC. 48161

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #19) of 17 residents reviewed for accuracy of assessments. The facility failed to accurately assess Resident #19, in that her MDS coded her as having no delusions or hallucinations despite physician's documentation to the contrary. This failure could place residents at risk of not receiving necessary care and/or treatment. Findings include: Record review of Resident #19's admission record, dated 12/06/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, muscular dystrophy (a group of inherited conditions affecting the muscles, gradually leading to disability), type 2 diabetes (insufficient production of insulin, causing high blood sugar), delusional disorders (a type of mental health condition in which a person cannot distinguish between what is real and what is imagined, often resulting in an unshakeable belief in something that is untrue), and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Record review of Resident #19's Quarterly MDS with an ARD date of 11/06/23 revealed a BIMS of 15 which indicated intact cognition. Section E of the MDS was titled Behavior and question E0100 had directions to check all that apply. The question had Hallucinations (perceptual experiences in the absence of real external sensory stimuli) and Delusions (misconceptions or beliefs that are firmly held, contrary to reality) as options to check. Both options were left unchecked and the option None of the above was checked. Section I of the MDS listed psychotic disorder and schizophrenia among the active diagnoses for Resident #19. Record review of Resident #19's care plan with a completion date of 11/21/23 revealed, Resident #19 is At risk for impaired cognitive function/dementia or impaired though processes r/t Difficulty making decisions and dx of delusional disorders. The care plan also indicated Resident #19 has Potential for a behavior problem r/t r/t DX of schizoaffective disorder and delusions disorders, Hx of yelling out and using profanity type of language, aggravation, and hallucinations . Record review of Resident #19's primary physician's progress note with 11/01/23 as the date of service revealed Resident #19 is a poor historian due to cognitive/psychiatric impairment. The progress note further revealed Resident #19 stated she won't drink protein drinks because it contains Chromium 22 that attracts radiology and causes cancer. The progress note stated Resident #19 continues to state she is pregnant. The progress note also stated Resident #19 was Insight Impaired and had Grandiose delusions. During an observation and interview on 12/04/23 at 08:56 AM Resident #19 was lying on her back in bed with the head of the bed raised to a sitting position watching TV and eating breakfast off an over-the-bed table. Resident #19 stated staff took good care of her and she had been impregnated by one of doctors who worked in the facility. She stated that due to the European lineage on both of their parts the pregnancy has been rather unusual, and the gestation period will be longer. Resident #19 stated they planned to move to New Mexico due to New Mexico having a constitution that keeps blacks out. During an observation on 12/04/23 at 09:04 AM the surveyor had just exited Resident #19's room leaving Resident #19 alone in the room and overheard Resident #19 having a conversation with someone while alone in her room. She was telling someone to shut up, leave her alone, stop hurting her stomach, and to give her life back. During an observation on 12/05/23 08:49 AM Resident #19 was in her bed with the head of the bed elevated talking to someone who was not visible in the room. She stated she wanted that person to stop hurting her and asked them to please shut up. During an observation and interview on 12/05/23 at 09:04 AM Resident #19 was asked if she ever refused to take any of her medications. She replied, Yeah, because I am a doctor, and I don't want to take any opioids. She stated it was hard to move her legs because of the robots but she would not let staff work with her because they are not professionals, and they are not really knowledgeable. During an interview on 12/06/23 at 01:18 PM LVN E stated if she saw a behavior in a resident, she documented it in the progress notes or on the MAR. During an interview on 12/06/23 at 01:21 PM ADON stated Resident #19 would not have an area to document behaviors on her MAR because she was not taking any psychotropic medications. He stated it was a normal behavior for Resident #19 to talk to people who are not there and to yell out and to talk about being pregnant by a doctor from the facility. ADON stated the facility had a psychiatrist visit Resident #19, but she refused to speak to the psychiatrist. He stated they have had to remove Resident #19 from the dining hall on occasion due to her behaviors and comments about people with different skin colors. During an interview on 12/06/23 at 01:22 PM LVN C stated she had documented Resident #19's behaviors in the progress notes of her EHR. During an interview on 12/06/23 at 01:29 PM MDS LVN stated he was responsible for completing the MDS assessments. He stated he filled out Section E of the MDS based on information gleaned from nursing notes, and we talk as an IDT in the mornings and in our morning meeting. MDS LVN stated the IDT was made up of DON, ADM-T, SW, BOM, ADON, and DOR. He stated the ARD date was the day he started an assessment and the look back period was the seven days prior to that date. When asked why Resident #19 was coded in MDS Section E as having no delusions or hallucinations he stated he was not sure and would have to look. MDS LVN stated a possible negative outcome of a MDS not reflecting behaviors on the part of a resident was something might get missed and the resident might not get treated properly. During an interview on 12/06/23 at 01:33 PM ADM-T stated she could not speak to a possible negative outcome of Resident #19 being coded for no delusions or hallucinations on her MDS as she [ADM-T] was not real familiar with Resident #19. During an interview on 12/06/23 at 01:35 PM DON stated some mornings in morning meetings Resident #19's behaviors were not mentioned. She said of Resident #19, Some mornings she is very pleasant and then some mornings I will walk in there and she is talking to the window. DON stated they had a psychiatrist go and speak to Resident #19 but Resident #19 would not talk to him and said, Get that man outta here. During an interview on 12/06/23 at 01:37 PM MDS LVN stated he did look at physician's notes when he was completing Section E of the MDS. He stated he was not sure why he did not see the physician's note regarding Resident #19 with a service date of 11/01/23. During an interview on 12/06/23 at 02:08 PM MDS LVN stated the policy he followed for completing the MDS assessment was the RAI. Record review of the RAI, version 1.18.11 dated October 2023, revealed the following instructions for completing Section E of the MDS: . 1. Review the resident's medical record for the 7-day-look-back period. 2. Interview staff members and others who have had the opportunity to observe the resident in a variety of situations during the 7-day-look-back period. 3. Observe resident during conversations and the structured interview in other assessment sections and listen for statements indicating an experience of hallucinations, or the expression of false beliefs (delusions). Record review of an undated facility policy titled; Off-site Storage of Records revealed in part: . The facility maintains clinical records for each resident that are complete, accurately documented, .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection in 1 of 1 dining rooms. -LVN A failed to maintain proper hand hygiene while passing meal trays to multiple residents in the dining room and before feeding a resident. -CNA C and LVN B failed to perform hand hygiene before sitting down to assist residents with eating. This failure had the potential to affects residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: Observation on 08/03/2023 at 8:15am of Breakfast service being served in the dining room revealed LVN A scratched her nose, then proceeded to scratch her armpit and then took food tray without performing HH. LVN A delivered tray to resident, opened milk carton, took lid off of food and juice. LVN A returned tray to dirty window (area where dirty dishes are returned to kitchen to be washed) and went back to line for next tray and proceeded to take another tray from the window with no HH being performed. LVN A then set up food for 2nd resident, opening milk carton and removing lids to food and juice for this resident. LVN A left dining room and did not perform HH on way out of dining room. Observation on 08/03/2023 at 8:39am LVN A was standing next to table for a few minutes and then left dining room, returned a couple of minutes later. LVN A sat down next to Resident #1 and started to feed resident without performing hand hygiene. CNA C came to take the place of LVN B and did not perform HH before assisting Resident #2 with her remaining breakfast. No hand hygiene was performed by LVN B between getting another resident more cream of wheat from the kitchen, and returning to Resident #2, whom she was feeding. During an interview on 08/03/2023 at 9:14am, LVN A was asked what the protocol was for hand hygiene, she stated that anytime you have contact with a resident. LVN A was asked why hand hygiene wasn't performed during meal pass. LVN A stated that she was nervous and there was no reason for not performing hand hygiene, LVN A stated, I just didn't. During an interview on 08/03/2023 at 3:08pm, DON was asked what the protocol was for HH during tray pass. DON stated that hands need to be sanitized between each tray, and any direct contact with residents. Record review of facility provided policy titled Hand Hygiene revised 10/2022; page 1 and 3 of policy are present, page 2 was not given by facility. No mention of hand hygiene noted on partial policy provided.

Based on interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 out of 4 residents reviewed for clinical records (Resident #1). The facility failed to accurately document information for Resident #1 due to another Resident's name being present in care plan. This failure can place residents at risk of inaccurate needs or services based on comprehensive assessment. Findings included: Record review, dated July 12, 2023, of Resident #1's face sheet revealed a [AGE] year-old male admitted into the facility on [DATE]. Resident #1 diagnoses included but not limited to cerebral palsy (inability to control muscles), interstitial pulmonary (inflammation causing lungs to not get enough oxygen), Chronic Obstructive Pulmonary Disease,(COPD -Blockage of airway), Cystic Fibrosis (disorder that damagers lungs, digestive tract and other organs), Reduced mobility, unsteadiness of feet, cognitive communication deficit, dysphagia (difficulty swallowing), aphasia (loss of ability to understand speech), schizoaffective disorder; bipolar type, intellectual disabilities, muscle weakness, need for assistance with personal care. Record review of Resident #1's MDS assessment Section C-Cognitive Pattern, dated 7/10/23, revealed the resident was not assessed due to limited communication skills. Record review on 7/12/23 of Resident #1's care plan, dated 3/27/23, revealed a goal for PASARR indicating a positive screening. The information presented for the focus goal stated, I, [Resident] is receiving PASRR service through Texas Panhandle Services. [Wrong Resident] has a PASRR positive diagnosis Dx: IDD due to Cerebral Palsy. Case worker is [Employee] w/TPC. Incorrect name of resident identified in focus goal. Record review on 7/12/23 of Resident #1's care plan, dated 3/27/23 and revised on 6/7/23, revealed a goal for PASARR indicating a positive screening. The information presented for the focus goal stated, I, [Resident], is receiving PASRR service through Texas Panhandle Services. [Wrong Resident] has a PASRR positive diagnosis Dx: IDD due to Cerebral Palsy. Case worker is [Employee] w/TPC. Incorrect name of resident identified in focus goal. Interview on 7/12/23 at 3:01 PM, the MDS Coordinator confirmed that wrong resident name was care planned. Stated and confirmed that the wrong name was put in the care plan. MDS Coordinator indicated that DSS is the employee who entered the goal. Interview on 7/12/23 at 3:13 PM, the DSS confirmed another name, [Resident], is in the care plan. DSS confirmed that another name was on both care plans completed. Negative outcome indicated by DSS could be records associated with wrong patient name and inaccurate information on the patients involved. Interview on 7/12/23 at 3:15 PM, the DON read care plan verbatim. Looked at 6/2023 showed had Resident #1 and [Resident] name in one chart. Negative outcome of two people's names, it's a care plan saying there's a wrong diagnosis. Instead of putting Resident #1, she said [Resident] has Cerebral Palsy as well and is primary diagnosis for PASARR positive assessment. They both have a diagnosis of Cerebral Palsy just wrong name was put in Resident #1 chart.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 21 residents (Resident #8 and Resident #14) reviewed for comprehensive care plans in that: Resident #8 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures could place residents at risk of receiving care that is not person-centered, substandard, unable to meet their needs, or inadequate to prevent complications. The findings included: Record review of Resident #8's face sheet, dated 11/01/22, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Admission MDS assessment, dated 08/28/22, revealed, in Section I titled, Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section N titled Medications revealed Resident #8 had received an anticoagulant for 7 days during the look back period. Record review of Resident #8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Start Date 08/15/22 . Record review of Resident #8's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's care plan, initiated on 08/15/22 but not yet completed, did not contain documentation for focus, goals or intervention for the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's face sheet, dated 11/01/22, revealed an [AGE] year-old female admitted to the facility on [DATE], readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's Admission MDS assessment, dated 10/07/22, revealed, in Section I titled, Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <100 (top number of blood pressure less than 100) or DBP<60 (bottom number of blood pressure less than 60) .start date 10/17/22. Record review of Resident #14's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's care plan, completed 10/18/22, did not contain documentation for focus, goals or intervention for the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/02/22 at 10:18 AM, MDSC stated he was responsible for completing care plans. He stated Resident #8's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated not having these documented could have resulted in staff not being aware and the resident could have become dizzy due to the [CONDITION(S)] and fall and potentially have increased bleeding due to the [MEDICATION(S)]. MDSC also stated that Resident #14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated not having these documented could have resulted in staff not being aware and the resident could have become dizzy due to her [CONDITION(S)] and fall from that or have a [CONDITION(S)] and fall potentially have increased bleeding due to the [MEDICATION(S)]. He stated he had received training on completing care plans through his company's resource personnel. Record review of facility provided policy titled Policy/Procedure - Nursing Administration, dated 08/2017, with a subject of Comprehensive Person-Centered Care Planning revealed, in part, POLICY: 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 .PROCEDURES: .4. The comprehensive care plan will be developed by the IDT with seven (7) days of the completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized service as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plans.

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 2 of 6 residents (Resident #1 and Resident #2) observed for infection control practices. CNA A and PTA B were observed entering Resident #1's room without proper PPE when Resident #1 was on COVID-19 related TBP. CNA C was observed entering Resident #2's room without proper PPE when Resident #2 was on COVID-19 related TBP. This failure may place residents at risk for transmissible diseases, including but not limited to, COVID-19. The findings included: Record review of Resident #1's face sheet, dated 09/20/22, revealed a [AGE] year old female admitted the facility on 09/16/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Admission MDS assessment revealed it was still in progress. Record review of Resident #1's care plan, dated 09/19/22, revealed, in part, At risk for psychosocial well-being r/t the pandemic .Resident is at risk for s/sx of COVID-19 . Educate staff, resident and visitors of COVID-19, of signs and symptoms and precautions. Record review of Resident #1's immunization chart, undated, revealed, in part, [CONDITION(S)]-COV-2 (COVID-19) (Dose 1) Consent Refused. During an observation on 09/20/22 at 8:57 AM, Resident #1 had a sign on her room door which revealed, in part, DROPLET PRECAUTIONS .EVERYONE MUST: .Make sure their eyes, nose and mouth are fully covered before room entry . There was no additional notification about PPE requirements to be worn in the room. During an observation on 09/20/22 at 9:02 AM, CNA A entered Resident #1's room wearing a gown, gloves and N95 respirator over a surgical mask. She was not wearing eye protection. She shut the door upon entrance to the room. During an interview on 09/20/22 at 9:19 AM, CNA A stated she did not wear eye protection when in Resident #1's room. She stated she did not wear eye protection because Resident #1 was on TBP only due to her not being vaccinated against COVID-19. CNA A stated she was educated by the DON on what PPE to wear in a resident's room who was on quarantine related to COVID-19, but she did not remember if the DON specified if she was supposed to wear eye protection. CNA A stated she probably should have worn eye protection and not wearing eye protection could have resulted in the spread of infection. During an observation and interview on 09/20/22 at 11:05 AM, PTA B entered Resident #1's room wearing a surgical mask only. The resident was sitting down, and PTA B was talking to her and moving around a floor mat. When PTA B exited the room, PTA B stated Resident #1 was on quarantine only due to not being up-to-date with the COVID-19 vaccines. PTA B stated she did not don additional PPE, other than her surgical mask, due to only being in Resident #1's room briefly and not physically contacting the resident and not being within 6 feet of the resident. PTA B stated that was how she was trained regarding PPE, by either the DON, the ICP or the ADON. During an observation and interview on 09/20/22 at 11:30 AM, PTA B was in Resident #1's room wearing a gown, gloves, surgical mask, and goggles that were on her head, not covering her eyes. Resident #1 was standing up with a walker, PTA B was standing next to her within 6 feet and had her hand behind Resident #1's back. PTA B stated she would be in the room for about another 15 minutes. During an interview on 09/20/22 at 11:36 AM, the ICP stated herself and the DON both were responsible for keeping up with COVID-19 policies at the facility. She stated for the residents on quarantine related to COVID-19, full PPE was to be worn in the room which included a N95 respirator, eye protection, gown, and gloves. She stated Resident #1 was not vaccinated for COVID-19 per her preference and Resident #2 was not up-to-date with his COVID-19 vaccinations. The ICP stated if staff were not wearing the appropriate PPE in a resident's room who was on quarantine related to COVID-19, the staff could have been exposed to COVID-19 or if the resident subsequently became COVID-19 positive, the staff could have spread it to other residents, resulting in an outbreak. She stated staff were reminded about COVID-19 protocols during their all-staff meetings on the first Tuesday of every month and she performed random audits monthly of observing staff wearing proper PPE in resident's room. During an Interview on 09/20/22 at 1:59 PM, PTA B stated when she was with Resident #1 earlier in Resident #1's room, she was wearing a surgical mask only. PTA B stated she asked her director, the DOR, if she was supposed to wear a surgical mask or N95 respirator when in Resident #1's room and the DOR told her a surgical mask was ok unless the resident was COVID-19 positive or if she had been in contact with a COVID-19 positive person. PTA B stated her goggles were on top of her head while she was assisting Resident #1 with her walker because her goggles had started to fog up. PTA B stated she should have had the goggles over her eyes due to droplet precautions. During an observation and interview on 09/20/22 at 3:10 PM, Resident #1 was lying in bed, no distress noted. She appeared well-groomed and her husband was at the bedside. She stated she had not received any COVID-19 vaccinations per her choice and had never had COVID-19 that she was aware of. She stated she came to the facility from a local hospital on 09/16/22. She stated just that day, 09/20/22, staff started wearing gowns and eye protection (in addition to masks and gloves) when in her room but over the weekend, they had only been wearing masks and gloves. Record review of Resident #2's face sheet, dated 09/20/22, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Admission MDS assessment revealed it was still in progress. Record review of Resident #2's care plan, dated 09/19/22, revealed, in part, At risk for psychosocial well-being r/t the pandemic .Resident is at risk for s/sx of COVID-19 . Will minimize exposure of COVID-19 presence in the community . Educate staff, resident and visitors of COVID-19, of signs and symptoms and precautions . Record review of Resident #2's immunization chart, undated, revealed, in part, [CONDITION(S)]-COV-2 (COVID-19) (Dose 2) .2/3/2021 .[CONDITION(S)]-COV-2 (COVID-19) (Dose 1) .1/13/2021 . During an observation on 09/20/22 at 8:55 AM, Resident #2 had a sign on his room door that revealed, in part, DROPLET PRECAUTIONS .EVERYONE MUST: .Make sure their eyes, nose and mouth are fully covered before room entry . There was no additional notification about PPE requirements to be worn in the room. During an observation and interview on 09/20/22 at 11:20 AM, Resident #2 was in his room, lying in bed. He did not appear in distress. He stated staff had been wearing only masks in his room since he arrived at the facility on 09/16/22 but just that day, 09/20/22, staff had started wearing the rest of the PPE in addition to their masks, such as gowns, eye protection and gloves. He stated he was told it was for COVID-19 precautions. He stated he told staff when he was first admitted that he only had the first two COVID-19 vaccinations and had not yet been able to get any additional vaccinations. During an observation and interview on 09/20/22 at 11:55 AM, CNA C entered Resident #2's room wearing a gown, goggles, surgical mask and gloves to take him a lunch tray. She sat the lunch tray down in front of Resident #2 and then doffed the PPE and exited the room. CNA C stated she was supposed to have worn an N95 respirator in Resident #2's room but did not because she was just trying to pass the lunch trays. She stated not wearing the proper PPE could have resulted in spreading the infection to other residents. During an interview on 09/20/22 at 3:19 PM, the DON stated a face shield, N95 or KN95 respirator, gown and gloves were required to be worn when in a resident's room who was on quarantine related to COVID-19. She stated goggles were supposed to covering the eyes and it was not acceptable to wear goggles on the head when in the quarantine rooms. She stated by not wearing eye protection properly, staff could have risked the resident coughing in their face and into their mucous membranes which could have potentially spread COVID-19 in their building. The DON also stated staff were to wear N95 or KN95 respirators when in quarantined rooms and a surgical mask was not acceptable. She stated not wearing the correct mask in those rooms could have resulted in the spread of disease. The DON stated the ICP was responsible for educating staff on TBP, but anyone could correct anyone else at any time if they saw someone not wearing proper PPE. During an interview on 09/20/22 at 3:47 PM, the DOR stated the policy for TBP was the same for everyone when entering a resident's room on quarantine related to COVID-19; a gown, N95 respirator, gloves and eye protection were to be worn. She stated that was her current understanding of the PPE requirements and that was what she would instruct her staff to do. During an interview on 09/20/22 at 3:58 PM with the ADM, when asked about a facility policy regarding what PPE to wear in a room with a resident on quarantine related to COVID-19, the ADM stated the facility referred to the HHSC guidance. Record review of facility provided document titled, In-Service Training Report, dated 07/27/22, with a subject of, PPE guidelines/use, revealed, in part, Content .See Attached .July 27, 2022 RE: PPE and COVID .With the building having active COVID-19 cases, it imperative ALL STAFF understand and use all proper PPE. When entering ANY ROOM that has isolation precautions, YOU MUST FOLLOW PPE guidelines This is NEVER an option as we ALWAYS have to follow proper infection control guidelines. The in-service was signed by PTA B and CNA C. Record review of facility provided document titled, In-Service Training Report, dated 08/08/22, with a subject of, Facemasks, revealed an attachment that stated, Use Personal Protective equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 .Remember: PPE must be donned correctly before entering the patient area (e.g., isolation room .) .PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas .Preferred PPE-Use N95 or Higher Respirator .face shield or goggles .N95 or higher respirator .One pair of clean, non-sterile gloves .Isolation gown . The in-service was signed by CNA A, PTA B and CNA C. Record review of document titled, COVID-19 Response for Nursing Facilities, from Texas Health and Human Services, date 06/27/22, revealed, in part, Full PPE is required (NIOSH-approved N-95 or equivalent or higher-level respirator, gown, gloves, and eye protection) for healthcare personnel working inside the Isolation (COVID-19 positive) zone and Quarantine (Unknown COVID-19) zone.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation and distribution. -Food stored in the freezer was not properly labeled, dated and stored. These failures could place residents who eat food served by the kitchen at risk of food-borne illness from cross-contamination. Findings include: During an observation of the kitchen on 9-20-2021 at 8:24 AM, the freezer in the pantry room was found to have an open bag of hash browns with no label or date on the bag. There also was a cookies and cream pie that was not labeled and had no date in the same freezer. On the freezer door there was a sign that stated All foods must be dated before being put in the freezer. During an interview with CK A on 9-20-2021 at 8:29 AM he was asked if it was expected that all food in the freezer be labeled and dated. CK A replied that all foods in the freezer should be labeled and dated. CK A was then asked when foods should be labeled and dated. CK A responded that foods going into the freezer should be labeled as soon as they are placed in the freezer. CK A confirmed that both the open bag of hash browns and the cookies and cream pie were not labeled and dated. CK A was then asked what risks were associated with not labeling or dating foods that are in the freezer. CK A replied that the kitchen could serve food to residents that are out of date and could make residents sick. He was then asked who was responsible for to check dates and train kitchen staff on how to label and date food. CK A responded that it was the dietary managers job to check dates and train kitchen staff, but the dietary manager had walked of the job the previous week. When asked why the food was not labeled CK A stated that it must have been missed and threw away the hash browns and pie while investigator was watching. During an interview with DON on 9-21-2021 at 10:14 AM, she was asked if it was her and the facility's expectation that opened food in the freezer be labeled and dated. DON responded that all food in the freezer should be labeled and dated. DON was then asked who was responsible for training kitchen staff on properly labeling food. DON responded that it was the dietary manager's responsibility and confirmed that the dietary manager had walked out the previous week. DON was then asked what risks were associated with not labeling and dated foods. DON responded that outdated food could be served to residents and it could cause the residents a GI illness. Record review of facility provided policy, dated 8/2007, titled Food, Sanitary Conditions, revealed the following: 4. Foods placed in the freezer are to be left in the original wrapping with an identifying label. If an item must be re-wrapped a moisture proof wrapping or closed container should be used to prevent freezer burn. All items must be labeled and dated.

Based on interview and record review, the facility failed to incorporate the recommendations from the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 out of 16 residents (Resident #23) who were reviewed for PASARR compliance. The facility failed to submit and get approved a NFSS request, and initiate NFSS for Resident #23 within 20 business days of a PASARR related IDT meeting that determined the need for specialized and habilitative services for the resident. This failure placed the resident at risk of not receiving specialized and/or habilitative services to meet her needs and treatment goals. Findings Include: Record review of Resident #23's face sheet, dated 09/20/2021, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #23's MDS, dated [DATE], revealed that the resident had a BIMS score of 07 out of 15, indicating severe cognitive impairment. Section G of the MDS indicated that Resident #23 required extensive assistance from staff with bed mobility, transfers, eating, personal hygiene, and dressing; and was totally dependent on staff for toilet use. Record review of Resident #23's comprehensive care plan, not dated, revealed the following: FOCUS Resident receiving PASRR services PASRR positive diagnosis. Dx: IDD Interventions IDT meeting to be completed as required. Notify local authority of any significant changes. Notify physician and responsible party of any changes. Record review of Resident #23's PASRR Level 1 Screening, dated 01/29/2021, revealed that the resident was positive on the screening for possible developmental disability. Record review of Resident #23's PE, dated 04/23/2021, revealed that the resident was recommended for specialized and habilitative services. Record review of Resident #23's PASRR Comprehensive Service Plan Form, dated 05/04/2021, revealed that an IDT meeting regarding Resident's #23's PASRR services was conducted and that specialized and/or habilitative services were recommended including ST, OT, alternate placement services, independent living skills training, and service coordination. During an interview on 09/20/2021 at 9:08 AM, Resident #23 denied having any knowledge of specialized or habilitative services that she was supposed to be receiving and was not. During an interview on 09/20/2021 at 2:47 PM, Individual B reported that she is a PASARR specialist, and that the facility is required to submit and get approved a NFSS request for a resident's PASARR services within 20 days of the IDT meeting in which the provision of such services is agreed upon. Individual B reported that it had been beyond the 20-day requirement and the facility had either not submitted a NFSS request or gotten it approved. During an interview on 09/21/2021 at 9:40 AM, DON reported that she was currently responsible for resident PASRRs, a responsibility she has assumed since 08/20/2021. DON reported that the person who was previously responsible for resident PASRRs was no longer employed at the facility. DON confirmed that Resident #23 was admitted to the facility on [DATE] and that her PASRR Level 1 was completed on 01/29/2021. DON confirmed that a PE for Resident #23 was completed on 04/23/2021 and that the resident was positive for developmental disability. DON reported that Resident #23 was recommended for OT and ST which the resident should be receiving. DON reported that the initial IDT meeting regarding Resident #23's PASARR services was conducted on 05/04/2021 during which it was determined the recommended specialized services were needed. DON reported that the facility first submitted a NFSS request on 09/09/2021, which was denied on 09/10/2021 due to date discrepancies on the form. DON reported that a second NFSS request was submitted on 09/15/2021 and was notified of needed corrections on 09/17/2021. DON reported that she tried to complete the tasks for the correction, but the system was not recognizing her actions. DON reported that she needs to contact PASARR personnel to determine what action she needs to take to get the NFSS request approved. DON reported that they (the facility) are supposed to get NFSS request approved within 20 days after the IDT meeting for the PASARR, and that approval for the NFSS request for Resident #23's services should have been submitted and acquired by 05/24/2021. DON reported that she did not know why a NFSS request was not submitted and/or approved by that date for Resident #23. When asked about the potential consequences of the NFSS request not being submitted and/or approved on time, DON replied, She [the resident] would remain in her state and possibly decline. During an interview on 09/21/2021 at 12:49 PM, DON reported that the facility did not have a policy regarding PASARR but that they adhere to the guidance on the website tmhp.com, specifically a document titled Detailed Item by Item Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services (NFSS). Record review of facility provided document titled Detailed Item by Item Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services (NFSS), dated 04/30/2021, revealed in part: Initiating PASRR nursing facility specialized services The nursing facility has 20 business days from the date of the initial IDT or a specialized services review meeting to initiate all PASRR nursing facility specialized services (NFSS) for those with a positive PE for ID/DD recommended and agreed to at the meeting. The following nursing facility habilitative specialized services must be requested by completing all required fields in the NFSS form on the LTC online Portal: Occupational Therapy (OT) Speech Therapy (ST)

Based on interview and record review, the facility failed to not admit, on or after January 1, 1989, any new residents with intellectual or developmental disability unless the State intellectual disability or developmental disability authority has determined prior to admission whether the individual requires specialized services for intellectual disability for 2 out of 16 residents (Resident #13 and Resident #23) reviewed for PASRR. The facility failed to ensure the completion of a PE for Resident #13 within 40 days of admission, after she had been in the facility for at least 30 days and her PASARR level 1 indicated that she was potentially positive for intellectual and developmental disabilities. The facility failed to ensure the completion of a PE for Resident #23 within 7 days after her PASARR level 1 indicated that she was potentially positive for developmental disability. This failure placed residents at risk of not receiving specialized and/or habilitative services to meet their needs and treatment goals. Findings Include: Record review of Resident #13's face sheet, dated 09/20/2021, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#13's MDS dated [DATE] revealed that the resident had a BIMS that could not be calculated. Section C1000 revealed that the resident was severely cognitively impaired. Section G of the MDS indicated that Resident #23 required extensive assistance from staff with bed mobility, transfers, eating, personal hygiene, and dressing; and was totally dependent on staff for toilet use. Record review of Resident #13's comprehensive care plan, not dated, revealed the following: FOCUS At risk for impaired cognitive function/dementia or impaired thought processes r/t diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interventions COMMUNICATION: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. Record review of Resident #13's PASRR Level 1 Screening, dated 12/15/2021, revealed that the resident was positive on the screening for possible intellectual disability and developmental disability. Record review of Resident #13's PE, dated 04/23/2021, revealed that the evaluation was completed 129 days after the completion of her PASRR Level 1 screening, and 129 days after her admission to the facility. The PE indicated that she did qualify for specialized and habilitative services. Record review of Resident #23's face sheet, dated 09/20/2021, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #23's MDS, dated [DATE], revealed that the resident had a BIMS score of 07 out of 15, indicating severe cognitive impairment. Section G of the MDS indicated that Resident #23 required extensive assistance from staff with bed mobility, transfers, eating, personal hygiene, and dressing; and was totally dependent on staff for toilet use. Record review of Resident #23's comprehensive care plan, not dated, revealed the following: FOCUS Resident receiving PASRR services PASRR positive diagnosis. Dx: IDD Interventions IDT meeting to be completed as required. Notify local authority of any significant changes. Notify physician and responsible party of any changes. Record review of Resident #23's PASRR Level 1 Screening, dated 01/29/2021, revealed that the resident was positive on the screening for possible developmental disability. Record review of Resident #23's PE, dated 04/23/2021, revealed that the evaluation was completed 85 days after the completion of her PASRR Level 1 screening, and 84 days after her admission to the facility. The PE indicated that she did qualify for specialized and habilitative services. During an interview on 09/21/2021 at 9:40 AM, DON reported that she was currently responsible for resident PASRRs, a responsibility she has assumed since 08/20/2021. DON reported that the person who was previously responsible for resident PASRRs was no longer employed at the facility. DON confirmed that Resident #13 was admitted on [DATE] and had a PASRR Leve 1 completed on 12/15/2020. DON confirmed that the earliest PE for Resident #13 was completed on 04/23/2021 and that the resident was positive for intellectual and developmental disabilities. DON confirmed that Resident #23 was admitted to the facility on [DATE] and that her PASRR Level 1 was completed on 01/29/2021. DON confirmed that the earliest PE for Resident #23 was completed on 04/23/2021 and that the resident was positive for developmental disability. DON reported that Resident #13 was recommended for services, which the resident's representative refused. DON reported that Resident #23 was recommended for OT and ST which the resident should be receiving. DON reported the facility may have PEs for the residents that were completed earlier on file in their paper records, and that she would look for them. During an interview on 09/22/2021 at 8:29 AM, DON reported that the facility did not have any records of PEs that were completed for Resident #13 or Resident #23 prior to the PEs completed on 04/23/2021. DON stated, sooner than that when asked when the PEs for the resident should have been completed. Record review of facility provided policy, not dated, titled PASRR - Expedited Admission Categories revealed the following 1. Convalescent Care a. Refers to a range of health services designed to help people recover from serious illness, surgery or injury. These services can consist of medical, nursing, or skilled care or therapy. They can be delivered in a variety of settings, included rehabilitation, hospitals, outpatient therapy sites, skilled nursing facilities and patient's homes. i. LA must perform and submit the PE within 7 days of the PL1 screening date 3. Severe Physical Illness a. An illness resulting in ventilator dependence or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . i. LA must perform and submit the PE within 7 days of the PL1 screening date

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 1 out 5 dumpsters (Dumpster 1) on the facility property. There was a large dumpster (Dumpster 1) in the grass on the facility property that was overfilled and not covered. This failure could affect residents by placing them at risk for infection and a decreased quality of life due to having an exterior environment which could attract vermin, flying pests, rodents, and other animals. Findings Include: During an observation on 09/20/2021 at 9:00 AM, there was a large dumpster (Dumpster 1) in the grass on facility property that was about 20 to 25 feet from the building. The dumpster was outside of and located near the rear of the facility. The dumpster had no lid or covering of any type and the trash inside was full to the top. Pieces and bags of trash could be seen sticking up above the top of the dumpster brim. During an observation on 09/20/2021 at 3:00 PM, Dumpster 1 was in the same location in which it was previously observed and remained with no lid or covering of any type. The trash inside was still full to the top. Pieces and bags of trash could still be seen sticking up above the top of the dumpster brim. During an observation on 09/21/2021 at 8:00 AM, Dumpster 1 was in the same location in which it was previously observed and remained with no lid or covering of any type. The trash inside was still full to the top. Pieces and bags of trash could still be seen sticking up above the top of the dumpster brim. During an observation on 09/21/2021 at 3:15 PM, Dumpster 1 was in the same location in which it was previously observed and remained with no lid or covering of any type. The trash inside was still full to the top. Pieces and bags of trash could still be seen sticking up above the top of the dumpster brim. During an observation on 09/22/2021 at 8:00 AM, Dumpster 1 was in the same location in which it was previously observed and remained with no lid or covering of any type. The trash inside was still full to the top. Pieces and bags of trash could still be seen sticking up above the top of the dumpster brim. During an interview on 09/22/2021 at 8:44 AM, MS reported that he was responsible for making sure that dumpsters got emptied, but that the city comes to empty them. MS reported that Dumpster 1 was a construction contractor's dumpster that was being used by the facility's contracted construction company for ongoing remodeling of the facility. MS confirmed that the dumpster was on the facility's property. During an observation and interview on 09/22/2021 at 8:49 AM, MS was taken to the site of Dumpster 1, and he confirmed that the dumpster was full to the point that trash could be seen rising above the top of it. MS confirmed that the dumpster had no cover on it. When asked why the dumpster was so full, MS replied, because we've been doing so much remodeling. When asked why the dumpster had not been emptied over the last three days, MS replied, we had to stop the contractors cause the State was in the building. When asked about the potential consequences of a full dumpster being uncovered, MS replied, vermin getting into it. Inspection of the trash in the dumpster revealed three trash bags on the top of the trash pile inside. The bags did contain disposed of food and drink containers. During an interview on 09/22/2021 at 9:00 AM, ADM was taken to the site of Dumpster 1, and he confirmed that the dumpster was on the facility's property. ADM reported that the dumpster was a contractor's dumpster being used for facility remodeling and confirmed that the dumpster was full. ADM was asked why the dumpster has remained full and not been emptied, and he reported that the contractor company had not returned to empty it. ADM was asked about the potential consequences of a full dumpster being left uncovered and replied, bugs, pests, birds, squirrels, rats. If it sits too long, risk of disease. ADM continued to say that it was an eye sore. Record review of facility provided policy titled Trash Removal, dated April 2021, revealed in part: Purpose To remove waste from all areas in order to provide protection against fire, pests, odor and infectious organisms. Procedure 8. Bring trash to dumpster, dumpster should be properly covered at all times.

Based on interviews and record review, it was determined the facility failed to implement their policies and procedures to prohibit neglect for 1 of 5 residents (Resident #5), who were assessed for constipation, received the necessary care and services to prevent a fecal impaction when: - The facility failed to recognize factors which placed Resident #5 at risk for impaction, when the resident continued to have ongoing diarrhea for approximately 50 days, and failed to monitor and evaluate Resident's #5's response to a medication ordered for diarrhea. This facility's failure is likely to have caused Resident #5 to not receive the proper care and services to prevent an impaction, maintain the highest possible level of functioning and well being, and cause an unavoidable decline in a resident's condition, and caused the resident to have abdominal pain. Resident #5 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The evidence is as follows: Resident #5 During an interview on 8/9/11 at 8:15 a.m., with Resident #5 in her room, she said she had just returned from the hospital. The resident said she told the nurses before she went to the hospital, she felt constipated, and then she had diarrhea. The resident said the diarrhea had stopped while at the hospital, and she felt much better. Review of Resident #5's clinical record documented an admission to the facility on [DATE] with the following Diagnoses: [REDACTED]. - Review of the Quarterly MDS, dated [DATE], documented Resident #5 had no long/short memory, or decision making impairment. Resident #5 required the extensive assist of one for transfer, dressing, and personal hygiene, was frequently incontinent of bowel, and had an indwelling catheter. Review of Resident #5's Bowel movement (bm) flow sheets, for May, June and July documented the following: - May 2011 : 5/6 Medium x 3, 5/8 Medium x 4, 5/10 Large x 2, 5/14 Medium x 3, 5/21 Large x 2, 5/23 X-large x 2. - June 2011: 6/3 X-large x 3, 6/4 X-large x 2, 6/5 Medium x 4, 6/7 X-large x 2, 6/8 Large x 2, 6/23 X-large x 3, 6/25 X-large x 2, 6/30 X-large x 3. - July 2011: 7/3 X-large x 2, 7/20 Large x 4, 7/22 X-large x 2. (Note, no consistency of bm's was noted on the flow sheets) 1. During an interview on 8/10/11 at 10:45 a.m., with the DON, she said Resident #5 was having bm's all along. The resident "Had a high impaction which was found on X-ray, we didn't know". 2. During an interview on 8/8/11 at 1:50 p.m., with the ADON, he said the resident had been listed as having a bowel movement every day on the bowel movement flow sheet. The flow sheet did not list the consistency of the bowel movements. One of the Charge Nurses had talked to the MD concerning Resident #5's diarrhea, and was started on Questran. The ADON said the Charge Nurse did not think about an impaction because the diarrhea wasn't watery, and the resident had bowel sounds. - Review of a hand written statement, dated 8/3/11 and signed by the ADON documented the following: Explained to nurse (LVN "A") importance of doing a proper assessment regarding impaction's, because an impaction is very dangerous. Explained when a resident has diarrhea it may be beneficial to check rectally for an impaction. Explained she was not the only nurse involved, and the DON and ADON were discussing holding an in service with all the nurses. 3. During an interview on 8/9/11 at 2:35 p.m., with CNA "G", she said Resident #5's stools were loose and grainy for months. CNA "G" said " I would tell the nurse about the diarrhea". 4. During an interview on 8/9/11 at 2:45 p.m., with CNA "H", she said the resident's stools were runny, gritty, and never formed for at least 2 months. CNA "H" said the resident would say to her "Look at my stomach, it's hard". CNA "H" said she would report the diarrhea to the nurses. When asked if the nurse would observe the stool, said "No, not usually". 5. During an interview on 8/9/11 at 3:00 p.m., with CNA "I", said she had worked at the facility about 8 weeks, said Resident #5's , "Stools are like runny, they have never changed". When asked if she reported the diarrhea, said "Sure did". 6. During an interview on 8/9/11 at 10:15 a.m., with LVN "A", she said Resident #5 had told her "I can't stop having diarrhea". LVN "A" said she contacted the MD about the diarrhea, and he ordered Questran (used for the management of diarrhea). LVN "A" described the resident's stomach as "A little hard", and said, "It never crossed my mind she had an impaction, because she had diarrhea". When asked if she had performed a rectal exam, said "No, I didn't". - During a follow up interview on 8/10/11 at 10:20 a.m., with LVN "A", she said the diarrhea had started in June. The LVN described it as runny, "You could pour it out of a cup like water". LVN "A" said "It wasn't a little bit, it was half a depends full". LVN "A" said after the Questran was started, she did not monitor or evaluate the effectiveness of the medication. She said she relied on the CNA's to tell her about the diarrhea. LVN "A" said she saw Resident # 5's diarrhea once in June, when she contacted the MD. LVN "A" said "I had no idea what was causing the diarrhea, the resident was on an antibiotic at the time, I didn't know what was going on". - Review of Resident #5's nurse's notes, dated 6/6/11 and signed by LVN "A" documented the following - 10:00 a.m., Resident remains on antibiotic with no drainage from left ear. Pharmacy notified of not receiving newly ordered med. Will continue to monitor. (No documentation of diarrhea was noted.) - Review of Physician's progress notes concerning Resident #5 documented the following: - 5/5/11 Complains of diarrhea. Check Stool - 6/9/11 Wants diet liberalized, may have tomatoes. (Note no documentation about Questran being ordered for diarrhea on 6/6/11.) - Review of physician's orders [REDACTED]. Ova (Eggs) and Parasites, [MEDICAL CONDITION] (Test to check for bacteria in stool) - Review of the Laboratory results, dated 5/13/11 documented the following: Ova and Parasites, Not detected [MEDICAL CONDITION], Not detected - Review of the physician's orders [REDACTED]. Questran 4 gm pkt (packet) one, by mouth with water, twice a day. 7. During an interview on 8/8/11 at 4:45 p.m., with LVN "B", she said on the evening of July 27th, she noticed Resident #5 had abdominal distention and decreased bowel sounds. LVN "B" said she notified the PA. The PA came in later in the evening, assessed the resident ordered a STAT (Immediate) CT Scan of the abdomen. LVN "B" said she did not do a rectal exam. When asked if an order was needed to do a rectal exam to check for impaction, she said "No, it's on our standing orders". She said the CNA's had not informed her at any time of diarrhea stools, and she would not normally look at bm's, she relied on the CNA's for that. - Review of Resident #5's nurse's notes and signed by LVN "B" documented the following: - 6/8/11 2 p.m./10 p.m. Continues on Questran for loose stools, no distress noted. - 7/25/11 1730 (5:30 p.m.) PA here to assess resident. N/O(new order) for STAT CTAbdomen and Pelvis with contrast. Scheduled 8:15 a.m. on 7/26/11. STAT CBC, [MEDICAL CONDITION] toxin. Complains of tenderness to abdomen, slight distention noted, bowel sounds x 4 quads. - 7/26/11 2100 (9:00 p.m.) Resident continues with increased confusion, abdominal distention. Received results from CT scan, PA notified, results faxed. Received call from PA to transfer to emergency room per EMS. (Note resident in hospital until 7/29/11) - Review of the CT of Abdomen/Pelvis scan results, dated 7/26/11 at 8:32 a.m., documented the following: Severe Obstipation (Extreme and persistent constipation caused by obstruction in the intestinal or eliminatory system 8. During a phone interview on 8/10/11 at 10:40 p.m., with the MD, he said he saw Resident #5 routinely. The resident would have intermittent diarrhea or constipation episodes. The MD said he would expect the facility to check for impaction, and notify him. He said he was "Out of town when it happened, so I really don't know what happened". 9. During a phone interview on 8/9/11 at 10:40 a.m., with the PA, she said she was notified Resident # 5 was uncomfortable. Upon her examination on 7/25/11, she said Resident #5 "Was not herself, not as alert and appeared uncomfortable". The PA said Resident #5 had decreased bowel sounds, her abdomen was distended and tender, but had no rigidity. She said she ordered a CT, and some lab, and was not aware of any diarrhea issues. The PA said she notified Resident's #5's son about her condition, and said "The son understood this was worse than constipation". - Review of Facility Progress Notes, dated 7/25/11, no time listed, and signed by the PA documented the following: - Bowel sounds diminished, abdomen is protuberant (large, swollen) distended and hardened. Diffuse (all over) tenderness in all four quadrants with out guarding, rigidity, and rebound. Suspect Impaction versus Obstruction, condition more likely due to impaction. - Review of the Physician Orders, dated 7/25/11, no time listed, and signed by the PA, documented the following: - STAT CT- Abdomen and pelvis with contrast , CBC, [MEDICAL CONDITION]. - Review of the CT of Abdomen/Pelvis scan results, dated 7/26/11 at 8:32 a.m., documented the following: Severe Obstipation (Extreme and persistent constipation caused by obstruction in the intestinal or eliminatory system) 10. Review of the Emergency Department Room notes on 7/26/11, had no MD documentation. 11. Review of the Hopsital Admission History and Physical, dated 7/26/11, no time listed, documented the following: - [AGE] year old female transferred from nursing home, because she was not acting her usual self, having increasing abdominal distension and complaining of abdominal pain. A CT Scan performed on 7/26/11 showed severe Obstipation. The ER physician noticed severe fecal impaction and manually disimpacted the bowel. 12. During an interview on 8/10/11 at 2:15 p.m., with RN "B", she said she knew the resident had diarrhea, but had not seen any of the residents stools. RN "B" said "She had an infection and I thought the diarrhea was because of that. After the X-ray we figured out what was wrong". RN "B" said she had not done a rectal exam or had seen any of the stools. - Review of Nurse's Notes, dated 7/30/11 at 00:48 a.m., , and signed by RN "B" documented the following: - Abdomen distended and hard on palpation. States has some tenderness on palpation. Hypoactive bowel sounds x 4 at this time. 13. During an interview on 8/10/11 at 11:25 a.m., with RN "A" she said Resident #5 complained of abdominal pain, and she sent the resident to the emergency roiagnom on [DATE]. - Review of the Nurse's Notes, and signed by RN "A" documented the following: - 7/30/11 1430 (2:30 p.m.) Resident complains of abdominal pain, rated 10/10 (0=no pain 10=severe pain). Abdomen distended and tender to touch. Bowel sounds hypoactive x 4. Notified FNP on call, received order for STAT KUB (Flat X-ray of Abdomen). Administered [MEDICATION NAME]. - 7/31/11 9:45 a.m. Resident stated she had pain in abdomen. Rated pain at 10. Administered [MEDICATION NAME]. Abdomen distended and tender to touch, hypoactive bowel sounds x 4. - 7/31/11 10:35 a.m. Resident stated she still had pain, rates pain at 10. - Review of the physician's orders [REDACTED]. STAT KUB - Review of the KUB Radiology report, dated 7/30/11 at 4:04 p.m., documented the following: Moderate colonic ileus (an obstruction of the intestines) with stool. 16. Review of the Emergency Department Physician Record, dated 7/31/11 at 12:44 p.m., documented the following: - Admit 7/26/11 for confusion, back to nursing home on 7/29/11. Last 2 days has had increasing distention of abdomen. Was noted to be impacted at presentation to ED on 7/26/11, was manually disimpacted in the ED. (7/26/11). Diagnosis, Colonic Ileus (an obstruction of the intestines) [DIAGNOSES REDACTED] (obstruction at a flexure, bend in colon). - Review of the CTAbdomen/Pelvis report dated, 7/31/11 at 11:55 a.m., documented the following: A large amount of stool is seen. - Review of the Emergency Department Physician order [REDACTED]. [MEDICAL CONDITION] Tube, to low suction. (Used to decompress the stomach in treating obstruction) - Review of the Emergency Department Nursing Notes, dated 7/31/11 at 2:10 p.m., documented the following: [MEDICAL CONDITION] tube placed right nares (nostril) placed on low suction. - Review of the [MEDICATION NAME] Enema X-ray Report, dated 7/31/11 at 3:04 p.m., documented the following: The exam is compromised because the colon is full of stool. 17. Review of Admission History and Physical, dated 7/31/11, no time listed, documented the following: - [AGE] year old female admitted with abdominal distention, Obstipation, and a ileus for which she has been placed on nothing per mouth status, and has a [MEDICAL CONDITION] tube to suction. 18. Review of the facility form titled, Start Up Orders, no date, documented the following: - May check for and remove fecal impaction per licensed nurse whenever necessary. 19. Review of a facility submitted form untitled, undated, identified 6 residents as having constipation frequently. 20. Review of CMS 672 titled, Resident Census and Conditions of Residents, dated 8/8/11, documented the facility had a census of 66.

Based on interviews and record review, it was determined the facility failed to ensure 1 of 5 residents (Resident #5), who were assessed for constipation, received the necessary care and services to attain or maintain the highest practicable physical well being, to prevent a fecal impaction when: - The facility failed to recognize factors which placed Resident #5 at risk for impaction, when the resident continued to have ongoing diarrhea for approximately 50 days, and failed to monitor and evaluate Resident's #5's response to a medication ordered for diarrhea. This facility's failure placed Resident #5 and the five other residents, who were identified as having constipation, at risk to not receive the proper care and services to prevent an impaction, maintain the highest possible level of functioning and well being, cause an unavoidable decline in a resident's condition, and caused the resident to have unnecessary abdominal pain. Resident #5 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. The evidence is as follows: Resident #5 During an interview on 8/9/11 at 8:15 a.m., with Resident #5 in her room, she said she had just returned from the hospital. The resident said she told the nurses she felt constipated, and then she had diarrhea. The resident said the diarrhea had stopped while at the hospital, and she felt much better. Review of Resident #5's clinical record documented an admission to the facility on [DATE] with the following Diagnoses: [REDACTED]. - Review of the Quarterly MDS, dated [DATE], documented Resident #5 had no long/short memory, or decision making impairment. Resident #5 required the extensive assist of one for transfer, dressing, and personal hygiene, was frequently incontinent of bowel, and had an indwelling catheter. - Review of the Comprehensive Plan of Care, dated 7/12/11, decremented a problem need related to Incontinence of bowel. Monitoring for incontinence every 2 hours/prn, change promptly and apply a protective skin barrier. Monitor for skin breakdown, report to MD. Assess for possible toileting program annually and prn. There was no care plan addressing constipation. Review of Resident #5's Bowel movement (bm) flow sheets, for May, June and July documented the following: - May 2011 : 5/6 Medium x 3, 5/8 Medium x 4, 5/10 Large x 2, 5/14 Medium x 3, 5/21 Large x 2, 5/23 X-large x 2. - June 2011: 6/3 X-large x 3, 6/4 X-large x 2, 6/5 Medium x 4, 6/7 X-large x 2, 6/8 Large x 2, 6/23 X-large x 3, 6/25 X-large x 2, 6/30 X-large x 3. - July 2011: 7/3 X-large x 2, 7/20 Large x 4, 7/22 X-large x 2. (Note, no consistency of bm's was noted on the flow sheets) 1. During an interview on 8/10/11 at 10:45 a.m., with the DON, she said Resident #5 was having bm's all along. The resident "Had a high impaction which was found on X-ray, we didn't know". 2. During an interview on 8/8/11 at 1:50 p.m., with the ADON, he said the resident had been listed as having a bowel movement every day on the bowel movement flow sheet. The flow sheet did not list the consistency of the bowel movements. One of the Charge Nurses had talked to the MD concerning Resident #5's diarrhea, and was started on Questran. The ADON said the Charge Nurse did not think about an impaction because the diarrhea wasn't watery, and the resident had bowel sounds. - Review of a hand written statement, dated 8/3/11 and signed by the ADON documented the following: Explained to nurse (LVN "A") importance of doing a proper assessment regarding impaction's, because an impaction is very dangerous. Explained when a resident has diarrhea it may be beneficial to check rectally for an impaction. Explained she is not the only nurse involved, and the DON and ADON were discussing holding an in service with all the nurses. 3. During an interview on 8/9/11 at 2:35 p.m., with CNA "G", she said Resident #5's stools were loose and grainy. CNA "G" said " I would tell the nurse about the diarrhea". 4. During an interview on 8/9/11 at 2:45 p.m., with CNA "H", she said the resident's stools were runny, gritty, and never formed. CNA "H" said the resident would say to her "Look at my stomach, it's hard". CNA "H" said she would report the diarrhea to the nurses. When asked if the nurse would observe the stool, said "No, not usually". 5. During an interview on 8/9/11 at 3:00 p.m., with CNA "I", said she had worked at the facility about 8 weeks, and said Resident #5's , "Stools are like runny, they have never changed". When asked if she reported the diarrhea, said "Sure did". 6. During an interview on 8/9/11 at 10:15 a.m., with LVN "A", she said Resident #5 had told her "I can't stop having diarrhea". LVN "A" said she contacted the MD about the diarrhea, and he ordered Questran (used for the management of diarrhea). LVN "A" described the resident's stomach as "A little hard", and said, "It never crossed my mind she had an impaction, because she had diarrhea". When asked if she had performed a rectal exam, said "No, I didn't". - During a follow up interview on 8/10/11 at 10:20 a.m., with LVN "A", she said the diarrhea had started in June. The LVN described it as runny, "You could pour it out of a cup like water". LVN "A" said "It wasn't a little bit, it was half a depends full". LVN "A" said after the Questran was started, she did not monitor or evaluate the effectiveness of the medication. She said she relied on the CNA's to tell her about the diarrhea. LVN "A" said she saw Resident # 5's diarrhea once in June, when she contacted the MD. LVN "A" said "I had no idea what was causing the diarrhea, the resident was on an antibiotic at the time, I didn't know what was going on". - Review of Resident #5's nurse's notes, dated 6/6/11 and signed by LVN "A" documented the following - 10:00 a.m., Resident remains on antibiotic with no drainage from left ear. Pharmacy notified of not receiving newly ordered med. Will continue to monitor. (No documentation of diarrhea was noted.) - Review of Physician's progress notes concerning Resident #5 documented the following: - 5/5/11 Complains of diarrhea. Check Stool - 6/9/11 Wants diet liberalized, may have tomatoes. (Note no documentation about Questran being ordered for diarrhea on 6/6/11.) - Review of physician's orders [REDACTED]. Ova (Eggs) and Parasites, [MEDICAL CONDITION] (Test to check for bacteria in stool) - Review of the Laboratory results, dated 5/13/11 documented the following: Ova and Parasites, Not detected [MEDICAL CONDITION], Not detected - Review of the physician's orders [REDACTED]. Questran 4 gm pkt (packet) one, by mouth with water, twice a day. 7. During an interview on 8/8/11 at 4:45 p.m., with LVN "B", she said on the evening of July 27th, she noticed Resident #5 had abdominal distention and decreased bowel sounds. LVN "B" said she notified the PA. The PA came in later in the evening, assessed the resident ordered a STAT (Immediate) CT Scan of the abdomen. LVN "B" said she did not do a rectal exam. When asked if an order was needed to do a rectal exam to check for impaction, she said "No, it's on our standing orders". She said the CNA's had not informed her at any time of diarrhea stools, and she would not normally look at bm's, she relied on the CNA's for that. - Review of Resident #5's nurse's notes and signed by LVN "B" documented the following: - 6/8/11 2 p.m./10 p.m. Continues on Questran for loose stools, no distress noted. - 7/25/11 1730 (5:30 p.m.) PA here to assess resident. N/O(new order) for STAT CT Abdomen and Pelvis with contrast. Scheduled 8:15 a.m. on 7/26/11. STAT CBC, [MEDICAL CONDITION] toxin. Complains of tenderness to abdomen, slight distention noted, bowel sounds X 4 quads. - 7/26/11 2100 (9:00 p.m.) Resident continues with increased confusion, abdominal distention. Received results from CT scan, PA notified, results faxed. Received call from PA to transfer to emergency room per EMS. (Note resident in hospital until 7/29/11) 8. During a phone interview on 8/10/11 at 10:40 p.m., with the MD, he said he saw Resident #5 routinely. The resident would have intermittent diarrhea or constipation episodes. The MD said he would expect the facility to check for impaction, and notify him. He said he was "Out of town when it happened, so I really don't know what happened". 9. During a phone interview on 8/9/11 at 10:40 a.m., with the PA, she said she was notified Resident # 5 was uncomfortable. Upon her examination on 7/25/11, she said Resident #5 "Was not herself, not as alert and appeared uncomfortable". The PA said Resident #5 had decreased bowel sounds, her abdomen was distended and tender, but had no rigidity. She said she ordered a CT, and some lab, and was not aware of any diarrhea issues. The PA said she notified Resident's #5's son about her condition, and said "The son understood this was worse than constipation". - Review of Facility Progress Notes, dated 7/25/11, no time listed, and signed by the PA documented the following: - Bowel sounds diminished, abdomen is protuberant (large, swollen) distended and hardened. Diffuse (all over) tenderness in all four quadrants with out guarding, rigidity, and rebound. Suspect Impaction versus Obstruction, condition more likely due to impaction. - Review of the Physician Orders, dated 7/25/11, no time listed, and signed by the PA, documented the following: - STAT CT- Abdomen and pelvis with contrast , CBC, [MEDICAL CONDITION]. - Review of the CT of Abdomen/Pelvis scan results, dated 7/26/11 at 8:32 a.m., documented the following: Severe Obstipation (Extreme and persistent constipation caused by obstruction in the intestinal or eliminatory system) 10. Review of the Emergency Department Room notes on 7/26/11, had no MD documentation. 11. Review of the Admission History and Physical, dated 7/26/11, no time listed, documented the following: - [AGE] year old female transferred from nursing home, because she was not acting her usual self, having increasing abdominal distension and complaining of abdominal pain. A CT Scan performed on 7/26/11 showed severe Obstipation. The ER physician noticed severe fecal impaction and manually disimpacted the bowel. 12. During an interview on 8/10/11 at 2:15 p.m., with RN "B", she said she knew the resident had diarrhea, but had not seen any of the residents stools. RN "B" said "She had an infection and I thought the diarrhea was because of that. After the X-ray we figured out what was wrong". RN "B" said she had not done a rectal exam or had seen any of the stools. - Review of Nurse's Notes, dated 7/30/11 at 00:48 a.m., , and signed by RN "B" documented the following: - Abdomen distended and hard on palpation. States has some tenderness on palpation. Hypoactive bowel sounds x 4 at this time. 13. During an interview on 8/10/11 at 11:25 a.m., with RN "A" she said Resident #5 complained of abdominal pain, and she sent the resident to the emergency roiagnom on [DATE]. - Review of the Nurse's Notes, and signed by RN "A" documented the following: - 7/30/11 1430 (2:30 p.m.) Resident complains of abdominal pain, rated 10/10 (0=no pain 10=severe pain). Abdomen distended and tender to touch. Bowel sounds hypoactive x 4. Notified FNP on call, received order for STAT KUB (Flat X-ray of Abdomen). Administered [MEDICATION NAME]. - 7/31/11 9:45 a.m. Resident stated she had pain in abdomen. Rated pain at 10. Administered [MEDICATION NAME]. Abdomen distended and tender to touch, hypoactive bowel sounds x 4. - 7/31/11 10:35 a.m. Resident stated she still had pain, rates pain at 10. - Review of the physician's orders [REDACTED]. STAT KUB - Review of the KUB Radiology report, dated 7/30/11 at 4:04 p.m., documented the following: Moderate Colonic ileus (an obstruction of the intestines) with stool. 16. Review of the Emergency Department Physician Record, dated 7/31/11 at 12:44 p.m., documented the following: - Admit 7/26/11 for confusion, back to nursing home on 7/29/11. Last 2 days has had increasing distention of abdomen. Was noted to be impacted at presentation to ED on 7/26/11, was manually disimpacted in the ED. (7/26/11). Diagnosis, Colonic Ileus (an obstruction of the intestines) [DIAGNOSES REDACTED] (obstruction at a flexure, bend in colon). - Review of the CT Abdomen/Pelvis report dated, 7/31/11 at 11:55 a.m., documented the following: A large amount of stool is seen. - Review of the Emergency Department Physician order [REDACTED]. [MEDICAL CONDITION] Tube, to low suction. (Used to decompress the stomach in treating obstruction) - Review of the Emergency Department Nursing Notes, dated 7/31/11 at 2:10 p.m., documented the following: [MEDICAL CONDITION] tube placed right nares (nostril) placed on low suction. - Review of the [MEDICATION NAME] Enema X-ray Report, dated 7/31/11 at 3:04 p.m., documented the following: The exam is compromised because the colon is full of stool. 17. Review of Admission History and Physical, dated 7/31/11, no time listed, documented the following: - [AGE] year old female admitted with abdominal distention, Obstipation, and a ileus for which she has been placed on nothing per mouth status, and has a [MEDICAL CONDITION] tube to suction. 18. Review of the facility form titled, Start Up Orders, no date, documented the following: - May check for and remove fecal impaction per licensed nurse whenever necessary. 19. Review of a facility submitted form untitled, undated, identified 6 residents as having constipation frequently. 20. Review of CMS 672 titled, Resident Census and Conditions of Residents, dated 8/8/11, documented the facility had a census of 66.

Based on interviews and record review, it was determined the facility failed to implement their written policies and procedures to prohibit neglect for 1 of 5 residents (Resident #5), who were assessed for constipation, received the necessary care and services to prevent a fecal impaction when: - The facility failed to recognize factors which placed Resident #5 at risk for impaction, when the resident continued to have ongoing diarrhea for approximately 50 days, and failed to monitor and evaluate Resident's #5's response to a medication ordered for diarrhea. This facility's failure is placed the ikely to have caused Resident #5 to not receive the proper care and services to prevent an impaction, maintain the highest possible level of functioning and well being, and cause an unavoidable decline in a resident's condition, and caused the resident to have abdominal pain. Resident #5 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. The evidence is as follows: 1. Review of the facility submitted Policy and Procedure titled, Abuse Policy, dated 1/2008 documented the following: - It is the policy of this facility to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare had been or may be adversely affected by abuse or neglect caused by another person. - Abuse, any act failure to aact or incitement ot act done willfully, knowingly, or recklessly through words, or physical action which causes or could cause mental or phsical injury to harm or death to a resident. - Neglect, the failure to provide goods and services necessary to avoid physical harm, anguish, or mental illness. 2. During an interview on 8/9/11 at 8:15 a.m., with Resident #5 in her room, she said she had just returned from the hospital. The resident said she told the nurses she felt constipated, and then she had diarrhea. The resident said the diarrhea had stopped while at the hospital, and she felt much better. Review of Resident #5's clinical record documented an admission to the facility on [DATE] with the following Diagnoses: [REDACTED]. - Review of the Quarterly MDS, dated [DATE], documented Resident #5 had no long/short memory, or decision making impairment. Resident #5 required the extensive assist of one for transfer, dressing, and personal hygiene, was frequently incontinent of bowel, and had an indwelling catheter. Review of Resident #5's Bowel movement (bm) flow sheets, for May, June and July documented the following: - May 2011 : 5/6 Medium x 3, 5/8 Medium x 4, 5/10 Large x 2, 5/14 Medium x 3, 5/21 Large x 2, 5/23 X-large x 2. - June 2011: 6/3 X-large x 3, 6/4 X-large x 2, 6/5 Medium x 4, 6/7 X-large x 2, 6/8 Large x 2, 6/23 X-large x 3, 6/25 X-large x 2, 6/30 X-large x 3. - July 2011: 7/3 X-large x 2, 7/20 Large x 4, 7/22 X-large x 2. (Note, no consistency of bm's was noted on the flow sheets) 3. During an interview on 8/10/11 at 10:45 a.m., with the DON, she said Resident #5 was having bm's all along. The resident "Had a high impaction which was found on X-ray, we didn't know". 4. During an interview on 8/8/11 at 1:50 p.m., with the ADON, he said the resident had been listed as having a bowel movement every day on the bowel movement flow sheet. The flow sheet did not list the consistency of the bowel movements. One of the Charge Nurses had talked to the MD concerning Resident #5's diarrhea, and was started on Questran. The ADON said the Charge Nurse did not think about an impaction because the diarrhea wasn't watery, and the resident had bowel sounds. - Review of a hand written statement, dated 8/3/11 and signed by the ADON documented the following: Explained to nurse (LVN "A") importance of doing a proper assessment regarding impaction's, because an impaction is very dangerous. Explained when a resident has diarrhea it may be beneficial to check rectally for an impaction. Explained she is not the only nurse involved, and the DON and ADON were discussing holding an in service with all the nurses. 5. During an interview on 8/9/11 at 2:35 p.m., with CNA "G", she said Resident #5's stools were loose and grainy for months. CNA "G" said " I would tell the nurse about the diarrhea". 6. During an interview on 8/9/11 at 2:45 p.m., with CNA "H", she said the resident's stools were runny, gritty, and never formed for at least 2 months. CNA "H" said the resident would say to her "Look at my stomach, it's hard". CNA "H" said she would report the diarrhea to the nurses. When asked if the nurse would observe the stool, said "No, not usually". 7. During an interview on 8/9/11 at 3:00 p.m., with CNA "I", said she had worked at the facility about 8 weeks, and said Resident #5's , "Stools are like runny, they have never changed". When asked if she reported the diarrhea, said "Sure did". 8. During an interview on 8/9/11 at 10:15 a.m., with LVN "A", she said Resident #5 had told her "I can't stop having diarrhea". LVN "A" said she contacted the MD about the diarrhea, and he ordered Questran (used for the management of diarrhea). LVN "A" described the resident's stomach as "A little hard", and said, "It never crossed my mind she had an impaction, because she had diarrhea". When asked if she had performed a rectal exam, said "No, I didn't". - During a follow up interview on 8/10/11 at 10:20 a.m., with LVN "A", she said the diarrhea had started in June. The LVN described it as runny, "You could pour it out of a cup like water". LVN "A" said "It wasn't a little bit, it was half a depends full". LVN "A" said after the Questran was started, she did not monitor or evaluate the effectiveness of the medication. She said she relied on the CNA's to tell her about the diarrhea. LVN "A" said she saw Resident # 5's diarrhea once in June, when she contacted the MD. LVN "A" said "I had no idea what was causing the diarrhea, the resident was on an antibiotic at the time, I didn't know what was going on". - Review of Resident #5's nurse's notes, dated 6/6/11 and signed by LVN "A" documented the following - 10:00 a.m., Resident remains on antibiotic with no drainage from left ear. Pharmacy notified of not receiving newly ordered med. Will continue to monitor. (No documentation of diarrhea was noted.) - Review of Physician's progress notes concerning Resident #5 documented the following: - 5/5/11 Complains of diarrhea. Check Stool - 6/9/11 Wants diet liberalized, may have tomatoes. (Note no documentation about Questran being ordered for diarrhea on 6/6/11.) - Review of physician's orders [REDACTED]. Ova (Eggs) and Parasites, [MEDICAL CONDITION] (Test to check for bacteria in stool) - Review of the Laboratory results, dated 5/13/11 documented the following: Ova and Parasites, Not detected [MEDICAL CONDITION], Not detected - Review of the physician's orders [REDACTED]. Questran 4 gm pkt (packet) one, by mouth with water, twice a day. 9. During an interview on 8/8/11 at 4:45 p.m., with LVN "B", she said on the evening of July 27th, she noticed Resident #5 had abdominal distention and decreased bowel sounds. LVN "B" said she notified the PA. The PA came in later in the evening, assessed the resident ordered a STAT (Immediate) CT Scan of the abdomen. LVN "B" said she did not do a rectal exam. When asked if an order was needed to do a rectal exam to check for impaction, she said "No, it's on our standing orders". She said the CNA's had not informed her at any time of diarrhea stools, and she would not normally look at bm's, she relied on the CNA's for that. - Review of Resident #5's nurse's notes and signed by LVN "B" documented the following: - 6/8/11 2 p.m./10 p.m. Continues on Questran for loose stools, no distress noted. - 7/25/11 1730 (5:30 p.m.) PA here to assess resident. N/O(new order) for STAT CTAbdomen and Pelvis with contrast. Scheduled 8:15 a.m. on 7/26/11. STAT CBC, [MEDICAL CONDITION] toxin. Complains of tenderness to abdomen, slight distention noted, bowel sounds X 4 quads. - 7/26/11 2100 (9:00 p.m.) Resident continues with increased confusion, abdominal distention. Received results from CT scan, PA notified, results faxed. Received call from PA to transfer to emergency room per EMS. (Note resident in hospital until 7/29/11) 10. During a phone interview on 8/10/11 at 10:40 p.m., with the MD, he said he saw Resident #5 routinely. The resident would have intermittent diarrhea or constipation episodes. The MD said he would expect the facility to check for impaction, and notify him. He said he was "Out of town when it happened, so I really don't know what happened". 11. During a phone interview on 8/9/11 at 10:40 a.m., with the PA, she said she was notified Resident # 5 was uncomfortable. Upon her examination on 7/25/11, she said Resident #5 "Was not herself, not as alert and appeared uncomfortable". The PA said Resident #5 had decreased bowel sounds, her abdomen was distended and tender, but had no rigidity. She said she ordered a CT, and some lab, and was not aware of any diarrhea issues. The PA said she notified Resident's #5's son about her condition, and said "The son understood this was worse than constipation". - Review of Facility Progress Notes, dated 7/25/11, no time listed, and signed by the PA documented the following: - Bowel sounds diminished, abdomen is protuberant (large, swollen) distended and hardened. Diffuse (all over) tenderness in all four quadrants with out guarding, rigidity, and rebound. Suspect Impaction versus Obstruction, condition more likely due to impaction. - Review of the Physician Orders, dated 7/25/11, no time listed, and signed by the PA, documented the following: - STAT CT- Abdomen and pelvis with contrast , CBC, [MEDICAL CONDITION]. - Review of the CT of Abdomen/Pelvis scan results, dated 7/26/11 at 8:32 a.m., documented the following: Severe Obstipation (Extreme and persistent constipation caused by obstruction in the intestinal or eliminatory system) 12. Review of the Emergency Department Room notes on 7/26/11, had no MD documentation. 13. Review of the Admission History and Physical, dated 7/26/11, no time listed, documented the following: - [AGE] year old female transferred from nursing home, because she was not acting her usual self, having increasing abdominal distension and complaining of abdominal pain. A CT Scan performed on 7/26/11 showed severe Obstipation. The ER physician noticed severe fecal impaction and manually disimpacted the bowel. 14. During an interview on 8/10/11 at 2:15 p.m., with RN "B", she said she knew the resident had diarrhea, but had not seen any of the residents stools. RN "B" said "She had an infection and I thought the diarrhea was because of that. After the X-ray we figured out what was wrong". RN "B" said she had not done a rectal exam or had seen any of the stools. - Review of Nurse's Notes, dated 7/30/11 at 00:48 a.m., , and signed by RN "B" documented the following: - Abdomen distended and hard on palpation. States has some tenderness on palpation. Hypoactive bowel sounds x 4 at this time. 15. During an interview on 8/10/11 at 11:25 a.m., with RN "A" she said Resident #5 complained of abdominal pain, and she sent the resident to the emergency roiagnom on [DATE]. - Review of the Nurse's Notes, and signed by RN "A" documented the following: - 7/30/11 1430 (2:30 p.m.) Resident complains of abdominal pain, rated 10/10 (0=no pain 10=severe pain). Abdomen distended and tender to touch. Bowel sounds hypoactive x 4. Notified FNP on call, received order for STAT KUB (Flat X-ray of Abdomen). Administered [MEDICATION NAME]. - 7/31/11 9:45 a.m. Resident stated she had pain in abdomen. Rated pain at 10. Administered [MEDICATION NAME]. Abdomen distended and tender to touch, hypoactive bowel sounds x 4. - 7/31/11 10:35 a.m. Resident stated she still had pain, rates pain at 10. - Review of the physician's orders [REDACTED]. STAT KUB - Review of the KUB Radiology report, dated 7/30/11 at 4:04 p.m., documented the following: Moderate colonic ileus (an obstruction of the intestines) with stool. 16. Review of the Emergency Department Physician Record, dated 7/31/11 at 12:44 p.m., documented the following: - Admit 7/26/11 for confusion, back to nursing home on 7/29/11. Last 2 days has had increasing distention of abdomen. Was noted to be impacted at presentation to ED on 7/26/11, was manually disimpacted in the ED. (7/26/11). Diagnosis, Colonic Ileus (an obstruction of the intestines) [DIAGNOSES REDACTED] (obstruction at a flexure, bend in colon). - Review of the CTAbdomen/Pelvis report dated, 7/31/11 at 11:55 a.m., documented the following: A large amount of stool is seen. - Review of the Emergency Department Physician order [REDACTED]. [MEDICAL CONDITION] Tube, to low suction. (Used to decompress the stomach in treating obstruction) - Review of the Emergency Department Nursing Notes, dated 7/31/11 at 2:10 p.m., documented the following: [MEDICAL CONDITION] tube placed right nares (nostril) placed on low suction. - Review of the [MEDICATION NAME] Enema X-ray Report, dated 7/31/11 at 3:04 p.m., documented the following: The exam is compromised because the colon is full of stool. 17. Review of Admission History and Physical, dated 7/31/11, no time listed, documented the following: - [AGE] year old female admitted with abdominal distention, Obstipation, and a ileus for which she has been placed on nothing per mouth status, and has a [MEDICAL CONDITION] tube to suction. 18. Review of the facility form titled, Start Up Orders, no date, documented the following: - May check for and remove fecal impaction per licensed nurse whenever necessary. 19. Review of a facility submitted form untitled, undated, identified 6 residents as having constipation frequently. 20. Review of CMS 672 titled, Resident Census and Conditions of Residents, dated 8/8/11, documented the facility had a census of 66.

Based on observations, interviews and record reviews, it was determined the facility - 1) Failed to ensure 1 of 4 sampled residents received adequate supervision during a mechanical stand-up lift transfer (Resident #11). 2) Failed to monitor 1 of 1 mechanical stand-up lift to ensure it consistently functioned safely; 3) Failed to ensure staff were trained to use the emergency stop button for 1 of 1 mechanical stand-up lift and the emergency bleed-off valve, which would enable the hydraulic lift arm to be manually lowered. While CNA "B" transferred Resident #11 (a resident with a kyphotic spine and osteoporosis) by means of a mechanical stand-up lift, the hydraulic lift arm independently activated causing Resident #11's torso to fully extend and resulting in a spinal fracture with permanent paralysis and subsequent death two days later. The nurse aide was unaware the mechanical stand-up lift had an emergency bleed-off valve to manually lower the hydraulic lift arm; thus, each time the nurse aide released the emergency stop button, it continued to rise. These failures placed the remaining 3 residents, who were transferred by means of the mechanical stand-up lift, at risk of injury and death. The evidence is as follows: 1. Review of an Incident/Accident Report revealed that on [DATE] at 7:20 p.m., CNA "B" transferred Resident #11 using a mechanical stand-up lift. It documented the mechanical lift malfunctioned and the hydraulic lift arm continued to rise. It documented the malfunction resulted in Resident #11 "hanging from the stand-up lift arm strap (with) her feet off the ground". It documented she sustained a possible spinal injury and she was transferred to a local hospital for treatment. It documented the stand-up lift malfunctioned as the lift arms moved up without the control being manipulated. It documented the mechanical stand-up lift was immediately removed from service and staff were instructed not to use the device. An attached witness statement, completed by LVN "A" on [DATE], documented when he arrived, the arms of the lift would not come down, so they had to lift Resident #11 out of the sling and place her on her bed. He documented CNA "B" told him she heard Resident #11's back "pop" and "she was jerking". 2. Review of Resident #11's clinical record revealed the following: - The record of admission documented she admitted to the facility on [DATE] and her current age was 83. - The [DATE] Physician's Recapitulation Orders documented her [DIAGNOSES REDACTED]. It also documented they were to use a stand-up lift during transfers as an enabler and for safety. The start date for the use of the lift was noted as [DATE]. - The quarterly MDS Resident Assessment, dated [DATE], documented she stood 63 inches tall (5 feet 3 inches), and weighed 101 pounds. It documented she had poor decision making skills, had some difficulty either finding the words to say or in finishing her thoughts, and required total assistance of one person with transfers. - The annual comprehensive MDS Resident Assessment, dated [DATE], documented she used a mechanical lift for transfers. - The care plan, updated on [DATE], failed to address the use of a mechanical lift for transfers. - The nurse's notes, dated [DATE] at 7:20 p.m., and completed by LVN "A", documented he was summoned to Resident #11's room and upon entering, he observed Resident #11 "hanging" from the stand-up lift. He noted the safety straps were up under her arms along her chest area with her arms completely in a raised position and her feet not touching the ground. He documented he and the nurse aide removed her from the lift and placed her on her bed. He noted the aide said she had the resident on the stand-up lift while she removed her soiled pants and briefs and the lift kept going up on its own without her pushing the button. He noted he tested the stand-up lift and when he was not pushing the controls, the lift arm went up on its own. - The Patient Transfer Form, dated [DATE], documented Resident #11 was transferred to a local hospital on [DATE] and the information provided for the receiving hospital was that during a transfer using a transfer lift it malfunctioned, that the nurse aide heard the resident ' s back pop, and the resident had stated she could not feel or move her legs. 3. Review of Resident #11's hospital record revealed the following: - The record documented she arrived in the emergency roiagnom on [DATE] at 8:13 p.m. - A CT scan revealed "destructive changes of the T11 vertebral body with soft tissue component extending to the posterior right hemothorax and into the spinal canal with associated severe central canal stenosis. Multiple lumbar spine compression fractures." - The hospital nurse's note documented, on [DATE] at 10:30 p.m., the physician discussed Resident #1's condition with the family and it was decided to move her to in-house hospice. 4. Review of Resident #11's hospice records documented she admitted to the in-house services on [DATE]. The nursing notes documented they received a call from the local hospital noting she had a spinal fracture and was now a paraplegic. 5. Review of a local Amarillo, Texas, newspaper's list of obituaries documented Resident #11 expired on [DATE]. 6. An observation of the mechanical stand-up lift with the ADON on [DATE] at 11:00 a.m., confirmed the lift was not in use and had been moved to the physical therapy department. At that time, Restorative Aide "C" demonstrated how the lift functioned. RA "C" activated the control device to lower the hydraulic lift arm. The lift arm then began to rise independently without the employee engaging the control. During the observation/interview with the ADON on [DATE] at 11:00 a.m., he said he had previously trained staff on how to perform mechanical lift transfers, but he had not focused the prior training/in-services on ensuring staff knew how to use the emergency stop button and manual release. He said they would begin training their staff that day ([DATE]) regarding how to use the emergency stop button and the manual release. 7. Review of past in-services, provided by the ADON, revealed the following evidence of training regarding physical/mechanical lift transfers: - On [DATE] - Subject: Hoyer lifts, Nursing Informing CNAs of Changes in Residents. Summary of Meeting: "(Resident #25) is now a Hoyer lift and is to be transferred with two (person) assistance. No exceptions. Nurses, you must perform teaching with your CNAs (example: new patient or old patient who is now a Hoyer lift). Includes all residents." Note: This in-service failed to provide evidence staff were trained on how to use a mechanical lift. - On [DATE] - Subject: Transfers and Gait Belts. Summary of Meeting: Use gait bet for proper transfers, plus nurse aides performed return demonstration for the use of gait belt procedures and transfers. Note: This in-service failed to provide evidence staff received training regarding mechanical lift transfers. - On [DATE] - Subject: Transfers/Positioning. Summary of Meeting: "Proper technique total body lift transfer; positioning in bed with pillows; proper don/doff TLSO." Note: This in-service failed to provide evidence staff received training regarding mechanical lift transfers. 8. During the observation/interview on [DATE] at 11:00 a.m., the ADON said Resident #11 was "very kyphotic" (curvature of the upper spine) and when in bed was unable to lay flat on her back. He said yesterday ([DATE]) Resident #23 had told him the stand-up lift was not functioning. He said he was later told by LVN "A" that it was again working, and they had transferred several other residents with the lift. 8. An observation of Resident #11's room on [DATE] at 2:20 p.m. revealed her room was at the end of 1 of the 4 resident room halls. Upon entering the room, the restroom was to the right-hand side, and just beyond the restroom, Resident #11's bed was the first bed to the right. It was also revealed Resident #11 had a roommate: Resident #24. 9. During an interview with Resident #24 on [DATE] at 2:25 p.m., she confirmed she was Resident #11's roommate. She said on the evening of Resident 11's injury, she had been seated in her wheelchair just outside the bedroom door. She said a nurse aide assisted Resident #11 to the restroom using the stand-up lift, so she could toilet, and then the nurse aide returned and used the stand-up lift to transfer her from the toilet to her room. She said while Resident #11 and the nurse aide were in the restroom, she heard a "pop" and then heard Resident #11 holler, "I can't stand, I can't hold on." She said the nurse aide then maneuvered the stand-up lift into the room and then lifted Resident #11 off the stand-up lift and onto her bed. She said the nurse aide then stepped out into the hall and hollered for LVN "A". She said the emergency medical technicians arrived shortly thereafter. 10. During an interview with CNA "B", on [DATE] at 2:50 p.m., she said she was the nurse aide who performed the transfer for Resident #11 on the evening of [DATE]. She said she had assisted Resident #11 to her room in her wheelchair and with the use of the mechanical stand-up lift, she transferred her from her wheelchair to the toilet for a bowel movement. She said she then left and upon returning to the restroom, she assisted Resident #11 from the toilet to the stand-up lift. She said Resident #11's pants were down around her ankles, because once in her room, she was going to remove her pants. She said while she was looking down and positioning Resident #11's catheter bag and tubing, she realized the lift was extending when she thought the lift had already stopped. She said she hit the red emergency stop button and then released the stop button believing it would allow the lift arm to lower, but instead the lift arm continued to rise. She said three times she hit the stop button and three times she released it and each time the hydraulic lift arm continued to extend. She said usually Resident #11 stood on the lift platform with her knees slightly bent and her upper body slightly leaning forward due to the curvature of her back, but due to the lift continuing to rise, Resident #11's was standing upright. She said her feet remained on the platform. She said she maneuvered the mechanical stand-up lift from the restroom and into her room and then aligned Resident #11 with her bed. She said prior to lowering Resident #11 to the side of her bed, Resident #11 was screaming and then she began jerking, her eyes had a blank gaze, her dentures started to coming out of her mouth, and she then went limp. She said she then lowered Resident #11 to the side of her bed with her arms "dangling" over the lift's arms. She said she ran out to the hall and called for LVN "A". She said when LVN "A" arrived, they lifted Resident #11 and placed her on her bed. She said LVN "A" told her not to use the lift again. She said while staff assessed Resident #11, she did not holler, although, she did tell them she could not feel her legs. She said she (CNA "B") used her cold hands to touch Resident #11's waist then down to her feet and each time she touched Resident #11, she told her she could not feel the touch of her hand. During the interview with CNA "B", she said prior to the incident, she had been told by other nurse aides that they had been having trouble with the stand-up lift. She said she had been told, that on a prior day ([DATE]), maintenance had checked the unit and said it was fine. She said until she received additional training on [DATE], she had only known the lift had a red emergency stop button. She said she was unaware there was a hydraulic bleed-off valve to use when you needed to manually lower the hydraulic lift arm. 12. During an interview with LVN "A" on [DATE] at 4:00 p.m., he confirmed he had been the nurse on duty on the evening of [DATE] at the time of the incident with Resident #11. He said CNA "B" called for him and when he entered Resident #11's room he found her "hanging from the lift". He said her feet dangled in the air and were not touching the floor of the lift. He said while he held Resident #11, CNA "B" unhooked the lift straps and they then lifted her off the lift and placed her on her bed. He said, at that time, Resident #11 laid flat instead on her bed instead of in her usual position. He said due to the curvature of her spine, her upper mid-back and head were usually off the bed when she was lying in bed. He said once they placed Resident #11 in her bed, she told them she could not feel her legs. He said she did not have labored breathing. During the interview with LVN "A", he said approximately a week prior to the incident, a resident told him he needed to look at the stand-up lift, and when he did, he observed the hydraulic lift arm was rising without anyone being near the device. He said two nurse aides in the area told him they had already reported the issue to maintenance, so he did not report the issue. 13. During an interview with CNA "F" on [DATE] at 3:50 p.m., she said she was not present at the time of the incident with Resident #11, but added that she entered her room after the incident. She said when she arrived, Resident #11 was on lying on her bed on her back, which was different from the way she usually laid in bed due to her kyphosis. She said her head would remain elevated off the bed, but at that time she was flat on her back. She said she noted her right hand was shaking, so she had to use her left arm to obtain her blood pressure. She said she also noted she was breathing at a faster rate and her abdomen was rising and falling at a rapid rate. During the interview with CNA "F" she said she had known of prior issues with the stand-up lift. She said in approximately the past two weeks, she had observed the stand-up lift's hydraulic lift arms to rise with no reason and without a resident on the unit. She said she did not report it. 14. During interviews with additional staff the following was revealed: a. On [DATE] at 2:04 p.m., CNA "C", she said on the prior day ([DATE]), she had a problem that morning with the mechanical stand-up lift. She said she was holding the down button on the control, but the hydraulic lift arm continued to go up. She said she told Maintenance "E" about the incident that day. She said she did not know the exact time, but she knew it was before the noon hour. She said she saw Maintenance "E" looking at the unit. She said she was later told, he would be ordering a new control for the unit. b. On [DATE] at 9:21 a.m., CNA "G" said during the prior week, while performing a transfer for Resident #23, the stand-up lift's hydraulic lift arms began to raise up when it should not have been raising. She said she believed that the incident had occurred on Wednesday ([DATE]) while in the shower room. She said the same situation had previously occurred possibly as much as two months ago. She said she had heard that maintenance had worked on the stand-up lift and that it had been fixed. She said she had heard they were ordering a new controller for it. c. On [DATE] at 9:35 a.m., CNA "H" said approximately a month ago she had seen the stand-up lift's hydraulic lift arm going up by itself. She said on the day of the incident with Resident #11 ([DATE]), she had been on duty. She said prior to Resident #11 leaving by ambulance, she had gone to her room to check on her and notice that her back was not bent up like it usually was when she was in bed. d. On [DATE] at 10:10 a.m., CNA "I" said she was on duty the evening of the incident with Resident #11, but had not witness the incident. She said she had used the stand-up lift just prior to the incident with Resident #11 and had no issues, although she was aware of prior concerns with the stand-up lift. She said approximately two weeks ago she had observed the hydraulic lift arms to rise on their own. e. On [DATE] at 10:38 a.m., CNA "J" said she thought approximately one month ago she had observed the stand-up lift's hydraulic lift arm rise on its own. She said she told Maintenance "E". f. On [DATE] at 9:15 a.m., CNA "K" said she was aware the stand-up lift's hydraulic lift arm would, from time to time, activate and start rising on its own. She said this occurred once in a while. She said on the weekend prior to the incident with Resident #11, the hydraulic lift arms had raised without the control being activated. She said she believed the problem had been on-going for about three weeks, but Maintenance "E" had been working on the device and she believed he had fixed it. g. On [DATE] at 10:15 a.m., CNA "L" said for approximately the last two weeks the stand-up lift had been malfunctioning. She said sometimes the hydraulic lift arm would not lift. She said sometimes it would keep lifting on its own. She said she had notified a nurse, but she could not recall who she had spoken to. 15. During an interview with Maintenance "E" on [DATE] at 11:25 a.m., he said on the day of the incident with Resident #11 ([DATE]), he had worked on the mechanical stand-up lift. He said the only issue was the cord to the mechanism was loose and he adjusted it. He said he inspected the unit and found no issues. He said on Wednesday of the prior week ([DATE]), the battery was not properly connected. He said they had ordered some new controls "because we kept them in stock, not because there was any issue." 16. Review of a written statement completed by Maintenance "E" for the facility on [DATE], documented that on approximately [DATE], a nurse aide reported the stand-up lift was not working. He documented he inspected the unit and discovered the controller was not plugged in completely to the actuator. He documented he securely plugged in the controller and the lift operated normally. He then documented that on [DATE], he was informed the stand-up lift was not working properly. He documented he cleaned the electrical connections and checked the operation of the lift and it worked properly. 17. A written statement obtained from Maintenance "E" on [DATE], revealed that on approximately [DATE], he was informed the lift was not working and he found the battery was not connected; not the controller as previously noted. He also noted that on [DATE], he found the control was completely plugged in and he checked the operation and it "worked fine". Note: There was no documented evidence he had cleaned the electrical connections. 18. During an interview with Maintenance "M" on [DATE] at 11:30 a.m., he confirmed he had worked on the mechanical stand-up lift, but said he had only tightened the knee pads on the lift. He said he had not had to work on any other part of the lift and the repair had been made on [DATE]. 19. Review of a written statement completed by Maintenance "M" for the facility on [DATE], documented that on [DATE], he tightened up the knee guard located at the bottom of the lift. He documented he checked the up and down operations and the emergency stop and everything functioned. 20. A written statement obtained from Maintenance "M" on [DATE], documented the tightening of the bolts on the knee pad on [DATE] and added that he had performed "no other maintenance on (the stand-up) lift". 21. Note: Neither Maintenance "E" nor Maintenance "M" provided evidence they had a preventative maintenance plan for the mechanical hydraulic stand-up lift or that they had repaired the stand-up lift. 22. Review of the Owner's Operating and Maintenance Manual for the Stand-up Lift - Model RPS,[DATE], provided by the ADON on [DATE], revealed the following: - On page 15, section: Maintenance Safety Inspection Checklist documented in an institutional setting the stand-up lift should be inspect/adjusted monthly to include the shifter handle, the mast, lift arms and linkage, and the electric actuator assembly. - On page 16, section: Care and Maintenance of Your Stand Up Lift, "Keep lift and slings clean and in good working order. Any defect should be noted and reported to your dealer as soon as possible." Note: No evidence was presented prior to exiting the faclity on [DATE] at 10:58 a.m., to indicate the stand-up lift received monthly maintenance on a monthly basis or to indicate the dealer had been contacted regarding concerns with a possible defect in the hydraulic lift arm. 23. Further review of the in-service records revealed that on [DATE] starting at 10:30 a.m. nurses, nurse aides, and administrative staff from all three shifts (total trained: 52) received training regarding the "proper use of Hoyer/Stand-up Lifts and emergency stop if the lift malfunctions". 24. Review of the facility provided list of residents who used a mechanical lift for transfers, received on [DATE], revealed 4 residents used the mechanical stand-up lift.

Based on observations, interviews and record reviews, it was determined the faclity failed to ensure 1 of 1 mechanical stand-up lift was maintained in safe operating condition. This resulted in 1 of 4 residents, who used the mechanical stand-up lift during transfers, sustaining a serious injury (Resident #11). While transferring Resident #11 with the assistance of the mechanical stand-up lift, the hydraulic lift arm independently activated resulted in Resident #11's torso being fully extended and resulting in a spinal fracture, permanent paralysis and subsequent death two days later. This failure placed the remaining 3 residents, who used a stand-up lift for transfers at risk of injuries and death. The evidence is as follows: 1. Review of an Incident/Accident Report revealed that on 11/16/10 at 7:20 p.m., CNA "B" transferred Resident #11 using a mechanical stand-up lift. It documented the mechanical lift malfunctioned and the hydraulic lift arm continued to rise. It documented the malfunction resulted in Resident #11 "hanging from the stand-up lift arm strap (with) her feet off the ground". It documented she sustained a possible spinal injury and she was transferred to a local hospital for treatment. It documented the stand-up lift malfunctioned as the lift arms moved up without the control being manipulated. It documented the mechanical stand-up lift was immediately removed from service and staff were instructed not to use the device. An attached witness statement, completed by LVN "A" on 11/17/10, documented when he arrived, the arms of the lift would not come down, so they had to lift Resident #11 out of the sling and place her on her bed. He documented CNA "B" told him she heard Resident #11's back "pop" and "she was jerking". 2. Review of Resident #11's clinical record revealed the following: - The record of admission documented she admitted to the facility on [DATE] and her current age was 83. - The November 2010 Physician's Recapitulation Orders documented her [DIAGNOSES REDACTED]. It also documented they were to use a stand-up lift during transfers as an enabler and for safety. The start date for the use of the lift was noted as 12/11/09. - The nurse's notes, dated 11/16/10 at 7:20 p.m., and completed by LVN "A", documented he was summoned to Resident #11's room and upon entering, he observed Resident #11 "hanging" from the stand-up lift. He noted the safety straps were up under her arms along her chest area with her arms completely in a raised position and her feet not touching the ground. He documented he and the nurse aide removed her from the lift and placed her on her bed. He noted the aide said she had the resident on the stand-up lift while she removed her soiled pants and briefs and the lift kept going up on its own without her pushing the button. He noted he tested the stand-up lift and when he was not pushing the controls, the lift arm went up on its own. 3. Review of Resident #11's hospital record revealed the following: - The record documented she arrived in the emergency roiagnom on [DATE] at 8:13 p.m. - A CT scan revealed "destructive changes of the T11 vertebral body with soft tissue component extending to the posterior right hemothorax and into the spinal canal with associated severe central canal stenosis. Multiple lumbar spine compression fractures." - The hospital nurse's note documented, on 11/16/10 at 10:30 p.m., the physician discussed Resident #1's condition with the family and it was decided to move her to in-house hospice. 4. Review of a local Amarillo, Texas, newspaper's list of obituaries documented Resident #11 expired on 11/18/10. 5. An observation of the mechanical stand-up lift with the ADON on 11/17/10 at 11:00 a.m., confirmed the lift was not in use and had been moved to the physical therapy department. At that time, Restorative Aide "C" demonstrated how the lift functioned. RA "C" activated the control device to lower the hydraulic lift arm. The lift arm then began to rise independently without the employee engaging the control. During the observation/interview with the ADON on 11/17/10 at 11:00 a.m., he said he had previously trained staff on how to perform mechanical lift transfers, but he had not focused the prior training/in-services on ensuring staff knew how to use the emergency stop button and manual release. He said they would begin training their staff that day (11/17/10) regarding how to use the emergency stop button and the manual release. 6. During the observation/interview on 11/17/10 at 11:00 a.m., the ADON said Resident #11 was "very kyphotic" (curvature of the upper spine) and when in bed was unable to lay flat on her back. He said yesterday (11/15/10) Resident #23 had told him the stand-up lift was not functioning. He said he was later told by LVN "A" that it was again working, and they had transferred several other residents with the lift. 7. During an interview with CNA "B", on 11/18/10 at 2:50 p.m., she said she was the nurse aide who performed the transfer for Resident #11 on the evening of 11/16/10. She said she had assisted Resident #11 from the toilet to the stand-up lift. She said while she was looking down and positioning Resident #11's catheter bag and tubing, she realized the lift was extending when she thought the lift had already stopped. She said she hit the red emergency stop button and then released the stop button believing it would allow the lift arm to lower, but instead the lift arm continued to rise. She said three times she hit the stop button and three times she released it and each time the hydraulic lift arm continued to extend. She said usually Resident #11 stood on the lift platform with her knees slightly bent and her upper body slightly leaning forward due to the curvature of her back, but due to the lift continuing to rise, Resident #11's was standing upright. She said her feet remained on the platform. She said she maneuvered the mechanical stand-up lift from the restroom and into her room and then aligned Resident #11 with her bed. She said prior to lowering Resident #11 to the side of her bed, Resident #11 was screaming and then she began jerking, her eyes had a blank gaze, her dentures started to coming out of her mouth, and she then went limp. She said she then lowered Resident #11 to the side of her bed with her arms "dangling" over the lift's arms. She said she ran out to the hall and called for LVN "A". She said when LVN "A" arrived, they lifted Resident #11 and placed her on her bed. She said LVN "A" told her not to use the lift again. She said while staff assessed Resident #11, she did not holler, although, she did tell them she could not feel her legs. She said she (CNA "B") used her cold hands to touch Resident #11's waist then down to her feet and each time she touched Resident #11, she told her she could not feel the touch of her hand. During the interview with CNA "B", she said prior to the incident, she had been told by other nurse aides that they had been having trouble with the stand-up lift. She said she had been told, that on a prior day (11/15/10), maintenance had checked the unit and said it was fine. She said until she received additional training on 11/17/10, she had only known the lift had a red emergency stop button. She said she was unaware there was a hydraulic bleed-off valve to use when you needed to manually lower the hydraulic lift arm. 8. During an interview with LVN "A" on 11/18/10 at 4:00 p.m., he confirmed he had been the nurse on duty on the evening of 11/16/10 at the time of the incident with Resident #11. He said CNA "B" called for him and when he entered Resident #11's room he found her "hanging from the lift". He said her feet dangled in the air and were not touching the floor of the lift. He said while he held Resident #11, CNA "B" unhooked the lift straps and they then lifted her off the lift and placed her on her bed. He said, at that time, Resident #11 laid flat instead on her bed instead of in her usual position. He said due to the curvature of her spine, her upper mid-back and head were usually off the bed when she was lying in bed. He said once they placed Resident #11 in her bed, she told them she could not feel her legs. He said she did not have labored breathing. During the interview with LVN "A", he said approximately a week prior to the incident, a resident told him he needed to look at the stand-up lift, and when he did, he observed the hydraulic lift arm was rising without anyone being near the device. He said two nurse aides in the area told him they had already reported the issue to maintenance, so he did not report the issue. 9. During an interview with CNA "F" on 11/18/10 at 3:50 p.m., she said she was not present at the time of the incident with Resident #11, but added that she entered her room after the incident. She said when she arrived, Resident #11 was on lying on her bed on her back, which was different from the way she usually laid in bed due to her kyphosis. She said her head would remain elevated off the bed, but at that time she was flat on her back. She said she noted her right hand was shaking, so she had to use her left arm to obtain her blood pressure. She said she also noted she was breathing at a faster rate and her abdomen was rising and falling at a rapid rate. During the interview with CNA "F" she said she had known of prior issues with the stand-up lift. She said in approximately the past two weeks, she had observed the stand-up lift's hydraulic lift arms to rise with no reason and without a resident on the unit. She said she did not report it. 10. During interviews with additional staff the following was revealed: a. On 11/17/10 at 2:04 p.m., CNA "C", she said on the prior day (11/16/10), she had a problem that morning with the mechanical stand-up lift. She said she was holding the down button on the control, but the hydraulic lift arm continued to go up. She said she told Maintenance "E" about the incident that day. She said she did not know the exact time, but she knew it was before the noon hour. She said she saw Maintenance "E" looking at the unit. She said she was later told, he would be ordering a new control for the unit. b. On 11/19/10 at 9:21 a.m., CNA "G" said during the prior week, while performing a transfer for Resident #23, the stand-up lift's hydraulic lift arms began to raise up when it should not have been raising. She said she believed that the incident had occurred on Wednesday (11/10/10) while in the shower room. She said the same situation had previously occurred possibly as much as two months ago. She said she had heard that maintenance had worked on the stand-up lift and that it had been fixed. She said she had heard they were ordering a new controller for it. c. On 11/19/10 at 9:35 a.m., CNA "H" said approximately a month ago she had seen the stand-up lift's hydraulic lift arm going up by itself. She said on the day of the incident with Resident #11 (11/16/10), she had been on duty. She said prior to Resident #11 leaving by ambulance, she had gone to her room to check on her and notice that her back was not bent up like it usually was when she was in bed. d. On 11/19/10 at 10:10 a.m., CNA "I" said approximately two weeks ago she had observed the hydraulic lift arms to rise on their own. e. On 11/19/10 at 10:38 a.m., CNA "J" said she thought approximately one month ago she had observed the stand-up lift's hydraulic lift arm rise on its own. She said she told Maintenance "E". f. On 11/19/10 at 9:15 a.m., CNA "K" said she was aware the stand-up lift's hydraulic lift arm would, from time to time, activate and start rising on its own. She said this occurred once in a while. She said on the weekend prior to the incident with Resident #11, the hydraulic lift arms had raised without the control being activated. She said she believed the problem had been on-going for about three weeks, but Maintenance "E" had been working on the device and she believed he had fixed it. g. On 11/19/10 at 10:15 a.m., CNA "L" said for approximately the last two weeks the stand-up lift had been malfunctioning. She said sometimes the hydraulic lift arm would not lift. She said sometimes it would keep lifting on its own. She said she had notified a nurse, but she could not recall who she had spoken to. 11. During an interview with Maintenance "E" on 11/18/10 at 11:25 a.m., he said on the day of the incident with Resident #11 (11/16/10), he had worked on the mechanical stand-up lift. He said the only issue was the cord to the mechanism was loose and he adjusted it. He said he inspected the unit and found no issues. He said on Wednesday of the prior week (11/10/10), the battery was not properly connected. He said they had ordered some new controls "because we kept them in stock, not because there was any issue." 12. Review of a written statement completed by Maintenance "E" for the facility on 11/17/10, documented that on approximately 11/11/10, a nurse aide reported the stand-up lift was not working. He documented he inspected the unit and discovered the controller was not plugged in completely to the [MEDICATION NAME]. He documented he securely plugged in the controller and the lift operated normally. He then documented that on 11/15/10, he was informed the stand-up lift was not working properly. He documented he cleaned the electrical connections and checked the operation of the lift and it worked properly. 13. A written statement obtained from Maintenance "E" on 11/18/10, revealed that on approximately 11/10/10, he was informed the lift was not working and he found the battery was not connected; not the controller as previously noted. He also noted that on 11/15/10, he found the control was completely plugged in and he checked the operation and it "worked fine". Note: There was no documented evidence he had cleaned the electrical connections. 14. During an interview with Maintenance "M" on 11/18/10 at 11:30 a.m., he confirmed he had worked on the mechanical stand-up lift, but said he had only tightened the knee pads on the lift. He said he had not had to work on any other part of the lift and the repair had been made on 11/16/10. 15. Review of a written statement completed by Maintenance "M" for the facility on 11/17/10, documented that on 11/16/10, he tightened up the knee guard located at the bottom of the lift. He documented he checked the up and down operations and the emergency stop and everything functioned. 16. A written statement obtained from Maintenance "M" on 11/18/10, documented the tightening of the bolts on the knee pad on 11/16/10 and added that he had performed "no other maintenance on (the stand-up) lift". 17. Note: Neither Maintenance "E" nor Maintenance "M" provided evidence they had a preventative maintenance plan for the mechanical hydraulic stand-up lift or that they had repaired the stand-up lift. 18. Review of the Owner's Operating and Maintenance Manual for the Stand-up Lift - Model RPS350-1, provided by the ADON on 11/17/10, revealed the following: - On page 15, section: Maintenance Safety Inspection Checklist documented in an institutional setting the stand-up lift should be inspect/adjusted monthly to include the shifter handle, the mast, lift arms and linkage, and the electric [MEDICATION NAME] assembly. - On page 16, section: Care and Maintenance of Your Stand Up Lift, "Keep lift and slings clean and in good working order. Any defect should be noted and reported to your dealer as soon as possible." Note: No evidence was presented prior to exiting the faclity on 11/19/10 at 10:58 a.m., to indicate the stand-up lift received monthly maintenance on a monthly basis or to indicate the dealer had been contacted regarding concerns with a possible defect in the hydraulic lift arm. 19. Further review of the in-service records revealed that on 11/17/10 starting at 10:30 a.m. nurses, nurse aides, and administrative staff from all three shifts (total trained: 52) received training regarding the "proper use of Hoyer/Stand-up Lifts and emergency stop if the lift malfunctions". 20. Review of the facility provided list of residents who used a mechanical lift for transfers, received on 11/17/10, revealed 4 residents used the mechanical stand-up lift.