Every finding on record at Arbor Hills Rehabilitation and Healthcare Center

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #8 and #18) of 17 residents reviewed for infection control. The facility failed to ensure CNA I and CNA N used the required PPE for Resident #8, who was on enhanced barrier precautions during incontinent care on [DATE].The facility failed to label and store Resident #18's personal care items at sink area of a semi-private shared room.CNA I changed gloves during incontinent care without performing hand hygiene.These failures placed residents, staff and visitors at risk for cross contamination, unwanted infections, and decease in quality of life. 1.Record review of Resident #8's face sheet reflected date of admission was [DATE] and diagnoses which included history of essential (primary) hypertension( high blood pressure), hypothyroidism ( thyroid gland isn't producing enough thyroid hormones), edema, hemiplegia and hemiparesis( weakness to one side of the body) following cerebral infarction affecting left dominant side, hyperlipidemia ( high fat in the blood), aphasia (difficulty talking), obstructive and reflux uropathy, peripheral vascular disease, atherosclerosis of native arteries.Record review of Resident's #8's quarterly MDS assessment dated [DATE] reflected the resident's BIMS score was 04, which indicated cognition was severely impaired. Resident #8 was incontinent of bowel and continent of bladder with use of indwelling Foley catheter. Record review of Resident's #8's care plan dated [DATE] reflected: I have ADL self-care performance deficit and totally dependent on staff for all ADLs .An observation of incontinent care on [DATE] at 4:35 PM, revealed CNA I and CNA N entered Resident #8's room without putting on a gown. An EBP (Enhanced Barrier Precautions) sign was posted outside of the room next to the door which instructed what PPE is the staff should use before providing care for Resident #8. There was also a container with PPE supplies outside of Resident #8's door. Both CNAs performed hand hygiene and put on gloves. During care CNA I changed gloves twice, she did not wash or use hand sanitizer, and the CNA I picked up a cleaned brief place it on Resident #8 and fasten it. In an interview with CNA I on [DATE] at 5:15 PM, she said she was supposed to wear a gown. She could not provide rationale for why she needed to wear a gown. CNA I said she received infection control in-services recently but did not really understand the importance of EBP and she was going to ask the DON but never got around to asking her. The last in-service she had for infection control. The facility did verbal instruction but no one did monitoring/return demonstration. She said she was nervous and was very sorry. Unable to interview CNA N on [DATE] she left for the day. In an interview with the DON on [DATE] at 6:15 PM, she stated any resident who had a Foley catheter was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted outside the door, which explained what PPE was to be worn and for what task the PPE is to be worn for. She stated any contact with a resident with a catheter required the use of gown and gloves. She stated the staff had received trainings on the use of Enhanced Barrier Precautions and hand washing.Interview with ADON on [DATE] at 11:24 AM, she said she had been working with the facility for 5 years, she does round with the nurse's aides before the CNA gets on the floor to work, also watching them hands on and check them off on hand washing and using PPE. 2.Record review of Resident #18's Facesheet, dated [DATE], reflected the resident was a [AGE] year-old male with an admission date of [DATE] and diagnoses which included but not limited to: bipolar disorder, current episode mixed, severe, with psychotic features, unspecified mood [affective] disorder, Parkinsonism, recurring depression disorder, insomnia, lack of coordination, and cognitive communication deficit. Record review of Resident #18's undated Care Plan reflected resident had been evaluated as a wandering risk with a diagnoses of Parkinson's and resided in the secure unit. Date initiated: [DATE]. The resident had an Activities of Daily Living (ADL) self-care performance deficit. Date Initiated: [DATE]. The resident has impaired cognitive function/dementia or impaired thought processes. Date Initiated: [DATE] Record review of Resident #18's MDS dated [DATE] reflected resident had a BIMS Score of 15 which indicated intact cognition. Section E0200. Behavioral Symptom - Presence and Frequency Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) Behavior of this type occurred 4 to 6 days, but less than daily. E0900. Wandering - Presence & Frequency. Behavior of this type occurred 1 to 3 days. Behavior of this type occurred 4 to 6 days, but less than daily. E1100. Change in Behavior or Other Symptoms. How does resident's current behavior status, care rejection, or wandering compared to prior assessment (OBRA or Scheduled PPS)? Not Applicable (N/A) because no prior MDS assessment.Record review of Resident #18's Progress Notes dated [DATE] at 04:33 p.m., reflected staff will continue to anticipate the resident's needs, provide comfort/support, encourage social interaction. Record review of Resident #18's Progress Note dated [DATE] at 04:12 p.m., reflected he smoked cigarettes 7-times daily. Arm and hand functions were full. Required reminder cues. Hearing is poor, ambulates with assist walker. Observation and interview on [DATE] at 09:37 a.m., reflected Resident #18 was lying in bed-B watching television. Resident #18 aroused when spoken to but had not responded to questions asked of him. At the sink in the room's bathroom, personal property: an orange bar of soap, toothpaste with no cap/lid, and toothbrush with no cap sitting directly at the bathroom sink area of connecting bathroom with no identifiable name or labeling. Observation on [DATE] at 09:41 a.m., reflected personal property: an orange bar of soap, toothpaste with no cap/lid, and toothbrush with no cap sitting directly at the bathroom sink area of connecting bathroom with no identifiable name or labeling. During an interview on [DATE] at 9:38 a.m., CNA M stated that she was not aware there was a bar of soap, toothbrush, and toothpaste at the sink of shared room of Resident #18. She stated that all resident personal items were to be bagged and not left at the sink. She stated that she had attempted to move Resident 18's personal items from the sink, the resident told her no. When CNA M was asked what interventions and procedures for storing resident's personal items, she was unaware other than keep their items in a secured bin within the locked shower room. During an interview on [DATE] at 9:45 a.m., CNA L stated that Resident #18's family member placed his personal items at the sink to assist in him remembering to use those items. She stated she was not aware if the family member had been educated on the importance of stowing resident's personal items away. She stated that it was important to stow away resident's personal items to prevent the potential that other residents could come in and use those items.During an interview on [DATE] at 09:43 a.m., Resident #18 stated he had liked his personal items at the sink to remember to use them. He stated he had not been offered any alternative storage areas for his personal items. During an interview on [DATE] at 01:20 p.m., the ADON stated that she was unaware that Resident #18's personal items: soap, toothpaste and toothbrush were on the room's bathroom sink unlabeled. She stated that once known, unlabeled personal items were to be discarded to maintain infection control. She stated she that staff had been having a hard time getting the resident to give up the soap once it had been left at the sick unlabeled. She stated they had attempted to place pump soap of the same brand, but the resident preferred bars of soap. She stated that his personal items could and should be placed in a labeled bag. She stated she would normally throw the items away if they were seen at the sink and replaced with new items. She stated normally residents have their own drawer on a shelf in the shower room for their personal items. She stated that the shower room required a key and punch in code to enter the area. She stated that staff receive in-service education at orientation on where and how to store resident's personal items, and interventions to implement in the event a resident had resisted the storage locations. She stated she had addressed the staff in the memory care unit regarding Resident #18's personal items location went over with them the policy regarding the storage of personal items. During an interview on [DATE] at 03:11 p.m., the ADM and the DON stated that they had made rounds and put up, labeled all resident's personal items of soap, toothpaste and toothbrushes. The DON stated that they had attempted to redirect Resident #18 about storage of his personal items in a bag with labeling and the importance of doing so for infection control purposes. The DON stated that the resident had preferred his personal items at the sink but was educated on having it placed away to keep away from the other residents who cold wonder into his room and use them. During an interview on [DATE] at 04:44 p.m., the ADM stated that a search was conducted, and they had no specifics policy on storing resident's personal items. Record review of the facility policy revised [DATE] on Enhanced Barrier Precautions.Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO)Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs)refer to infection prevention and control interventions designed to reduce the transmission of multi-drug -resistant organisms (MDROs) during high contact resident care activities.2. Enhanced barrier precautions apply when: a. A resident with an infected or colonized with a CDC -targeted, MDRO but does have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained. Review of CDC guidelines revealed: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: accessed on [DATE] indicated Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Record review of the policy titled Infection Control Plan updated date of [DATE] revealed: Infection Prevention and Control Program. Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation 1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Asked and not received, a facility policy specific to resident's personal property in resident rooms.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #68) of 5 residents reviewed for accurate records.-The facility failed to document neuro checks neurological assessments (neurochecks) according to facility policy when Resident #68 was found on the floor in her room on 07/30/2025. Failure to not accurately document residents' health status in real time could put them at risk of changes in condition not being detected after an unwitnessed fall or injury. Record review of Resident #68's face sheet dated 08/15/2025, indicated she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses included degenerative disease of the nervous system, hypertension (high blood pressure), anemia (low iron), sciatica (damage of nerve in the lower back), anxiety disorder, and Dementia (decline in cognitive function that affects memory, thinking, and social abilities and could include memory loss, changes in personality and emotional control issues).Record review of Resident #68's Quarterly MDS dated [DATE] revealed a BIMS score of 4, indicated severe cognitive impairment. Resident #68 required substantial assistance with tasks such as toileting, showering or bathing self, dressing and taking off footwear, and requiring supervision for eating and oral hygiene. Record review of Resident #68's total order summary report captured 08/14/2025, indicated she had orders for vital signs and neuro checks for 72 hours due to a diagnosis of unwitnessed fall for every shift for post fall assessment for 3 days with start date of 07/30/2025 and an end date of 08/02/2025.Record review of Resident #68's neuro assessments after her unwitnessed fall on 07/30/2025, indicated she had two neurochecks completed on 7/30/2025 at 10:25 a.m., by LVN T which reflected Resident #68 was oriented to herself, had equal pupils, no pain or concerns with mobility and on 7/30/2025 at 11:14 p.m., by LVN F which reflected Resident #68 was alert with equal pupils and oriented to self with no pain or concerns with mobility. Record review of Resident #68's care plan dated 08/15/2025, indicated Resident #68 had focus areas of actual fall and forgets limitation, with interventions including therapy screening, monitor/document/report as needed for 72 hours to MD for signs and symptoms such as pain, bruises, change in mental status, and agitation. Record review of Resident #68's July and August 2025 MARs indicated Resident #68 had neuro checks for 07/30/2025 in the evening and night shift, 07/31/2025 for day, evening and night shift, 08/01/2025 for day, evening and night shift, and 08/02/2025 for day shift totaling 9 shifts as ordered by the physician.Record review of Resident #68's incident report completed by LVN T dated 07/30/2025, indicated she was seen laying on the floor between the bathroom and her room space, she was calling out for someone to get her off the floor. Resident #68 was unable to give a description. LVN T completed skin assessments and bilateral ranges of motion with no injuries noted and Resident #68 presented a normal baseline. Vitals and neuro-checks were completed at that time. LVN T notified the family, DON and physician on 07/30/2025. Interview with the MD on 08/14/2025 at 8:20 a.m., said they used to be notified of Resident #68's incidents including falls until Resident #68 got on hospice. The MD said Hospice would send hospice residents out for immediate situations but not for everything, like unwitnessed falls. Interview with the DON on 8/14/2025 at 10:23 a.m., she said she only found two neuro-assessments done for Resident #68's unwitnessed fall on 07/30/2025. The DON said she believed more neuro-assessments should have been done and would review the facility's policy.Observation and interview with Resident #68 on 08/14/2025 at 11:15 a.m., Resident #68's sitter was pushing her around the facility. Resident #68 appeared to be well-groomed, comfortable, smiling at her sitter and staff and appeared to be in a pleasant mood. Resident #68 said she never fell at the facility, and that she was active and staff provided her with things to do all day. Interview with the ADON on 08/14/2025 at 1:13 p.m., she said she just came back to work recently but she knew Resident #68. The ADON said nurses knew that neurochecks should be done after an unwitnessed fall and that if they were not in the system, it just was not done. She said if neurochecks was not completed, nurses could miss the signs of injury during initial assessment and residents could black out or have a brain bleed that was not observed.Interview with LVN M on 08/14/2025 at 1:29 p.m., she said she worked with Resident #68 and was unsure if she was working at the facility at the time of the fall. She said if a resident was found on the floor she would evaluate the resident for any injuries, report to the physician and family, complete a report and take care of any orders. LVN M said they would then do neurochecks and other assessments. LVN M said an incident report would trigger for neurochecks to be done over 72 hours, and it would show up in a resident's online medical chart for nurses to complete. Nurses would also be notified in the 24-hour report. If neurochecks was not completed as required, residents could get brain bleeds or clots that went undetected. Attempted interview with LVN F on 08/15/2025 at 9:14 a.m., she did not answer. LVN F was the person who did the initial neuro-assessment for Resident #68.Interview with LVN T on 08/15/2025 at 10:43 a.m., he said he worked with Resident #68 and said she had several falls where staff had found her on the floor. When that happened, nurses assessed her, notified the physician or NP, family and the DON. For unwitnessed falls, nurses did neurochecks for every shift. LVN T said nurses documented neurochecks in resident MARs. If the neurochecks was not done timely, LVN T said that residents could have a change in condition that went unnoticed. LVN T remembered Resident #68 had an initial neuro assessment and during his shift he brought her closer to the nurse's station and around staff and talked with her and said she did not have any changes in condition for 72 hours. Interview with LVN V on 08/15/2025 at 11:43 a.m., she remembered doing Resident #68's neurochecksbut could not remember for which fall. LVN V said residents with documented unwitnessed falls would trigger neuro-checks in their medical chart and would indicate the frequency of assessments. LVN V said sometimes the neuro-checks would not show up and only LVN N knew how to do it. LVN V said she should know how to trigger the neurochecks but that LVN N would always help her. LVN V never told the DON.Interview with the Administrator and DON on 08/15/2025, the DON said if Resident #68 did not get neurochecks done as required, it could cause an injury or neurological situation to be missed. The DON was not aware that neurochecks was not triggered in residents' medical charts after a fall, and she would contact the technology department to investigate. Record review of the facility's Fall Prevention policy, last revised 06/05/2025 read in part that if a resident incident or accident was witnessed, the licensed nurse must, .b. If the resident hit his/her head or if the incident is unwitnessed initiate neurological checks .Pertinent documentation must be completed .e. Neuro check sheet, if applicable i. Every 30 minutes x 4 hrs ii. Every 1 hour x 4 hrs iii. Every 4 hours x 24 hrs iv. Every 8 hours x remaining 72 hours or as ordered by M.D.

Based on observation, interview, and record review, the facility failed to ensure that residents who are unable to carry out activities of daily living receives the necessary services 1 of 3 residents (Resident #8) reviewed for ADLs.1. The facility failed to ensure CNA I cleaned Resident #8 properly during incontinent care on 8/14/25.These failures could place residents at risk for pain, infection and hospitalization. Record review of Resident #8's face sheet reflected date of admission was 6/4/23 and diagnoses included history of essential (primary) hypertension( high blood pressure), hypothyroidism ( thyroid gland isn't producing enough thyroid hormones), edema, hemiplegia and hemiparesis( weakness to one side of the body) following cerebral infarction affecting left dominant side, hyperlipidemia ( high fat in the blood), aphasia (difficulty talking), obstructive and reflux uropathy, peripheral vascular disease, atherosclerosis of native arteries.Record review of Resident's #8's quarterly MDS assessment dated [DATE] reflected the Resident #8's BIMS score was 04, reflected cognition was severely impaired. Resident #8 was incontinent of bowel and continent of bladder with use of indwelling Foley catheter. Record review of Resident's #8's care plan dated 5/24/2025 reflected I have ADL self-care performance deficit and totally dependent on staff for all ADLs.I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days .Observation on 08/14/25 at 04:33 PM, of incontinent and Foley Catheter care done CNA I and CNA N assisted Resident #8. Resident #8 had small pasty BM, CNA I did not clean around the buttocks before placing a clean brief on Resident #8.Interview with CNA I on 8/14/25 at 5:15 PM, she said she thought she did clean around Resident #8's buttocks and she knew not cleaning around the buttocks meant she left the area unclean . CNA I further said she usually wiped around the buttocks at the start and end of incontinent care, but she did not this time. She was nervous. She knew if she did not clean a resident well it could cause itchiness, skin break down, urinary tract infections, and odors. CNA I said she had in-service for incontinent care and skilled check.Interview with the DON 8/14/25 at 5:51 PM, regarding incontinent care training, the DON said she and the ADON monitored the CNAs randomly monthly and not performing good incontinent care could result in infection, skin break down, and UTIs.Interview with the ADON on 8/15/25 at 11:24 AM, she said she had been working with the facility for 5 years, she does rounds with the nurse aides before the CNA gets on the floor to work, also watching them hands on and check them off on hand washing, incontinent/Foley catheter care.Record review of the facility policy on Perineal Care Revised 6/24/25 reflected:PurposeThe purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Preparation1. Review the resident's care plan to assess for any special needs of the resident.2. Assemble the equipment and supplies as needed.Note: Enhanced Barrier Precautions (EBP) would be used during peri care if resident has any qualifying condition.For a male resident:a. Wet washcloth and apply soap or skin cleansing agent.m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.n. Dry area thoroughly.

Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three residents (Resident #18) reviewed for quality of care.The facility failed to ensure Resident #18 was accurately Care Planned as a smoker. This failure placed residents at risk for not receiving appropriate care and interventions to meet their needs. Record review of Resident #18's Facesheet, dated 08/15/2025, reflected the resident was a [AGE] year-old male with an admission date of 07/02/2025 and diagnoses which included but not limited to: bipolar disorder, Parkinsonism, recurring depression disorder, cognitive communication deficit, and lack of coordination.Record review of Resident #18's MDS dated [DATE] reflected his BIMS was 15, which indicated intact cognition. Section J reflected resident had Health Conditions Other Health Conditions Shortness of Breath. Section J reflected Current Tobacco UseRecord review of Resident #18's undated Care Plan reflected resident had been evaluated as a wanderer and resided in the secure unit and had an ADL self-care performance deficit. There were no focus areas related to Resident #18 being a smoker and he was not care-planned for smoking. Record review of Resident #18's Baseline Care Plan dated 07/02/2025. Resident required supervised smoke breaks.Record review of undated List of Smokers reviewed on 08/13/2025 at 11:21 a.m., reflected that Resident #18 was not listed as a smoker. Record review of undated Smoking Schedule revised on 08/13/2025 at 11:21 a.m., reflected: smoking times were at 7:00 a.m., 9:30 a.m., 11:00 a.m., 2:00 p.m., 4:15 p.m., and 6:30 p.m.Record review of Resident #18's Progress Note dated 07/08/2025 at 04:33 p.m., reflected, staff will continue to anticipate the resident's needs, provide comfort/support, encourage social interaction. Record review of Resident #18's Progress Note dated 08/07/2025 at 04:12 p.m., created by the Activities Director reflected that resident smoked 7-times cigarettes daily.Record review of Resident #18's Smoke Evaluation dated 08/14/2025 at 03:56 p.m., reflected Resident currently smokes and/or vapes: Reason for Smoking / Vaping Safety Evaluation. Wants to smoke/vape again after cessation and or new habits. resident knows the location(s) of the designated smoking/vaping areas. Resident can get to these areas independently. When observed, Resident can safely light smoking materials. Resident can extinguish smoking materials completely in an appropriate receptacle. Resident can dispose of ashes or other tobacco-related residue appropriately. Resident does not use supplemental oxygen. Resident does not shake/have tremors while smoking/vaping. Resident does not fall asleep while smoking/vaping. Resident had not or was not known to have had any past accidents/incidents with smoking/vaping materials. There were no visible burn marks on the resident's clothing or other personal affects. The resident does not have finger dexterity problems. The resident was considered to be medium to high risk for elopement/wandering and was a smoker/vaper. THEREFORE, RESIDENT REQUIRES SUPERVISION TO SMOKE/VAPE regardless of ability to manage smoking/vaping materials or activity. Based on the above evaluation determine resident smoking/vaping safety status. Smoking Safety Evaluation additional actions: Resident/RP (if not resident/Family educated on smoking/vaping policy). Results of smoking safety evaluation reviewed with Resident/Resident RP (if not resident)/Family. Plan of care updated to represent resident's current smoking/vaping status.Observation on 08/13/2025 at 8:11 a.m., during observation of kitchen dumpsters, Resident #18 had been observed smoking inside the iron gated area in the back of the facility with staff present.Observation and interview on 08/13/2025 at 09:37 a.m., reflected Resident #18 lying in bed-B watching television. Resident #18 aroused when spoken to but had not spoken to questions.During an interview on 08/13/2025 at 9:38 a.m., CNA M stated that Resident #18 had been a smoker in the memory care unit since she had begun working with the facility a few months prior. During an interview on 08/14/2025 at 10:37 a.m., CNA L stated that she learned that Resident #18 had been a smoker when she began working at the facility few months prior as he had cigarettes and a lighter in his personal items and that a family member also brought him cigarettes when they came to visit. During an interview on 08/14/2025 at 03:11 p.m., the ADM and the DON stated Resident #18 had recently admitted 2-months ago and should have been listed on the smoking list, after receiving a smoking evaluation a few days after admitting. The DON stated thereafter that resident would have been care planned as a smoker. She stated that she was not aware that the resident had not been care planned as a smoker and it had been the responsibility of the MDS coordinator who recently passed away. During an interview on 08/14/2025 at 03:52 p.m., the SW stated she had been unaware that Resident #18 had been a smoker. She stated she had been off shift a week and half and the last she had known the resident had been trying to get in touch with a family member who must have brought him cigarettes while the SW was off shift. During an interview on 08/15/2025 at 04:44 p.m., the ADM and the DON stated that in-services had been started with the nursing staff for addressing the completion of the smoking evaluations for new residents but had that they had not gotten to all the nurses yet and could not provide documentation at that time.Record review of Facility Smoking Policy reviewed and revised date of 07/01/2025 reflected, Supervised Smoking. SAFE SMOKING ENVIRONMENT. It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for Facility smoking privileges. The facility is responsible for informing residents, staff, visitors and other affected parties of facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to: Residents who smoke, including possible adverse effects on treatment. Passive smoke to others, fire. SMOKING EVALUATION. Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely. Resident smoking evaluations will be conducted: Admit/Readmit, Quarterly, and a Change in Condition .

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11% based on 4 errors out of 34 opportunities, which involved 2 of 7 residents (Resident #223, and Resident #1) reviewed for medication errors. 1-LVN U left a substantial amount of albuterol sulfate inhalation solution 0.083% (2.5MG/3ML) in the mask chamber after the medication was administrated through a nebulizer machine to Resident #223. 2-LVN U poured away a substantial amount of miralax power17mg, and poured away all pink medication (metoprolol 50 mg) during medication administration through g tube. LNV U left a substantial amount of white medication the portion cup after the medication was administered through g tube to Resident #1 These failures could place residents at risk for increased negative side effects, and a decline in health. Findings included: Record review of Resident #223's face sheet dated 06/13/24 revealed an [AGE] year-old female was admitted on [DATE]. Resident #223 had diagnoses which included: chronic obstructive pulmonary disease (lung disease causing restricted airflow and breading problems), hypertension (when the pressure in the blood vessels is too high), and heart failure (heart does not pump enough blood for the body's needs). Record review of Resident #223's MAR dated June 2024 reflected in part . Albuterol sulfate inhalation nebulization (2.5mg/3ml) 0.085% . special instructions: via nebulizer three times a day for (COPD) start date 06/08/24 . Record review of Resident #223's Physician order dated June 2024 reflected in part . Albuterol sulfate inhalation nebulization (2.5mg/3ml) 0.085% . special instructions: via nebulizer three times a day for (COPD) start date 06/08/24 . During an observation on 6/12/24 at 9:10 a.m., revealed LVN U administered albuterol sulfate inhalation breathing treatment (2.5mg/3ml) 0.083% through a nebulizer to Resident #223. There was barely any mist from the machine, administered for 35 minutes. Then LVN U took the mask from Resident #223's face and stated he had finished administering the medication. The mask chamber still had 95% of the medication left in it. LVN U said he would pour the medication out in the restroom sink. LVN U stated Resident #223 did not get all of the medication. LVN U poured the medicines into the sink. During an interview on 06/12/24 at 1:09 p.m., the DON said the chamber of the breathing treatment mask should empty after LVN U administered the breathing treatment between 15 and 20 minutes to Resident #223. The DON said LVN U should have assessed the machine or gotten help to find out why there was medication left in the chamber instead of pouring the medication away. The DON said if a substantial amount of the breathing treatment were left in the chamber, the medication would not be effective because Resident #223 did not receive all her medication. The DON said the nurse managers (DON and ADON) monitored the nurses during rounding. During an interview on 06/12/24 at 2:43 p.m., LVN U said Resident #223 did not receive the correct dosage ordered because some of the medication was left in the mask chamber. LVN U said the medication would not be effective for the intended treatment. LVN U said he had a skills check on medication administration, and it included breathing treatment. LVN U said the DON or ADON monitors the nurses during rounding. 2. Record review of Resident #1's face sheet dated 06/13/24 revealed an [AGE] year-old female initially admitted on [DATE] and readmitted to the facility on [DATE]. Resident #1 had diagnoses which included: hypertension (when the pressure in the blood vessels is too high), gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach), heart failure (heart does not pump enough blood for the body's needs) and cerebral infarction (damage to the brain tissue caused by a disruption in the blood flow to the brain). Record review of Resident #1's physician order dated June 2024 reflected in part . Miralax powder 17gm/scoop PEG - Tube one tome a day; gastric tube . special instructions: constipation start date 02/09/23 . metoprolol tartrate tablet 50mg; amount 1 tablet every 12 hours; gastric tube special instructions: hypertension . Record review of Resident #1's MAR dated June 2024 reflected in part . Miralax powder 17gm/scoop PEG - Tube one tome a day; gastric tube . special instructions: constipation start date 02/09/23 . metoprolol tartrate tablet 50mg; amount 1 tablet every 12 hours; gastric tube special instructions: hypertension . During an observation on 06/13/24 at 7:40 a.m., revealed LVN U inserted the syringe into the pot, which he said was for medication administration. LVN U poured 60 ml of Miralax into the syringe without flushing the g tube. The Miralax would not flow down, and while he was trying to milk the g tube tubing, the syringe came out of the pot, and 30 ml of Miralax poured on the resident's gown and blanket. The ADON entered Resident #1's room while LVN U was still administering the medication. When LVN U was administering the pink medication, the syringe fell out of the pot, and the medication poured away. When he finished administering the medication, revealed one of the portion cups had a substantial amount of white medicine left in the cup. The ADON observed the portion cup and said a lot of medication residue was left in the cup. During an interview on 06/13/26 at 8:24 a.m., the ADON said she observed the pick medication, which poured away, and the portion cup, which had a lot of medication residue. The ADON said if some of the Miralex spilled, it meant Resident #1 did not get the medications as ordered, which was a medication error, and the medications would not be effective. The ADON said the DON, and she monitored nurses during rounding. During an interview on 06/13/24 at 9:29 a.m., LVN U said some of the marlax spilled, and the metoprolol was the pink medication (metoprolol tartrate 50mg), which was poured away during administration. LVN U said one of the portion cups had a significant amount of white medication residual, which meant the resident did not get the required amount of medication prescribed for Resident #1. LVN U said the medicines would not be effective for treating the condition in which the medications were supposed to be treated. LVN U said the DON and the assistant DON monitored the nurses when they made rounds. During an interview on 06/13/24 at 9:50 a.m., the DON said if Resident #1 did not get a full dose of her medications as was ordered by the physician, then it was a medication error, and the medicines would not be effective. The DON said the nurse managers monitored the nurses during rounding. Record review of the facility medication administration dated 2001 MED - PASS, Inc (Revised April 2019) reflected in part . Medications are administered in a safe and timely manner, and as prescribed . Record review of facility policy on administering medications through an enteral tube dated January 2023 reflected in part . Purpose . the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . Record review of the facility nebulizer competency created 1.25.2023 reflected in part . Continue this inhalation technique until all medication in the nebulizer cup has been aerosolized (usually about 15 minutes) .

Based on observation and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 Station 1 nurse's cart) of 2 nurse medication cart and 1(Station 1 medication room) of 2 medication room reviewed for medications. -1 of 2 nurse medication cart (station 1) had 1 expired medication, breathing treatment opened and not dated opened breathing treatments with expired open dates. -1 of 2 medication rooms (medication room) had breathing treatments stored in a temperature above manufacturer's required temperature. These failures could affect residents, placing them at risk for altered effectiveness of the medication and worsening of the resident's symptoms, requiring medical intervention. The findings include: During an observation on 06/12/24 at 2:08 p.m. of nurse medication for station 1 medication cart with the ADON revealed the following: a blister packet of ondansetron HCL 4mg and it 8 tablets and it was expired on 04/29/24. 2 Fluticasone prop 50 mcg, 2 spray both nostrils was open but was not dated with open date or discard date. opened Budesonide inhalation suspension foil was not dated. opened albuterol sulfate inhalation solution 0.83% 2.5mg/3ml was opened on 04/29/24. ipratropium bromide 0.5mg/albuterol 3mg inhalation opened 05/15/24. During an interview on 06/12/24 at 2:20 p.m., the ADON said the nurses are responsible for pulling expired medications from the cart to prevent the medication from being administered to residents. The ADON stated the potency of the drug would have been reduced and it would not be effective for the required treatment. The ADON said the breathing treatments and inhalers should be dated when open because they have a different shelf life from unopened foil. The ADON said nurses should not administered medication past the required opened date because the medication would not be effective. The ADON said she would found out the self-life of opened albuterol sulfate inhalation and ipratropium and get back to the surveyor. During an interview on 06/12/24 at 2:25 p.m., the ADON said combination breathing treatment was good for one week when the foil was opened and two weeks for non-combined breathing treatment. The ADON said the open foil for the breathing treatments had expired because the date on the opened box foil exceeded the required open date. During an interview on 06/12/24 at 2:38 p.m., LNV U said the inhalation packet and nasal spray should be dated when the nurse opened the packet because it had a duration of effectiveness once opened. LVN U said if the medication were not dated and was administered to the resident after the opened date had expired, the medication would not be effective. LVN U said once a resident's medication expired, the nurse should had removed the medication from the cart which prevented the nurse from administrating the expired medicines to the resident because it would not be effective or might cause a negative outcome for the resident. LVN U did not answer why the expired medication was not removed from the medication cart. LVN U said he was trained in medication administration and storage. LVN U said the DON or ADON monitored the nurses when they made rounds. During an observation on 06/12/24 at 3:13 p.m., the Maintenance Director checked the medication room temperature at station 1, which was 81 degrees according to the infrared thermometer. During an observation of the medication room storage on 06/12/24 at 3:30 p.m. with the ADON revealed the following medications were stored above the manufacturer-suggested temperature in the medication room: 3 boxes of albuterol, 2 boxes of albuterol and ipratropium bromide 1 albuterol sulfate inhalation 1 Advair diskus 1 box of budesonide inhalation During an interview on 06/12/24 at 3:51 p.m., the DON said the medications were(3 boxes of albuterol, 2 boxes of albuterol and ipratropium bromide, 1 albuterol sulfate inhalation, 1 Advair diskus, and 1 box of 1 budesonide inhalation wrapped in foil and kept at the manufacturer's suggested temperature to preserve its effectiveness. The DON said if the medication was administered to residents when it was not stored appropriately, then the medication would not be effective. During an interview on 06/13/24 at 1:16 p.m., the Administrator said she did not know when the A/C in station 1 stopped working, and it may be about a week or so. The administrator said the A/C company they usually use was backed up. The administrator said she made an emergency call last night (06/12/24), and another company came out last night, and they could not fix it. During an interview on 06/13/24 at 2:00 p.m., the Maintenance Director said the A/C in section 1 went out about three weeks ago. The maintenance director said the corporation reached out to another A/C company, which came out yesterday (06/12/23), but they could not fix it because the compressor was broken and had to be replaced. Record review of the facility storage medication dated 2001 MED - PASS, Inc. (Revised April 2019) read in part . the facility stores all drugs and biologicals in a safe, secure, and orderly manner .policy interpretation and implementation . #1. Drugs and biologicals are stored .under proper temperature .#5 . outdated are returned or destroyed . Record review of the albuterol sulfate inhalation aerosol box read in part . store at 68 to 77 degrees Fahrenheit please visit . https://lupin.com/abbterol . Record review of the storage direction on the Advair Diskus read in part . store at room temperature between 68 and77 degrees Fahrenheit . Record review of the storage direction on budesonide read in part . store at room temperature between 68 and77 degrees Fahrenheit . Record review of the storage direction on budesonide read in part . store at room temperature between 68 and77 degrees Fahrenheit . Record of https://www.nephronpharm.com/sites/default/files/products/package-inserts/Albuterol_Sulfate_0_083-Package%20insert.pdf read in part . store albuterol sulfate inhalation solution 0.83%between 36 and 77degrees . Record of https://www.hdrxservices.com/did-you-know-nebulizer-storage-recommendations/ read in part . expiration date once foil pouch is opened was 7 days .

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL's) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 3 of 11 residents (Resident #170, Resident #6, and Resident #223) reviewed for ADLs. 1. The facility did not provide Resident #170 with showers after the resident reported asking for a shower on his scheduled shower day of 06/11/2024. 2. The facility failed to ensure Resident #6 was provided grooming (toenails care). 3. The facility failed to ensure Resident #223 was provided grooming (shower). These failures could place residents who were dependent on staff for showering at risk of not receiving care and services to meet their needs. Findings included: 1.1Record review of Resident #170's face sheet dated 06/12//2024 revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included: gangrene (a dangerous and potentially fatal condition that happens when the blood flow to a large area of tissue is cut of), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), type 2 diabetes mellitus (high blood sugar) with foot ulcer, gout (arthritis that causes severe pain, swelling, redness and tenderness in joint), hyperlipidemia (condition in which there are high levels of fat particles (lipids) in the blood), edema (swelling caused by too much fluid trapped in the body's tissues), and diabetes mellitus with diabetic neuropathy (nerve damage that occurs with diabetics). Record review of Resident #170's Resident Assessment and Care Screening MDS, dated [DATE], revealed Focus: The resident admitted for short term care. Record review of Resident #170's Baseline Care Plan, dated 06/09/2024, revealed the resident had a surgical wound where gangrenous tissue was removed from the left foot 5th digit and surrounding area. Goal: The residents surgical wound will heal without complications by the review date Initiated: 06/10/2024. Intervention: Monitor for swelling, redness, drainage, odor, increased pain, document wound progress weekly, treatment as ordered, wound vac as ordered. During an observation and interview on 06/11/2024 at 09:34 a.m., revealed, Resident #170 was in his room, sitting on side of bed with family at the bedside. Both legs still from his toes to his mid-thigh appeared dry and flaky. He stated that he admitted on [DATE] in the early morning hours and had not had a bath or a shower since admitting. He stated he requested some wipes or a wet towel from CNA A to give himself a bath on a.m. of both 06/10/2024 and 6/11/2024, but he had not yet received the items. He stated that he had a wound vac on his left foot and was not sure if he could take a shower, but he definitely wanted to wipe down. During an observation and interview on 06/11/2024 at 03:35 p.m., revealed Resident #170 was in his room lying back on his bed. Both legs still from his toes to his mid-thigh appeared dry and flaky. He stated he had not yet received towels to wipe down nor had a staff offered him a bed bath or shower. During an observation and interview on 06/12/2024 at 01:36 p.m. Resident #170 was lying back on his bed with left foot wrapped in gauze. Both legs still from his toes to his mid-thigh appeared dry and flaky. He stated that he told CNA A that he would like a shower. He stated that CNA A told him that it was not his shower day, but that she would find out when his shower day would be, and he would be given a shower/bed bath on that day. He stated again, he had not gotten a bath since admitting 06/09/2024. He stated that his foot was now wrapped in gauze so he was unsure would he receive a shower but would like to receive some wipes so he could do a wipe down of his under arms and private area at least, because he wanted to be clean, and he could use some lotion. During an interview on 06/12/2024 at 02:51 p.m. the DON stated she was not aware that Resident #1 had requested a shower. She stated that she would go speak to the resident and ensure he received a shower. During an interview on 06/12/2024 at 03:02 p.m., the DON stated that she spoke with the CNA B on his hall who would give the Resident #1 a bath. During an observation/interview on 06/13/2024 at 9:58 am., LVN A stated that she was the charge nurse on Resident #1's hall. She stated she had no reports of a resident who declined or requested a shower. She stated she was unaware that Resident #170 requested a wipe down. She stated based off the shower schedule, Resident #170 should have been provided a shower/bed bath on Tuesday, Thursday and Saturday which would have been 6/11/2024 and 6/13/2024 on the 2 pm - 10 pm shift. She looked through the shower book for shower sheets and there were no shower sheets available for Resident #170. She stated that if there were shower sheets, they would have been completed by the resident's CNA and then provided to the ADON for review. During an interview on 06/13/2024 at 10:23 am. CNA A stated she had worked for the facility for nearly 6-months. She stated she worked on Resident #170's hall 06/11/2024 from 2pm to 10 pm. She stated Resident #170 asked for a wipe down or shower on 06/11/2024. She stated that she told the resident it was not his shower day, but she would try and squeeze him in, but was unable to get to the resident. She stated she did not inform LVN A that the resident needed a bath. She stated that she does not recall by who but was told that Resident #170 received a shower and shave on 06/12/2024 on the 2pm to10 pm shift. She stated that she was to complete shower sheets on residents after completing resident showers. She stated that she did not complete any shower sheets on the residents she provided showers to between 06/11/2024 - 6/13/2024. She stated it was important that residents receive showers and completing the shower sheets to show that the showers were performed, and residents were clean. She stated that she did document in the resident's electronic chart. During an interview on 06/13/24 at 01:27 p.m., the Administrator stated that she was not aware that Resident #170 had requested a towelettes to wipe down on 06/11/2024 or 06/12/2024. She stated that residents were assigned shower days 3-times a week, but if a resident asked for one in between, staff were to provide a shower. She stated if a resident requested wipes or a towel to wipe down, staff were to provide the resident with soap, water, and a towel. She stated that generally new admits were assessed by the admission nurse and usually the following day by physical therapy and thereafter, the resident would be offered a shower or receive a shower on their next assigned shower day. She stated that CNA B worked on Resident #170's hall and was responsible for providing the resident with a bed bath or shower. She stated that if Resident #170 did not receive a shower that it was a mistake. She stated that she expected her staff to follow resident shower schedules. During an interview on 06/13/2024 at 1:59 p.m. CNA B stated that she had worked for the facility for 1 year. She stated that on 06/11/2024, she was Resident #170's CNA. She stated that she offered the resident a shower, but he told her, Not right now he was waiting on his wound vac to be connected. She stated that she left and did not check back to see if the resident needed a shower before her shift ended at 2:00 p.m. She stated that she did not informed LVN A and did not make notation that the resident would wait on his shower until later. She stated she should have gone back around and remind the resident that he could have a shower and report to LVN A if he declined. She stated the shower policy and procedure made note that the staff were to document showers. 2.Record review of Resident #6's face sheet dated 06/13/24 revealed a [AGE] year-old male was initially admitted on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses which included: cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area), dementia (impaired ability to remember think or make decision that interferes with doing everyday activities), peripheral vascular disease(the reduce of blood flow to a body part other than the brain) and heart failure (heart does not pump enough blood for the body's needs). Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected in part . [Resident #6's] BIMS of 09 which indicated moderately impaired cognition. [Resident #6] functional status revealed resident dependent on staff with all ADL's . Record review of Resident #6's care plan-initiated date 03/03/24 reflected in part .(Resident #6) had ADL self-care performance deficit related to dementia, hemiplegia, and stroke. Interventions: skin inspection: the resident requires skin inspection during routine care observation . During an observation on 06/11/26/24 at 11:25 a.m., revealed Resident #6's toenails were long; the right big toenail was calcified and long, and the toenail pointed upward. Both second toenails were long. During an interview on 06/13/24 at 11:05 a.m., the Administrator said the nurse would tell the social worker the name of the resident who needed to see the podiatrist and the resident's name on the podiatrist list. The administrator said the podiatrist would send the list of residents they had before she came to the facility. Then, the social worker would add any resident who needed to see the podiatrist to the list sent by the podiatrist. The administrator said if the nurses could not cut the resident's toenails, the social worker would put the resident's name on the podiatrist list. The administrator said if the toenails were causing the resident pain, they would ask the podiatrist to see the resident or take the resident to another doctor. During an interview on 06/13/24 at 11:12 a.m., the ADON said the podiatrist came to the facility on ce every three months. The ADON said the podiatrist has the names of all the residents, with the expectation of the residents who went to their doctor. The ADON said the podiatrist cut the diabetic residents' toenails, and if the resident did not have diabetes, the nurses would cut the resident's toenails. The ADON said if the resident's toenails were thick and calcified, the podiatrist would cut them. The ADON said if the resident's toenails got caught on socks, it could cause pain to the resident. During an observation and interview on 06/13/24 at 11:18 a.m., the ADON said she could see Resident #6's toenails were long, and the toenail on the right big toe was long and pointed upward. The ADON said she was not aware Resident #6 needed to see a podiatrist. The ADON said she and the DON monitored the nurses doing rounding. During an interview on 06/13/24 at 12:41 p.m., the DON said the podiatrist came once every three months. The DON said that when it was time for the podiatrist to come, they would send a list of the residents they would see, and the facility would send a list of new residents that were not on the list. The DON said the nurses cut the residents' toenails if they do not have diabetes, and the podiatrist would cut the toenails of the diabetic residents. The DON said if a resident needed to have their toenails cut by the podiatrist, the facility would made arrangements for the resident's toenails to be cut. During an interview on 06/13/24 at 1:13 p.m., the DON said she went and assessed Resident #6's toenails. The right big toenail was very long, and the other toenails were long but not as long as the right big toenail. The DON said the nurse monitored the aides when they made rounds. The DON said she was unaware that Resident #6's toenails were long and that the treatment nurse did skin assessments on all residents, including Resident #6. During a telephone interview on 06/13/24 at 1:53 p.m., the Social Worker said the podiatrist comes about every two months, and they were in the facility at the beginning of June 2024. The social worker said she became aware if a resident needed to see a podiatrist when the nurse told her. The social worker said nobody had told her Resident #6 wanted to see the podiatrist. The social worker checked the last zipped file the podiatrist sent and said the previous time the podiatrist came to the facility was 05/09/24, and Resident #6's name was not on the list. During an interview on 06/13/24 at 2:09 p.m., LVN U said the treatment nurse did the skin assessment for all the residents, including Resident #6, and when the wound care nurse was not available, the floor nurse does the skin assessment and gives the skin assessment to the wound care nurse. LVN U said nobody told him Resident #6's toenails were long. LVN U said the aide had to report to the nurse that Resident #6's toenails were long, and the nurse would send the names of the residents to the DON or ADON, and they would give the name to the activity director who sent the residents name to the podiatrist. LVN U said if Resident #6's toenails were not cut, the circulation would be poor, and the toenails could get caught on the bed linen, which could cause injury to Resident #6. During an interview on 06/13/24 at 2:37 p.m., CNA A said she gave Resident #6 a bed bath yesterday (06/12/24), and his toenails were long, but she did not tell the nurse because she forgot. CNA A said the podiatrist came once a month. CNA A said the aides told the nurse about the resident's toenails, and the nurse told the office staff. CNA A said if Resident #6 toenails were long, it could cause Resident #6's toenails to grow inward and may hurt or cut Resident #6's skin. CNA A said the charge nurse monitored the aides when the nurses made rounds. During an interview on 06/13/24 at 4:45 p.m., the Treatment Nurse said she does the skin assessment for all the residents. The Treatment Nurse said she told the Social Worker that Resident #6 toenails were long, and the social worker said she would put Resident #6 on the list. The treatment nurse said she was just told today (06/13/24) that the podiatrist does not see skilled residents, and Resident #6 was a skilled resident. The Treatment Nurse said Resident #6's long toenails could have ingrown toenails, or the toenails could have gotten snagged and hurt the resident. 3.Record review of Resident #223's face sheet dated 06/13/24 revealed an [AGE] year-old female was admitted on [DATE]. Resident #223 had diagnoses which included: chronic obstructive pulmonary disease (lung disease causing restricted airflow and breading problems), hypertension (when the pressure in the blood vessels is too high), and heart failure (heart does not pump enough blood for the body's needs). Record review of Resident #223's MDS assessment revealed the resident MDS was not due until 06/13/24. Record review of Resident #223's baseline care plan dated 06/08/24 reflected in part . (Resident #223) required moderate to extensive assistance with shower/bath . During observation and interview on 06/11/24 at 11:56 a.m., Resident #223 said she asked staff to shower on Saturday when she was admitted to the facility (06/08/24), and she was told by the staff that the residents were not showered on weekends. Resident #223 said she wanted to be showered and has yet to be showered as of today. During medication administration observation on 06/12/24 at 9:10 a.m., Resident #223 said the staff still had not showered her. Resident #223 said she felt dirty, and her hair was tangled and dirty. During an interview on 06/13/24 at 8:37 a.m., the ADON said residents are showered at least three times a week, and if a resident requested a shower over the weekend, the staff are supposed to shower the resident. The ADON said she was unaware Resident #223 wanted to be showered and was not. The ADON said the aides would had filled out shower sheets and the shower sheets were given to the DON. The ADON said if Resident #223 needed to be showered and she was not showered, then Resident #223 would feel dirty and unclean. During an interview on 06/13/24 at 9:00 a.m., the DON said residents could get showers on weekends, and she was not aware that Resident #223 did not get a shower over the weekend or on Monday (06/10/24). The DON said she was given a shower on Wednesday(06/12/24) evening. The DON said she did not have any shower sheets for Resident #223 before yesterday (Wednesday). The DON said if Resident #223 wanted a shower and it was not given, it was a dignity issue. During an interview on 06/13/24 at 9:44 a.m., LVN U said Resident #223 told her yesterday(06/12/24) around 8:00 a.m., and he told Resident #223 he would check when her shower day was and LVN U said he told one of the aides and he thought the aide was from the evening shift. LVN U said Resident #223 shower days were on Monday, Wednesday and Friday on the 2 to 10 p.m. shift. LVN U said he told the aide who was working the morning shift, and she said she was busy. LVN U said Resident #223 would not feel happy and may have body odor for days. During a telephone interview on 06/13/24 at 1:34 p.m., CNA M said she did not work with Resident #223 over the weekend and worked with Resident #223 yesterday(06/12/24). CNA M said when Resident #223 told her she needed a shower, she showered Resident #223, which was her shower day. Resident #223 loved it, and Resident # 233 said thank you after the shower. CNA M said if Resident #223 needed a shower over the weekend, the staff should have showered her because it was her right. CNA M said if Resident #223 needed a shower and she did not get showered, Resident #223 would be upset. Record review of the facility policy on bath, shower and tub dated 2001 MED - PASS, Inc. (Revised February 2018) reflected in part . the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Record review of the facility policy on fingernails, toenails care dated 2001 MED PASS, Inc. (Revised February 2018) reflected in part . the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . Record review of policy Activities of Daily Living (ADL), Supporting reflected: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. A sample of shower logs were requested on 06/12/2024 at 02:38 p.m. for Resident #70, while at the facility. The facility did not provide documentation of refusals for showers, showers or shower assistance given for the last 30-days prior to exit. 44669

Based on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 of 8 residents (Resident# 1) reviewed for enteral nutrition, in that: -CNA S lowered the head of bed on Resident #1 while the resident was receiving continuous gastrostomy feedings on 06/13/24. -CNA T entered Resident #1's room on 06/13/24 while the resident was receiving continuous gastrostomy feedings with the head of bed flat and did not elevate the head of bed instead, left the room to get the nurse. -LVN U flushed Resident #1's gastrostomy tube by pushing the water in instead of letting the water go in by gravity. The failures placed resident at risk for unwanted abdominal discomfort, aspiration (when food, drink, or foreign objects are breathed into the lungs) pneumonia, hospitalization , and decrease in quality of life. Findings: Record review of Resident #1's face sheet dated 06/13/2024 revealed an [AGE] yearl old female admitted to the NF originally on 01/22/2016 and again on 05/21/2024. The resident's diagnoses included the following: cerebral infarction (disrupted blood to the brain), heart failure, gastro-esophageal reflux disease (stomach content often flows up in the esophagus, a tube that carries food and liquids form the mouth to the stomach)without esophagitis (irritation of the esophagus), gastrostomy (surgical procedure that creates an opening into the stomach), angina pectoris ( a type of chest pain cause by reduced blood flow to the heart), type 2 diabetes mellitus (when the body has difficulty controlling the blood sugar and using it for energy) without complications, Alzheimer's Disease (a disease that destroys memory and other mental functions), pneumonia (infection in the lung), and contracture (shortening of the muscle, tendons, skin, and tissues preventing normal movement) of the right left knee, left knee, left hand, and right hand. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 3 indicating that resident cognition was severely impaired . Further review section V- Care Assessment Summary revealed that resident was triggered for having a feeding tube Record review of Resident #1's Comprehensive Care Plan dated 03/27/2021 and revised 06/02/2021 revealed the resident was being care planned for risk of aspiration, she had a stroke with increase dysphagia (difficulty swallowing), was now NPO with enteral feedings as her source of nutrition/hydration. The interventions included the following: -Every shift HOB elevated at all times 30-45 degrees. Record review of Resident #1's Physician's Orders for the month of June 2024 reflected the following: -Dated 09/24/2023 Enteral feed, Glucerna 1.2 cal at 65ml/hr times 22 out of 24 hrs. form 12am-2am, water 150ml/4Hrs. -Dated 07/23/2021 Enteral (related to the intestines) Feed every shift HOB elevated at all times 30-45 degrees. -Dated 07/23/2021 Flush PEG tube with 30ml H2O before first medication, 10ml between each medication, and 30 ml after last medication every shift. Record review of Resident #1's MAR for the month of June2024 revealed that resident was receiving gastrostomy feedings as ordered by the physician. Observation on 06/13/24 at 10:10AM revealed CNA S and CNA T were preparing to provide incontinent care for Resident #1. Resident #1 was resting in bed with the HOB elevated receiving continuous gastrotomy feedings Glucerna 1.5 cal at 65ml/hr along with a water flush. CNA S entered Resident #1's room washed her hands and went over to the resident's bed side and began to lower the head of the bed while the gastrostomy feeding was infusing. Further observation was made of a sign directly over the resident's bed that reflected Please keep my head of bed elevated at 45 degrees at all times thank You!! CNA S walked out of the room and returned right back with CNA T. CNA T sanitized her hands and placed on a pair of gloves. At 10:14AM CNA T removed her gloves and said she had to go and get the nurse. At 10:15AM CNA T returned to the room and said that the nurse was coming to the room. At 10:17AM LVN U came to the room to stop the continuous gastrostomy feedings. LVN U told CNA T to raise the head of bed. CNA T raised Resident #1's head of bed. Resident #1 did not appear to be in any distress, respirations were even and unlabored. LVN U told CNA S and CNA T before they proceeded with incontinent care he needed to disconnect the resident from her feedings and flush the resident's gastrostomy tube. At 10:19AM LVN U proceeded to draw up 60 ml of water in an irrigation syringe and flushed the resident's gastrotomy tube by pushing the water through the tube instead of letting the water go in by gravity. Interview on 06/13/24 at 10:33AM CNA S said she had been working at the NF since 2015. CNA S said she had been a CNA for almost [AGE] years and had taken care of residents with continuous gastrostomy feedings. CNA S said she had been trained that when caring for a resident with a gastrotomy tube to make sure she did not pull on the tubing, to always make sure that the tube was disconnected before providing care, and making sure the head of bed was elevated when feedings were infusing to prevent the resident from choking or aspirating. CNA S said she was called to Resident #1's room to assist with incontinent care and thought the resident feeding had been stopped. CNA S said it was her fault for not checking first before lowering Resident #1's head of bed. Interview on 06/13/24 at 10:38 AM CNA T said she had been working at the NF on and off for 6 years. CNA T said she had received training on how to provide care for residents receiving continuous gastrotomy feedings. CNA T said whenever a resident was receiving continuous gastrostomy feedings, the CNA was supposed to call the nurse prior to administering care so the feedings could be stopped and not to place resident head of bed flat when the feedings were infusing to prevent the resident from aspirating. CNA T said when she entered Resident #1's room she saw the resident lying with the head of bed flat. CNA T said she should have elevated the head of bed before leaving the room to go and get the nurse. CNA T said she did not know why she responded like that but her first clue was to get the nurse. Interview on 06/13/24 at 10:45AM LVN U said it was not correct for Resident #1's head of bed to be flat when receiving gastrostomy feedings because it placed resident a risk for aspirating. LVN U said the correct way to flush a G-tube is by of gravity. Interview on 06/13/24 at 11:02AM the DON said when administering medications and flushing the gastrostomy tube, then procedure should be done by way of gravity to avoid introducing air into the stomach. The DON said this placed the resident at risk for discomfort or pain. The DON said the gastrostomy feeding should be stopped before providing care and the head of bed should be elevated if the feedings are infusing. The DON said this needed to happen to prevent resident from aspirating. Record review of the NF policy on Enteral Nutrition revised January 2023 revealed in part: .Adequate nutritional support through enteral nutrition is provided to residents as ordered .The provider will consider the need for supplemental orders, including: Head of bed elevation . Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with insertion and /or use of feeding tube, such as aspiration .

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including breathing treatment administration was provided such care, consistent with professional standards of practice for 1 of 8 residents (Resident #1) reviewed for respiratory therapy in that: The facility failed to change Resident #1's respiratory equipment in a timely manner. This failure could place residents at risk for respiratory infections. The findings were: Record review of Resident #1's face sheet dated 06/13/2024 revealed an [AGE] yearl old female admitted to the NF originally on 01/22/2016 and again on 05/21/2024. The resident diagnoses included the following: cerebral infarction (disrupted blood to the brain), heart failure, gastro-esophageal reflux disease (stomach content often flows up in the esophagus, a tube that carries food and liquids form the mouth to the stomach)without esophagitis (irritation of the esophagus), gastrostomy (surgical procedure that creates an opening into the stomach), angina pectoris ( a type of chest pain cause by reduced blood flow to the heart), type 2 diabetes mellitus (when the body has difficulty controlling the blood sugar and using it for energy) without complications, Alzheimer's Disease (a disease that destroys memory and other mental functions), pneumonia (infection in the lung), and contracture (shortening of the muscle, tendons, skin, and tissues preventing normal movement) of the right left knee, left knee, left hand, and right hand. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 3 indicating that resident cognition was severely impaired. Further review did not reveal that resident was receiving respiratory treatment. Record review of Resident #1's Comprehensive Care Plan dated 03/21/2024 revealed that resident was being care planned for altered respiratory status/difficulty breathing r/t CHF & hs of pneumonia. The interventions included administer albuterol as ordered . Record review of Resident #1's Physician's Orders for the month of June 2024 reflected the following: -Albuterol Sulfate inhalation nebulization solution 0.63 mg/3ml (albuterol sulfate) 1 inhalation orally via nebulizer two time a day related to heart failure. Record review of Resident #1's MAR for the month of June 2024 revealed that resident was administereding the medication albuterol sulfate as ordered by the physician. Record review of Resident #1's Comprehensive Care Plan dated 03/21/2024 revealed that resident was being care planned for altered respiratory status/difficulty breathing r/t CHF & hs of pneumonia. The interventions included administer albuterol as ordered. Observation on 06/11/24 at 9:11AM revealed Resident #1 was resting in a recliner at bedside. Observation was made of a breathing machine on the left side of bed sitting on the nightstand. Connected to the machine was plastic tubing. Connected at the end of the tubing was a face mask. The mask was inside of a plastic bag. The date on the outside of the bag reflected 05/20/24. Further observation of the date on the mask reflected 05/20/24. Further observation was made of resident having a suctioning machine in the room by the breathing machine sitting on a table. There was an empty clear cannister connected to the suction machine. Connected to the cannister was tubing and at the end of the tubing was an oral yankauer (a device that is used to suction or remove fluids and debris) suction tip. The yankauer was inside of an open wrap. The date on the outside of the open wrap was dated 05/20/24. Observation on 06/13/24 at 10:40AM revealed Resident #1 was resting in bed quietly. Further observation was made in the room of respiratory equipment (oral yaunker and breathing mask) with a date that reflected 05/20/24. Observation was made of clear fluid like secretions inside of the cannister. Interview on 06/13/24 at 10:33AM the Infection Control Nurse/ADON said she had been the NF Infection Control Nurse for about a year. The ADON said respiratory equipment should be changed weekly on the Sunday night shift for infection control. The ADON said each resident had an ambassador who was a department head assigned to them. The ADON said that ambassador was supposed to check on the residents each day ensuring everything was bagged and labeled correctly. The ADON said she would have to check to see who Resident #1's ambassador was. Interview on 06/13/24 at 10:45AM LVN U said he did not know how often respiratory equipment should be changed. LVN U said he would guess maybe once or twice every two weeks. LVN U said he administered breathing treatments to Resident #1's once on his shift. LVN U said he sometimes used the oral yankauer to suction out resident mouth after a breathing treatment. Interview on 06/13/24 at 11:02AM the DON said respiratory equipment should be changed at least weekly for infection control. The DON said the NF did have a policy on the care of respiratory equipment. The DON said she would have to check to see if nonclinical staff had been in-serviced on what to look for as an ambassador when making rounds on the residents that they were assigned to. Interview on 06/13/24 at 11:25AM with the Ambassador for Resident #1 said she did rounds every morning and evening on the residents she was assigned to. The Ambassador said she checked to see if the residents' rooms were clean and if anything looked out of order in general. The Ambassador said she was not clinical. The Ambassador said she just looked to see if any equipment that the resident was using had a date on it. The Ambassador said if a resident was on oxygen, she did check to see if the humidifier bottle had fluids inside of it. The Ambassador said she was not familiar with how often respiratory equipment needed to be changed because she was not a nurse. Record review of the NF Infection Prevention and Control Program revised 01/01/2024 revealed in part: An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections.

Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three residents (Resident #7) reviewed for quality of care. The facility failed to ensure Resident #7 was assessed by LVN A for injuries after her fall on 06/11/2024. This failure placed residents at risk for potential injuries, pain, and hospitalization . The findings were: Record review of Resident #7's face sheet dated 06/12/2024 revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: hypertension, schizophrenia, psychosis not due to a substance. or known physiological condition, insomnia, other seizures, age-related osteoporosis without current pathological fracture (break in the bone not caused by force or impact), hypothyroidism (body lacking thyroid hormone), hyperlipidemia (high levels of fat in the blood), drug induced subacute dyskinesia (repetitive, involuntary movements), muscle weakness, other abnormalities of gait and mobility, dementia, with agitation, other lack of coordination. Record review of Resident #7's quarterly MDS, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses of drug induced subacute dyskinesia, hypothyroidism, other lack of coordination, age-related osteoporosis w/out current pathological fracture, muscle weakness, generalized, other abnormalities of gait and mobility, insomnia, seizure disorder, psychotic disorder, and schizophrenia. Further review revealed Resident #7's BIMS was 7 out of 15 which suggested severe cognitive impairment. Review of Resident #7's Care Plan revised 03/22/2023 revealed: Focus: Resident had impaired cognitive function/dementia or impaired thought processes r/t Dementia, Schizophrenia aeb- memory deficits, wanders, impaired decision making. Date Initiated: 09/16/2021. Goal: Resident will remain current level of cognitive function through the review date. Date Initiated: 09/16/2021. Intervention: Ask yes/no questions in order to determine the resident's needs. Date Initiated: 09/16/2021. COMMUNICATION: Use the resident preferred name (Resident #7). Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues stop and return if agitated. Date Initiated: 09/16/2021, Revision on: 12/21/2021. Cue, reorient and supervise as needed. Date Initiated: 09/16/2021. Engage the resident in simple, structured activities that avoid overly demanding tasks. The resident prefers (coloring, dancing, visiting, reading) Date Initiated: 09/16/2021. Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date Initiated: 09/16/2021. Observation on 06/11/2024 at 10:08 a.m., revealed Resident #7 and CNA C throwing a bouncy ball into a tabletop basketball hoop. CNA C threw the ball towards the hoop and the ball bounced off a crossed the room. Resident #7 immediately ran after the ball, upon reaching the ball the resident attempted to stop when her feet pivoted underneath her until she stopped losing her balance, fell to her buttocks, immediately bounced back up, picked up the ball, ran back towards the basketball hoop, and threw it at the hoop. CNA C asked resident was she ok three times, but the resident did not respond. A few minutes later Resident #7 was observed sitting in a chair with no expression. CNA C asked resident was she tired, and resident did not respond. Interview on 06/12/2024 at 03:02 p.m., the DON stated that she was not aware that Resident #7 had a fall in memory care on 06/11/2024 at 10:08 a.m. She stated the fall should have been documented to outline what assessments and follow-up from the fall were performed. She stated she would immediately assess the resident to ensure the resident had no injuries. Interview on 06/12/24 at 03:17 p.m., the DON stated that she had LVN A assess Resident #7. She stated that Resident #7 was eating chips and drinking soda when she entered the memory care unit. She stated that all of the resident's vitals were in the normal range and there were no visual indications of any injuries and the resident denied pain. She stated that LVN A would document her assessment and it would be available in the resident's electronic chart. Interview on 06/12/2024 at 03:40 p.m., CNA C stated that when Resident #7 fell she reported to the med aid who reported to LVN A. Interview on 06/13/24 at 9:58 am., LVN A stated on 06/11/2024 in the afternoon the med aid reported to her that Resident # 7 had placed her hand on a chair and bent down to pick up something, lost her balance while bending down and sat down on the floor, stood up and continued to play basketball. She stated that she was preforming another task when she received the report. She stated thereafter, she spoke with the resident and did not get an indication that the resident had a fall or any injuries. She stated had she known the resident had fallen, the resident would have had a head-to-toe assessment that would have included checking the resident's skin, assessing the resident's extremities for any bruising or bones out of place and an incident report would have been completed within 24-hrs. She stated on the afternoon of 06/12/2024 she learned from the DON that the resident incident actually consisted of the resident having a witnessed fall. At that time, she performed a head-to-toe assessment, and the assessment was completed the morning of 06/13/2024 when she came in on shift at 7:00 a.m. She stated that she had forgotten to complete the report before ending her shift on 06/12/2024. Record review of Resident #7's progress notes dated between 05/13/2024 to 06/12/2024 revealed no documentation relating to resident's fall on 06/11/2024 at 10:08 a.m. Record review on of Resident #7's Evaluations/Assessments dated between 05/08/2024 to 06/12/2024 revealed no documentation relating to resident's fall on 06/11/2024 at 10:08 a.m. Record review of an Incident Report dated 06/13/2024 at 7:01 a.m. revealed: Resident #7. Incident Location: Resident Room. Person Preparing Report: LVN A. Incident Description: Nursing Description: This nurse was called into memory unit common area. Staff reported resident had a witnessed fall without injury. Upon entering unit, resident was noted playing basketball. Resident Description: Resident unable to state what happened. Per Staff, something fell on the floor and resident bent down to pick it up. The resident placed one hand on the chair, bent down and lost balance causing her sit on floor. The resident propped herself back up and continued to play basketball. Immediate Action Taken: Description: this nurse assessed resident for injuries, none noted. Able to move all extremities with ease. Skin assessment done and no skin tears noted. Vitals signs WNL. Resident denies pain. Resident Taken to Hospital? No. Injuries Observed at Time of Incident: No. Injuries observed at time of incident. Record review of Fall Prevention Program Policy dated 06/10/2024 reflected: All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. If a fall occurs, the following will be done: a. The licensed nurse will complete a thorough assessment of the resident to evaluate for injury. b. The licensed nurse will notify the physician and the family/responsible party. c. Treatment will be initiated per physician orders. d. An incident report will be completed. e. The resident's plan of care will be updated to reflect interventions. f. The interdisciplinary team will be notified, a Post Fall Review completed, causative factors evaluated and appropriate referrals made (medication review, therapy, restorative, etc.). The Post Fall Review must be completed within 72 hours of a fall. g. Therapy Screen will be conducted. h. All resident falls will be monitored through the clinical standards committee. i. The DON or designee will track, and trend falls on a monthly basis. j. The DON/ designee will report results to the Quality Assurance/ Improvement Committee. k. If the resident with dementia sustains a fall, in addition to the nursing assessment, the facility will also prioritize diagnostics such as STAT Xray/transfer to ER for appropriate investigation and intervention.

Based on observation, interview, and record review the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for 1 of 8 residents (Resident #120) reviewed for infection control during care in that: -The NF failed to label and store resident personal care items that were in the bathroom of a semi-private room. -The NF failed to keep Resident #120's Foley catheter off the floor. These failures placed residents at risk for cross contamination, infections, and decease in quality of life. Findings: Record review of Resident #120's face sheet dated [DATE] revealed a[AGE] year old female admitted to the NF on [DATE] with the following diagnoses that included: urinary tract infection, anemia (low red blood cell count), gastrointestinal hemorrhage (bleeding), hypothyroidism (gland in the body that does not produce hormones to regulate important body functions), hypokalemia (low potassium), neuromuscular dysfunction of bladder (nerves and muscles of the balder do not communicate properly with the brain) and, hypertension (high blood pressure). Record review of Resident #120's Physician Orders for the Month of [DATE] reflected the following: -Dated [DATE] Foley catheter 16 fr 10 cc bulb -Dated [DATE] Foley catheter care Q shift and PRN Record review of Resident #120's baseline care plan dated [DATE] revealed that resident was being care planned for indwelling catheter r/t neurogenic bladder. The interventions included the following: Monitor/record/report to MD for s/s of UTI. Observation on [DATE] at 8:42AM in room [ROOM NUMBER]-A revealed Resident #120 awake in bed with the call light in reach. Further observation revealed the resident had a Foley catheter and the Foley bag was on the floor on the right side of the bed. Observation was made in the bathroom and on top of the counter was a small tube of toothpaste, bottle of shampoo cleanser, secret deodorant, can of shaving cream, and a gray wash basin all with no name of it. Resident #120's roommate was not in room. Interview on [DATE] at 8:45AM Resident #120 said the personal care items in the bathroom did not belong to her and that she did not know who the items belong to. Interview on [DATE] at 9:05AM with CNA Z said she was the CNA for Resident #120. CNA Z said the resident's Foley catheter should not be on the floor for infection control . CNA Z said all resident's personal care items should be labeled and placed inside of a plastic bag to avoid cross contamination. CNA Z could not explain why Resident #120's Foley bag was on the floor. Interview on [DATE] at 2:00PM the DON said resident personal care items should be labeled with resident's name and stored in a plastic bag to avoid cross contamination. The DON said the staff was aware of that. The DON said if a Foley catheter bag was found on the floor, the CNA should report this to the nurse so that the nurse can change the Foley bag to avoid placing residents at risk for infections. Record review of the NF Infection Prevention and Control Program revised [DATE] revealed in part: An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections.

Based on observation, interview and record review, the facility failed to care for resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident 63), reviewed for resident rights, in that: -LVN U was standing while feeding Resident #63 her lunch in the Dining Room. This failure placed residents at risk for feeling disrespected and diminished quality of life. Record review of Resident #63's face sheet dated 06/13/24 revealed a [AGE] year-old female admitted to the NF on 11/01/2023 and readmitted on [DATE]. Resident #63's diagnoses included the following; heart failure, type 2 diabetes mellitus (when the body has difficulty controlling the blood sugar and using it for energy), hemiplegia (partial or complete paralysis on one side of the body) and hemiparesis ( muscle weakness on one side of the body) following cerebral infarction (blood flow in the brain is disrupted) , hypertension (high blood pressure), dysphagia (difficulty swallowing), and cognitive communication deficit (difficulty in communicating). Record review of Resident #63's MDS dated [DATE] revealed a BIMS score of 3 indicating the resident's cognition was severely impaired. Further review of resident functional abilities section GG revealed that resident required supervision or touching assistance with eating. Record review of Resident #63's Physician's Orders for the month of June 2024 reflected the following order: -Dated 11/01/2023 Diet Regular texture, thin consistency. Record review of Resident #63's Comprehensive Care Plan dated 11/24/2023 and revised 02/23/2024 reflected in part: Resident has an ADL self-care performance deficit r/t dementia, stroke and requires staff assistance to complete all task. The interventions included eating set-up/ cueing and supervision-limited assist of 1 staff. Observation on 06/12/24 at 12:08PM in the Dining Room revealed LVN U was standing over Resident #63 on her right side while feeding the resident her lunch. Resident #63's lunch consisted of corn bread, black eye peas, green beans, breaded crispy pork steak, lemon pie for dessert, and beverage was water and tea. Interview on 06/13/24 at 9:50AM LVN U said when feeding a resident, he was supposed to sit at eye level to create a cordial interaction with the resident. He said that was the respectful thing to do. Interview on 06/13/24 at 11:02AM the DON said staff should not be standing when feeding a resident because it did not provide the resident with dignity. Record review of the NF policy on Resident Rights revised December 2016 reflected in part: .Employees shall treat all residents with kindness, respect, and dignity . Record review of the NF policy on Assistance with Meals revised 05/21/2024 revealed in part: .Residents who cannot feed themselves will be fed with attention to safety to safety, comfort and dignity, for example: -not standing over residents while assisting them with meals.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #222) reviewed for incontinent care. 1. The facility failed to ensure CNA Z and CNA E followed proper Foley bag placement during Hoyer lift transfer on Resident #222. This failure could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Record review of Resident #222's face sheet dated 06/13/24 revealed an [AGE] year-old male was admitted on [DATE]. Resident #222 had diagnoses which included: obstructive and reflux uropathy (urinary tract disorder that occur when urine flow is blocked, causing urine to backup and may cause injury to the kidneys), dementia (impaired ability to remember think or make decision that interferes with doing everyday activities), hypertension (high or raised blood pressure) and disorder of kidney and ureter kidney (damaged kidney and can't filter blood, blocks or slows the flow of urine). Record review of Resident #222's MDS assessment revealed the resident assessment was not due because he was a new admit. Record review of Resident #222's baseline care plan date 05/31/24 reflected in part .(Resident #222) had indwelling catheter . Record review of Resident #222's physician's order dated June 2024 reflected in part . change indwelling F/C PRN, dislodgement/patency .as needed related to obstructive and reflux uropathy start date 06/07/24 . During an observation on 6/11/24 at 11:45 a.m., revealed Resident #222 was being transferred from the wheelchair to the bed by CNA E and CNA Z. When CNA Z unhooked the Foley bag from the wheelchair the Foley bag fell on the floor, and CNA Z picked it up from the floor and placed the bag on Resident #22's lap. At the same time, CNA Z hung the Hoyer lift(medical equipment that allow a person to be lifted and transferred with a minimum of physical effort) pad strips to the Hoyer lift. When CNA Z and CNA E started to lift Resident #222 from the wheelchair, CNA E hung the Foley bag on the cradle of the Hoyer lift. When the resident was transferred to the bed, CNA E hung the Foley bag on the bed rail. During an interview on 06/11/24 at 12:09 p.m., Resident #222 said LVN U had not changed his Foley bag since he was transferred to bed. During an interview on 06/11/24 at 1:15 p.m., LVN U said CNA E or CNA Z did not tell him Resident #222's Foley bag fell on the floor. LVN U said either CNA E or CNA Z should have told him that Resident #222's Foley bag had fallen on the floor and that he would have changed the bag to prevent infection such as UTI. LVN U said the nurse monitored the aides to ensure they provide care as required. LVN U said he had skills checked off on how to work with a resident who had a Foley. LVN U said either CNA E or CNA Z should have held the Foley bag below the bladder, and the aides should not have hung the Foley bag on the Hoyer lift. During an interview on 06/12/24 at 1:19 p.m., the DON said if Resident #222's Foley bag fell on the floor, CNA Z should not have placed the Foley bag on Resident #222's lap because the floor was dirty. The DON said the Foley bag should be below the bladder during transfer and not hung on the Hoyer lift. The DON said the Foley bag should be below the bladder to drain the urine properly. The DON said there would be pain or discomfort for Resident #222, and he could get a UTI. During an interview on06/11/24 at 1:33 p.m., CNA Z said the Foley beg fell on the floor, and she placed the Foley bag on Resident #222's lap, and CNA E hung the Foley bag on the Hoyer lift when Resident #222 was lifted from the chair. CNA Z said after Resident #222 was transferred to bed, the Foley was hanged on the bed. CNA Z said the nurse should change the Foley bag because the floor was dirty, and the Foley could be pulled out too when CNA E hung the Foley bag on the Hoyer lift. CNA Z said the Foley bag should be changed to prevent the resident from getting infected. CNA Z said she had skills checked off on Foley care. CNA Z said the charge nurse monitored the aides during rounding . During an interview on 06/13/24 at 9:05 a.m., the ADON said CNA Z and CNA E should keep the Foley bag below the bladder even when Resident #222 was transferred with a Hoyer lift. The ADON said when CNA E hung the Foley bag on the Hoyer's lift, the bag was above the bladder, and the urine would have flowed backward into Resident #222's bladder, which could have caused pressure and pain. The ADON also said Resident #222 could develop a UTI. The ADON said CNA Z or CNA E should have called the nurse to come and change the bag once the Foley bag fell on the floor because the floor was dirty and there was an infection control issue. The ADON said the nurse monitored the aides during rounding. During an interview on 06/13/24 at 1:31 p.m., CNA E said she was told yesterday(06/12/24), after they had transferred Resident #222, to call the nurse to change the bag if a Foley bag fell on the floor. CNA E said she was taught to hang the Foley bag on the Hoyer during the Hoyer lift transfer, but she was told not to hang the Foley bag on the Hoyer yesterday but was not told where to place the Foley bag during transfer. CNA E said the Foley bag that fell on the floor and hung above the bladder could cause infection for Resident #222. CNA E said the charge nurses monitored aides when they made rounds. CNA E said she had a skill check-off and in-service on Foley care. Record review of the facility policy on catheter care, urinary revised and reviewed January 2023, Revised March 2024 reflected in part . the purpose of this procedure is to prevent catheter-associated urinary tract infections . general guidelines . maintaining unobstructed urine flow . #3. the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .infection control . #2b. be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (Nurse's cart for 100 and 200 hall) reviewed for medication storage. 1. The facility failed to ensure the nurse's cart for 100 and 200 halls the nurse's were responsible did not have expired vials of [MEDICATION(S)] 25 mg/ml ( milligram measure weight/millimeters=measure volume of liquid) . 2. The facility failed to ensure [MEDICATION(S)] Regular 100 unit/ml on the nurse's cart for 100 and 200 halls were dated after being opened. 3. The facility failed to ensure Hydrocortisone cream USP (united states pharmacopoeia) 2.5% (30 grams) was dated after being opened in Nurse's 100 and 200 hall . These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings include: Observation on 03/09/22 at 2:24 p.m., of the nurse medication cart for 100 and 200 halls revealed the following: The medication listed below were open, not dated and were not in the original packet: -1 vial of [MEDICATION(S)] regulation 100 unit/ml. - 1 Hydrocortisone cream 2.5% (30 grams) USP ( United States Pharmacopoeia ) - 4 vials of [MEDICATION(S)] 25 mg/ml (1 ml) were located in a Ziploc bag and had an expiration date of 1/2022 Interview with RN A on 03/09/22 at 2:45 PM, RN A said she only worked as needed and knew any medication opened should be dated when opened and it would prevent administering expired medication. RN A said she always check the medication cart when she comes on duty for expired medication . Interview with the Administrator on 3/09/22 at 3:00 PM, she said the DON just audited the medication carts last night, on 3/08/2022, and she missed those medication. Interview with the DON on 3/10/2022 at 10:55 a.m. revealed whatever nurse was on shift and the medication aide checked the medication cart for expired medications. The DON said the nurse and medication aide monitored medications and the pharmacist comes to the facility on ce a month to document and checked for expired medications. The DON knew that giving residents expired medications could change chemical composition of the drugs over time which can render them unsafe or ineffective. DON said expired medications were placed in a Biohazard box and taken to the her Office. Record review of facility policy on storage of medications, dated 2001 MED-PASS, Incorporated. (Revised April 2019) read . store all drugs and biologicals in a safe, secure and orderly manner .#5 .Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroy.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Residents #102 and #24) reviewed for infection control. 1. The facility failed to ensure CNA A washed her hands or used alcohol-based hand sanitizer while performing incontinent care for Resident #102. 2. The facility failed to ensure CNA A washed her hands or used alcohol-based hand sanitizer while performing incontinent and indwelling catheter care for Resident #24. These deficient practices could place residents at risk for infection. Findings include: 1. Record review of the admission sheet for Resident #102 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #102's admission MDS assessment, dated 2/25/22, revealed a BIMS of 14 out of 15, which indicated mild impaired cognition. He required extensive assistance from one-person physical assist for dressing, toilet use, and personal hygiene. He was always incontinent of bowel and was continent of bladder, the resident had a supra pubic catheter. Record review of Resident #102's care plan, dated 2/27/2022, revealed Resident #102 had bowel incontinence related to impaired mobility. Intervention: provide perineal care after each incontinent episode. It also revealed the resident required extensive assistance with one person with personal hygiene. [MEDICATION(S)] Tablet 150 MG ([MEDICATION(S)]) Give 1 tablet by mouth one time a day every Saturday related to candidiasis (yeast infection grows out of control in moist skin areas of the body), (for 2 Weeks). Do not use harsh detergents, soaps, fragrances, or other irritating substances. Hydrocortisone Cream1 %, apply to affected areas topically two times a day for Rash on both lower arms for 14 Day. Monitor skin rashes for increased spread or signs of infection. [MEDICATION(S)] Ointment 20 % Apply to peri-anal area topically every 12 hours for Rash. Observation on 03/08/22 at 2:07 PM revealed Resident # 102 laid in the bed and the resident pointed to his brief. CNA A entered Resident #102 room to perform incontinent care. CNA A placed a trash bag to lined resident trash can at the bedside, then donned clean gloves without washing her hands. CNA A opened Resident #102's brief, the resident had supra pubic catheter bag lying on the floor at his bed side. The CNA used wet wipes to clean around the penis 3 three times, changed gloves 3 times without using hand sanitizer or washing hands. CNA A did not clean the groin and the inner thighs were beefy red. CNA A then doffed gloves and washed hands, then donned clean gloves. Resident #102 repositioned himself to the right side on the bed. Resident #102 had a moderate bowel movement. CNA A cleaned in-between the buttocks 6 times and changed gloves without using hand sanitizer or washing hands. CNA A did not clean around the buttocks. CNA then doffed soiled gloves then used hand sanitizer then donned clean gloves. She then placed a cleaned brief on Resident #102, covered him with the bed linen, then picked up the urine bag from the floor and emptied 800 cc (cubic centimeter) yellow urine in urine jar to discard, Interview with CNA A on 3/8/22 at 2:28 PM revealed she should had done better washing her hands or using hand sanitizer after changing gloves while performing incontinent care. She said she worked PRN (as needed) with the facility and she had training on incontinent care a couple of weeks ago with somebody in the facility. She stated she knew if incontinent care was not done appropriately the resident would have a urinary tract infection, skin breakdown and odors. She said nobody had told her to clean the buttocks and the groin area while the trainer watched her perform incontinent care. Resident #24 2. Record review of the admission sheet for Resident #24 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #24's quarterly MDS assessment, dated 10/21/21, revealed a BIMS of 15 out of 15, which indicated no impaired cognition. He required extensive assistance from one-person physical assist for dressing, toilet use, and personal hygiene. He was always continent of bowel and bladder. Observation on 03/08/22 at 3:15 PM revealed Resident #24 laid in the bed, he had an indwelling catheter with 500 ml of yellow urine to the bedside drainage bag. CNA B performed incontinent and indwelling catheter care. CNA B washed her hands and donned clean gloves from her uniform pocket. She then placed wet wipes on the side of the resident bed, then undid Resident #24's brief. CNA then cleaned the indwelling catheter tubing, not in a circle motion away from the insertion site three times and doffed catheter, without washing her hands or using hand sanitizer. CNA B pulled out clean gloves from her uniform pocket don the gloves and did not open the groin and the buttocks to clean, then fasten the same old brief on. Interview on 3/10/22 at 3:20 PM with CNA B, said she had not completed training for incontinent care. CNA B said she should have washed her hands or used hand sanitizer between gloves changes during incontinent care because it was a risk for infection. C.NA B said she had In an interview on 3/10/22 at 10:06 AM with the ADON/LVN revealed she would be monitoring and in services on incontinent care to CNAs. The ADON/LVN stated it was her expectation that hands be washed or sanitized after removing soiled gloves. The ADON/LVN stated infections could occur. During an interview with the DON on 3/10/2022 at 11:15 AM, the DON said the former ADON just reigned on 2/22/22 and was the one who monitored incontinent care and infection control. She used in-service checklist for CNA A which showed staff were supposed to remove gloves and wash hands or use sanitizer after and before repositioning the resident. The DON stated that it was her expectation the competency checklist be followed. The DON stated not washing or sanitizing hands after removing soiled gloves risked cross contamination and was a concern and it could spread bacteria and infection. The DON said CNA B just started, and they did not have any skilled check list for incontinent care. Record review of the facility's Handwashing/Hand Hygiene policy (Revised August 2019) read in part: .This facility considers hand hygiene the primary means or prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . h. Before moving from a contaminated body site to a clean body site during resident care . m. After removing gloves . 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infection. Applying and Removing Gloves- 1. Perform hand hygiene before applying non-sterile gloves . Record review of the facility's Infection Prevention and Control Program (Revised August 2019) read in part: .1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program .7. Prevention of Infection- a. Important facets of infection prevention include .: (3). educating staff and ensuring that they adhere to proper techniques and procedures . (7). Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC) .

Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice for one of five residents reviewed for quality of care. (CR #1) The facility failed to ensure CR# 1 was monitored for choking while she ate in her room on [DATE] as outlined in her plan of care. The facility failed to ensure CR# 1 received ordered mechanically altered texture diet but instead was served regular diet -Chicken nugget and green beans for dinner which she ate unsupervised in her room. As a result, CR#1 was heard coughing a few minutes later, was found unresponsive few minutes later with signs of vomiting and some food in her mouth. CR#1 passed way at the hospital and autopsy revealed cause of death was aspiration by foreign object -food bolus. An Immediate Jeopardy (IJ) situation was determined to have existed on [DATE]. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures could place residents at risk of not receiving harm, and death. Findings included: CR#1's Face Sheet reflected the [AGE] year-old female was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR# #1's person centered care plan dated [DATE] revealed nutritional problems, with an intervention to monitor, document, report PRN any signs and symptoms of dysphagia, pocketing defined as holding food in the mouth without swallowing, choking, several attempts at swallowing , refusing to eat, appears concerned during meals. Comprehensive person-centered care plan further revealed CR #1was a full code status . Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's swallow study dated [DATE] revealed CR#1's reason for visit was problems with eating and drinking. Meal diet recommendations revealed mechanical soft solids with ground meats, mechanical soft solids with extra gravies/sauces. Thin liquids. Strategies for pills, choking risk- crush meds or liquid form. Conclusion: Patient is at high risk for aspiration pneumonia due to the following predictors: assisted oral alimentation, CHF, [CONDITION(S)], dysphagia, dementia, dysphagia, non-ambulatory, multiple medical diagnoses, [CONDITION(S)], [CONDITION(S)], patient is also at risk of choking episode. Based on the results of the MBSS, [CONDITION(S)] evaluation and the patient's general medical condition, their overall dysphagia severity is severe given their risk factors for aspiration, aspiration pneumonia and/or choking. Managing or treating the dysphagia with recommendations given is intended to reduce the risk for aspiration and development of aspiration pneumonia. In an interview with LVN A on [DATE] at 4:48 PM he stated he received CR#1 from [CONDITION(S)] and CR#1 was her usual self. He warmed CR#1's food and served it to her on her tray table. He left room and went to nursing station, heard a noise and went to CR#1's room to investigate. CR#1 was slumped to one side, vomiting and he propped her up and called for help. He checked her mouth and saw a little bit of food, chicken nuggets and green beans. He suspected a stroke and called 911. He stated the resident was awake but was not responding to questions. CR#1's breathing was a little labored , the resident was not talking and kept vomiting. LVN A stated he propped her up to get O2 saturation. EMTs came in and took CR#1 out. LVN A stated he thought CR#1 was having a stroke due to the signs that he saw and that was why he did not do the [NAME] maneuver. He said he did not think the resident was choking because resident was vomiting. LVN A states he did not do vitals on resident because everything happened so fast. Record review of CR#1's record revealed no incident report was complete regarding above incident . Record review of CR#1's record revealed no nutritional waiver from CR#1 or CR#1's Responsible party to consume any food not ordered by her physician. Record review of CR#1's EMS Patient Care record dated [DATE] stated Medic 3 dispatched to Skilled Nursing Facility for [AGE] year-old Female having stroke. Medic 3 went in route immediately from station 3 code 3. Requested dispatch to put a helicopter on standby. Patient aspirated on food. Assessment of chest, audible stridor. Visual inspection of the patient's mouth shows no foreign substance. Narrative: Patient is sitting in her wheelchair with a Skilled Nursing Facility staff member holding her head up. Patient has drool and food on her shirt. Patient is drooling, assessment and vitals are charted. Patient is in a paced rhythm at 60bpm with strong pulse. Patient BP is ,d+[DATE]. Patient's Sp02 is <50. Pupils are 4mm bilaterally and sluggish. Patient has audible wet stridor. Patient's oral airway is check with no food found in her mouth. Patient has a [CONDITION(S)] access to the Right shoulder. Skilled Nursing Facility is informed that the patient does not appear to be having a stroke but is believed to have aspirated. Skilled Nursing Facility then informs EMS that the patient recently failed a swallow test. The patient signed a waiver to be given regular food. Patient was given pureed food tonight but would not eat it and insisted on regular food. Patient was [NAME] chicken nuggets, mashed potatoes and green bean which are still on the table in the patient's room. Patient is going to be transported by helicopter to the nearest critical care hospital. Dispatch is contacted to launch the helicopter. A 5 min ETA once launched. Patient is put on 02 via filtamask at 10 Lpm. Patient is lifted from the wheelchair to the stretcher and secured. Patient is moved to the ambulance. Increased 02 Flow to 15 Lpm . Patient's BP is dropping, A 22 GA IV is established to the right hand. Patient is started on a NS drip WO . 12 lead EKG obtained. 12 lead is paced with a wide QRS. PHI in the ambulance. Report given to PHI staff. Assisted PHI with patient care. Assisted PHI with transfer to helicopter. PHI off the ground to hospital, Medic 3 out of service for decon and restock. Record review of CR#1's nursing notes dated [DATE] revealed blood pressure was the only assessment completed by facility on [DATE] at 9:58AM. Record review of CR#1's autopsy dated [DATE] revealed resident's cause of death as asphyxia by foreign body aspiration, reportedly witnessed to choke on food, food bolus visualized during intubation. In an interview with DON on [DATE] at 12:10 PM, she stated CR#1 had a modified [MEDICATION(S)] swallow study a few weeks before the incident and did not pass. She states the mechanical diet remained the same and she was not sure how LVN A could have missed the resident's diet or given the resident the incorrect tray with regular diet. She stated in the event of an incident of this nature, vitals should have been taken and a check of the airway should have been done during assessment of resident's change in condition. She stated if assessed that the resident is choking a [MEDICATION(S)] Maneuver would be done to dislodge food from resident and provide aid to the choking resident . In an interview with Administrator on [DATE] at 6:05PM, she states that staff are expected to call for help, assess resident and do the [MEDICATION(S)] Maneuver if applicable. She states staff have been retrained on dining services, choking, the [MEDICATION(S)] Maneuver and assessing residents when there is a change in condition. In an interview with LVN B on [DATE] at 2:00 PM, She stated she was trained on choking protocol every other week, the [MEDICATION(S)] Maneuver. In an Interview with CNA A on [DATE] at 2:55 PM, She stated if she noticed a resident was not responsive or looking like themselves, she will get the nurse because she does not have CPR certification. She stated she was trained on choking sometime in [DATE]. In an Interview with CNA B on [DATE] at 3:10 PM, he stated he has been in-serviced on choking once a month, stated he would call for help if he noticed a resident unresponsive or not themself, he stated if they were turning blue or something he would do the [MEDICATION(S)] maneuver and if the resident had no pulse or breath he would perform CPR because he was certified. In an Interview with CNA C on [DATE] at 3:55 PM, she stated if someone was choking, she would put her hands under there stomach area and push up demonstrating the [NAME] Maneuver. She states the facility had placed the residents at risk for choking in the dining area to keep eyes on them while they eat. Observation of the dining area on [DATE] revealed posters on the wall in English and Spanish depicting the procedure of the [NAME] maneuver with written instructions and visual pictures. Record review of facility's policy, First Aid Treatment stated the goal of staff training is to enable employees to provide basic life support and/or first aid intervention to injured residents or employees. In the case or life-threatening injuries or situations, the goal is patient stabilization until EMS arrives. Basic first aid intervention includes (but is not limited to) interventions for the following situations: choking, breathing emergencies . The goal of emergency intervention is to stabilize the resident and the situation until further treatment is available. Record review of facility's policy for Resident Incident and Visitor Accident Report stated: Licensed nurse must examine the resident and obtain vital signs, conduct further assessment as warranted, render appropriate treatment. Record review of facility's policy, Choking/ Relief of Foreign Body Obstructing Airway stated: Staff will assist resident who is choking by attempting to expel the foreign body from the airway. Procedure: Ask the resident if he or she is choking, remember, a choking victim cannot speak or breathe and needs your help immediately, ask the resident to cough or speak, if possible, to determine if his or her airway is obstructed. If able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign object. Call for help but stay with the resident. Quickly assure the resident that you are going to stay and assist him or her. If the resident cannot cough, only then should abdominal thrust be performed. Record review of the Descriptions of diet consistencies stated, Regular- no changes in texture- have whole meats, raw fruits, and vegetables of various sizes. No food textures are excluded. Chopped meat- this is meat in ¼- ½ inch pieces all other foods are regular textures. Mechanical soft- This diet is ground meat, and vegetables chopped per menu. Mechanical soft/pureed meats- this diet has pureed meat and vegetables that follow the mechanical soft diet. Pureed, all foods are smooth consistency. Record review of literature obtained from the International Dysphagia Diet Standardized Initiative (IDDS) website : https://iddsi.org/Resources on [DATE] revealed a mechanical soft diet is a texture-modified diet that restricts foods that are difficult to chew or swallow. It's considered Level 2 of the National Dysphagia Diet in the United States and includes foods that require no chewing .The goal of the diet is to make foods safer and help a person meet their nutritional needs. Most foods are allowed on the diet as long as they can be safely consumed .You can prepare foods at home or buy premade meals that are suitable for a mechanical soft diet. As of 2015, the International Dysphagia Diet Standardization Initiative (IDDSI) offers guidelines that provide in-depth recommendations and levels based on various medical conditions and risk of choking. A mechanical soft diet would be considered level 5 (minced and moist), according to the IDDSI guidelines. A mechanical soft diet is a type of texture-modified diet for people who have difficulty chewing and swallowing. Foods may be pureed, ground, finely chopped, or blended to make eating safer. Actions Taken include: Record review of QAPI dated [DATE] QAPI dated [DATE]; Problem: Diet order discrepancy. Immediate solution: three-way audit of diets prescribed to dietary services records, in service all staff on diet order and policy to include complete communication. Target date: [DATE] ;Follow up: Daily Long term solution: All diet orders to be followed up with clinical and dietary orders daily through start up. Target date: ongoing Follow up: [DATE] No new changes found. [DATE] dietary audit complete New dietary form, in-service to be done, more residents coming to dining room. QAPI corrective actions: All waivers completed, no new issues, audit complete in servicing etc. in progress, more residents coming to dining room for meals. Record review of Disciplinary Action Record dated [DATE] signed by LVN A and DON Record review revealed all shift staff were re-educated on abuse and neglect, assessment and vital signs, policy on choking on [DATE]. Record review revealed all shift staff in-serviced on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and weekly thereafter until [DATE] staff in-service on first aid. Record review revealed LVN A was in serviced on first aid, change in condition, choking and assessments on [DATE], [DATE], [DATE]. Record review of in service dated [DATE] revealed staff reeducated on checking food trays prior to giving tray to residents to make sure that the tray card and food match. In serviced revealed both dietary and nursing staff were in-service.

Based on observation, interview and record review, the facility failed to ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs for 1 of 20 residents (CR#1) reviewed for food form. The facility failed to ensure CR# 1 received ordered mechanically altered texture diet but instead was served regular diet (Chicken nugget and green beans) for dinner on [DATE] which she ate unsupervised in her room. As a result, CR#1 was heard coughing a few minutes later, was found unresponsive few minutes later with signs of vomiting and some food in her mouth. CR#1 passed way at the hospital and autopsy revealed cause of death was aspiration by foreign object -food bolus. An Immediate Jeopardy (IJ) situation was determined to have existed on [DATE]. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures could place residents at risk of not receiving harm, and death. Findings included: CR#1's Resident face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dysphagia and aspiration. Dysphagia described as difficulty swallowing. Aspiration can occur when food enters the airway or lungs by accident Record review of CR#1's person centered care plan revealed nutritional problems, with an intervention to monitor, document, report PRN any signs and symptoms of dysphagia, pocketing defined as holding food in the mouth without swallowing, choking, several attempts at swallowing , refusing to eat, appears concerned during meals. Record review of CR#1's swallow study dated [DATE] revealed CR#1's reason for visit was problems with eating and drinking. Meal diet recommendations revealed mechanical soft solids with ground meats, mechanical soft solids with extra gravies/sauces. Thin liquids. Strategies for pills, choking risk- crush meds or liquid form. Conclusion: Patient is at high risk for aspiration pneumonia due to the following predictors: assisted oral alimentation, CHF, [CONDITION(S)], dysphagia, dementia, dysphagia, non-ambulatory, multiple medical diagnoses, [CONDITION(S)], [CONDITION(S)], patient is also at risk of choking episode. Based on the results of the MBSS, [CONDITION(S)] evaluation and the patient's general medical condition, their overall dysphagia severity is severe given their risk factors for aspiration, aspiration pneumonia and/or choking. Managing or treating the dysphagia with recommendations given is intended to reduce the risk for aspiration and development of aspiration pneumonia. Record review of CR#1's physician orders dated [DATE] revealed an order summary for Renal diet Mechanical soft texture, regular consistency. Record review of CR#1's record revealed no nutritional waiver from CR#1 or CR#1's Responsible party to consume any food not ordered by her physician. During a phone interview on [DATE] at 3:00 P.M. CR#1's responsible party said the resident was supposed to receive a mechanical soft diet. The responsible party stated someone at the facility mentioned that CR#1 was given solid food. The responsible party states she contacted the facility regarding the incident and for answers about CR#1's care plan not being followed. The responsible party states the DON, Administrator and Medical Director met with her on a conference call and did not address the issue of not following the care plan and choking, stating the facility was not being honest and was going around the issue. The responsible party states she requested an autopsy. In an interview with LVN A on [DATE] at 4:48 PM he stated he received CR#1 from [CONDITION(S)] on [DATE] around 6:00pm and CR#1 was her usual self. He said he warmed CR#1's food which was green beans and chicken nuggets and served it to her on her tray table, left room and went to nursing station, heard a noise and went to CR#1's room to investigate. CR#1 was slumped to one side, vomiting and he propped her up and called for help. LVN A stated he checked her mouth and saw a little bit of food, chicken nuggets and green beans. He suspected a stroke and called 911. He stated CR#1 was awake but was not responding to questions. He stated CR#1's breathing was a little labored, she was not talking and kept vomiting, he stated he propped her up to do 02 saturation. He stated the EMT's came in and took CR#1 out. Record review of CR#1's record revealed no incident report was complete regarding above incident. Record review of CR#1's EMS Patient Care record dated [DATE] stated Medic 3 dispatched to Skilled Nursing Facility for [AGE] year-old Female having stroke. Medic 3 went in route immediately from station 3 code 3. Requested dispatch to put a helicopter on standby. Patient aspirated on food. Assessment of chest, audible stridor. Visual inspection of the patient's mouth shows no foreign substance. Narrative: Patient is sitting in her wheelchair with a Skilled Nursing Facility staff member holding her head up. Patient has drool and food on her shirt. Patient is drooling, assessment and vitals are charted. Patient is in a paced rhythm at 60bpm with strong pulse. Patient BP is ,d+[DATE]. Patient's Sp02 is <50. Pupils are 4mm bilaterally and sluggish. Patient has audible wet stridor. Patient's oral airway is check with no food found in her mouth. Patient has a [CONDITION(S)] access to the Right shoulder. Skilled Nursing Facility is informed that the patient does not appear to be having a stroke but is believed to have aspirated. Skilled Nursing Facility then informs EMS that the patient recently failed a swallow test. The patient signed a waiver to be given regular food. Patient was given pureed food tonight but would not eat it and insisted on regular food. Patient was [NAME] chicken nuggets, mashed potatoes and green bean which are still on the table in the patient's room. Patient is going to be transported by helicopter to the nearest critical care hospital. Dispatch is contacted to launch the helicopter. A 5 min ETA once launched. Patient is put on 02 via filtamask at 10 Lpm. Patient is lifted from the wheelchair to the stretcher and secured. Patient is moved to the ambulance. Increased 02 Flow to 15 Lpm . Patient's BP is dropping, A 22 GA IV is established to the right hand. Patient is started on a NS drip WO . 12 lead EKG obtained. 12 lead is paced with a wide QRS. PHI in the ambulance. Report given to PHI staff. Assisted PHI with patient care. Assisted PHI with transfer to helicopter. PHI off the ground to hospital, Medic 3 out of service for decon and restock. Record review of CR#1's autopsy dated [DATE] revealed the resident's cause of death as asphyxia a condition arising when the body is deprived of oxygen, suffocation by foreign body aspiration, reportedly witnessed to choke on food, food bolus visualized during intubation. In an interview with the Dietary Manager on [DATE] at 5:15 PM she stated mechanical soft meat is ground up. She stated nuggets are not considered mechanical soft, if a resident goes to [CONDITION(S)], they may be given a sack lunch, or the residents tray is put on the unit until they return. Once the tray is on the hall who ever passes it checks off the slip prior to giving it to resident. Record review of the Food and Nutrition services policy stated Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. Interview with Dietary Aid A on [DATE] at 1:45 PM, she stated every tray comes with a card, including the resident name, diet such as puree, regular, mechanically soft and the residents likes and dislikes. She stated the cook makes the tray, the dietary aid will call out what is needed on the tray such as regular, and the residents name. If the dislikes are on the menu, she will state the vegetable or meat the resident does not like and ask for an alternative. She stated the trays are put on the cart and the nurse or charge nurse looks over trays before they leave the dining unit. She stated once the cart with the trays leave the kitchen it is checked to ensure name, diet, and meal matches the slip before the tray is given to the resident. In an interview with LVN B on [DATE] at 2:00 PM, she stated that she checks the carts with the trays before they are sent to the different units. She stated that the CNA's are also responsible for checking the resident slip and tray including visually looking at the food and confirming a match before handing tray off to the resident. Interview with CNA A on [DATE] at 2:55 PM, she stated the trays leave the dining room after the nurse checks the trays. Once the trays are checked by the nurse the CNA's can pass the trays to residents, she states she was in serviced on dining to check the residents name, diet and make sure what is on the plate is what the resident is supposed to have. She stated if the tray is not correct then the nurse is alerted and takes the tray to the kitchen to get the correct tray before it is passed out. She stated if she notices a resident is not responsive or looking like themselves, she will get the nurse because she does not have CPR certification . She states she was trained on choking sometime in [DATE]. Interview with CNA B on [DATE] at 3:10 PM, he stated he has been in-serviced on choking once a month, stated he would call for help if he noticed a resident unresponsive or not themselves, he stated if they were turning blue or something he would do the [MEDICATION(S)] maneuver and if the resident had no pulse or not breathing he would perform CPR because he is certified. He stated his role in dining services is to make sure the tray matches the name; stated he looks at the food as well because some people can only have soft food. He stated the types of food consistency are solid, thicken liquid, puree and it is on the slip. He stated they can have meal replacements as well. He stated if the tray does not match the slip, he would tell the kitchen staff and that the nurse usually checks all the trays. In an interview with Administrator on [DATE] at 6:05 PM, she stated the facility intervention after the incident on [DATE] resulted in more residents eating in dining area if resident can. She states this week communal dining is suspended as a precaution due to the facility having an outbreak of COVID-19. She stated all residents that were able to, which included majority of the residents were eating in the dining area up until about a week ago and the outbreak. Observation of dining on [DATE] at 4:50 PM, revealed trays and slips matched the appropriate diet for residents on halls 100, 200, 300 and 400. Staff observed to check tray and slip before handing off tray to resident. Observation of dining on [DATE] at 5:10PM for residents on Mechanical soft and Puree diets revealed their trays were consistent with the tray slip and diet was appropriate for residents' individual needs. Record review of the Descriptions of diet consistencies stated, Regular- no changes in texture- have whole meats, raw fruits, and vegetables of various sizes. No food textures are excluded. Chopped meat- this is meat in ¼- ½ inch pieces all other foods are regular textures. Mechanical soft- This diet is ground meat, and vegetables chopped per menu. Mechanical soft/pureed meats- this diet has pureed meat and vegetables that follow the mechanical soft diet. Pureed, all foods are smooth consistency. Record review of facility's policy, Choking/ Relief of Foreign Body Obstructing Airway stated: Staff will assist resident who is choking by attempting to expel the foreign body from the airway. Procedure: Ask the resident if he or she is choking, remember, a choking victim cannot speak or breathe and needs your help immediately, ask the resident to cough or speak, if possible, to determine if his or her airway is obstructed. If able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign object. Call for help but stay with the resident. Quickly assure the resident that you are going to stay and assist him or her. If the resident cannot cough, only then should abdominal thrust be performed. Record review of literature obtained from the International Dysphagia Diet Standardized Initiative (IDDS) website : https://iddsi.org/Resources on [DATE] revealed a mechanical soft diet is a texture-modified diet that restricts foods that are difficult to chew or swallow. It's considered Level 2 of the National Dysphagia Diet in the United States and includes foods that require no chewing .The goal of the diet is to make foods safer and help a person meet their nutritional needs. Most foods are allowed on the diet as long as they can be safely consumed .You can prepare foods at home or buy premade meals that are suitable for a mechanical soft diet. As of 2015, the International Dysphagia Diet Standardization Initiative (IDDSI) offers guidelines that provide in-depth recommendations and levels based on various medical conditions and risk of choking. A mechanical soft diet would be considered level 5 (minced and moist), according to the IDDSI guidelines. A mechanical soft diet is a type of texture-modified diet for people who have difficulty chewing and swallowing. Foods may be pureed, ground, finely chopped, or blended to make eating safer. Actions Taken include: Record review of QAPI dated [DATE] QAPI dated [DATE] Problem: Diet order discrepancy. Immediate solution: three-way audit of diets prescribed to dietary services records, in service all staff on diet order and policy to include complete communication. Target date: [DATE] Follow up: Daily Long term solution: All diet orders to be followed up with clinical and dietary orders daily through start up. Target date: ongoing Follow up: [DATE] No new changes found. [DATE] dietary audit complete New dietary form, in-service to be done, more residents coming to dining room. Record review of in service dated [DATE] revealed staff reeducated on checking food trays prior to giving tray to residents to make sure that the tray card and food match. In serviced revealed both dietary and nursing staff were in-service.

Based on observation, interview, and record review the facility failed to ensure the residents have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for 7 of 7 (Residents #6, #12, #23, #26, #27, #29 #36), residents reviewed for private telephone use. The facility failed to provide Residents #6, #12, #23, #26,#27, #29 #36 private telephones to ensure their conversations could not be overheard. These failures could affect all resident who may need telephone and placed them at risk for a decline in the resident's psychosocial well-being and cause them to feel disconnected from family members. Findings included: Resident #36 Record review of Resident #36's face sheet, dated 12/16/2020 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of resident #36's physician orders [REDACTED]. Dorzolmide drops, 2%, [MEDICATION NAME] drops .05%, and [MEDICATION NAME] drops .2-.5% for [MEDICAL CONDITION], severe stage. Record review of Resident #36's Quarterly MDS, dated [DATE] revealed the resident had a BIMS score of 15, which indicated the resident had no cognitive impairment. Record review of Resident #36's Care Plan, with a goal date of 2/17/2021 revealed a Problem/Need: Sudden loss of vision (total). It revealed a problem on set which read: Resident is at risk for alteration in psychosocial well-being related to medically imposed restrictions due to COVID-19 precautions. The goal: Resident will not show a decline in psychosocial well-being or experience adverse effects through the next care review. Approaches: Provide alternative methods of communication with family/visitors. Interview on 12/14/2020 at 9:40 AM with Resident #36 said she had her phone was not working for the past few weeks. She expressed she had not talked to her family members. She said it had been difficult not talking to them and she wanted to talk to them. Observation on 12/14/2020 at 9:45 AM revealed when Resident #36's room phone was used to dial surveyors work cell there was a busy signal. Interview on 12/16/2020 at 12:41 PM with Resident #36's family member said she had not talked to Resident #36 since 12/01/2020. She said she has called the facility but did not want to make Resident #36 come out of her room to the nurses' station because she knows Resident #36 does not like to come out of her room. She said at the very least I would call her once a week. She said I tell the staff to tell her hello for me, but it's not the same with her hearing my voice. Interview on 12/16/2020 at 12:43 PM with CMA S said the resident phones stopped working and the only option was at the RN station which are not private and Resident #36 does not like to come out of her room. Interview on 12/16/2020 at 12:54 PM with Resident #36 said it did bring tears to her eyes that she was not able to talk to family and it is a necessity that I talk with my family and they are able to check up on me. She further said it upset her that she was not able to use the phone. Resident #29 Record review of Resident #29's face sheet, dated 12/16/2020, revealed an original admission date of [DATE] and re-admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of resident #29's physician orders [REDACTED]. Record review of Resident #29's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident had no cognitive impairment. Record review of Resident #29's Care Plan, with a review date of 10/8/2020, revealed a focus area which read: Resident is at risk for alteration in psychosocial wellbeing related to restriction due to COVID-19 precautions. The goal: Resident will not show a decline in psychosocial well-being or experience adverse effects through the next care review. Approaches: Provide alternative methods of communication with family/visitors. Interview on 12/15/2010 at 12:16 PM with Resident #29 said she has been married [AGE] years and normally calls her husband every evening. She said it has made her very sad not to be able to talk to him every night around 6:00 pm or 6:30 pm. She said she told unknown staff her phone was not working but she said she was not offered different options. She said we can't have visitors, and this is her only way of communication. She said the phones have not been working since a new company took over on 12/01/2020. Observation on 12/14/2020 at 12:18 PM revealed when Resident #29's room phone was used to dial surveyors work cell there was a busy signal. She called her spouses number and there was busy signal. Interview on 12/15/2020 at 12:21 PM with Resident #29's Spouse said it had been a couple of weeks and he had not talked to Resident #29. He said he normally talked to her every evening. He said it is hard to get staff to answer the main line. He said he was not notified that the phones would be turned disconnected. Interview on 12/15/2020 at 12:30 PM with Resident #29's family member said a new company bought out the old one and the phones were turned off on 12/01/2020. She said there was no prior notice given regarding the phones being disconnected. She said she talked to Resident #29 daily before the phones were disconnected. She said the high rate of COVID in the county prevented her from window visits. Resident #26 Record review of Resident #26's face sheet dated 12/16/2020, revealed an original admission date of [DATE] and re-admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #26's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 13, which indicated the resident had moderate cognitive impairment. Record review of Resident #26's Care Plan, with a review date of 12/8/2020, revealed a focus area which read: Resident is at risk for alteration in psychosocial wellbeing related to restriction due to COVID-19 precautions. The goal: Resident will not show a decline in psychosocial well-being or experience adverse effects through the next care review. Approaches: Provide alternative methods of communication with family/visitors. In an interview and observation on 12/16/2020 at 1:29 PM with Resident #26 said her phone had not worked in the last few days. She said she liked to talk to her family, but no one can contact her and that bothers her. The surveyor observed a list of 4 family members' names with phone numbers posted on the wall in Resident #26's room. She said she was not notified prior that the phones would be turned off. Resident #23 Record review of Resident #23's face sheet dated 12/16/2020, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Care plan and MDS requested from LVN K on 12/16/2020 at 11:48 AM but not receive at the time of exit. In an interview on 12/16/2020 at 1:33 PM with Resident #23 said my phone has not worked for several days I like to talk to my family every day, it makes me feel very sad that I can't talk to my family when I want. Resident #27 Record review of Resident #27's face sheet dated 12/16/2020, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #27's Annual MDS, dated [DATE] revealed the resident had a BIMS score of 15, which indicated the resident had no cognitive impairment. Record review of Resident #27's Care Plan, with a review date of 12/9/2020, revealed a focus area which read: Resident is at risk for alteration in psychosocial wellbeing related to restriction due to COVID-19 precautions. The goal: Resident will not show a decline in psychosocial well-being or experience adverse effects through the next care review. Approaches: Provide alternative methods of communication with family/visitors. In an interview on 12/16/2020 at 1:39 PM with Resident #27 said she had been trying to reach my friends on the phone for over a week. She said we like to talk every day, but they cut the phones off and that makes me very sad. Resident #27 said, We can't have visitors, there is nothing else to do but sit in my room and stare at the walls. What kind of life is that for people like me who likes to talk? She said she had not been offered alternate ways to talk to her family and friends. Resident #6 Record review of Resident #6's face sheet dated 12/16/2020, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's Quarterly MDS, dated [DATE] revealed the resident had a BIMS score of 15, which indicated the resident had no cognitive impairment. Record review of Resident #6's Care Plan, with a review date of 10/7/2020, revealed a focus area which read: Resident is at risk for alteration in psychosocial wellbeing related to restriction due to COVID-19 precautions. The goal: Resident will not show a decline in psychosocial well-being or experience adverse effects through the next care review. Approaches: Provide alternative methods of communication with family/visitors. In an interview on 12/16/2020 at 1:44 PM with Resident #6 said her bed side room phone is not working. She said she felt bad for the others who live here, they can't talk to the people who they care about like she can. She said she has offered her cell phone to them, so they can talk to their families because she knew how important it is to everyone. She said the staff said the residents could use the phones at the desk or office, but they avoid it because there is no privacy, and everyone can hear what people are saying. Resident #12 Record review of Resident #12's face sheet dated 12/16/2020, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #12's Annual MDS, dated [DATE] revealed the resident had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Record review of Resident #12's Care Plan, with a review date of 10/22/2020, revealed a focus area which read: Resident is at risk for alteration in psychosocial wellbeing related to restriction due to COVID-19 precautions. The goal: Resident will not show a decline in psychosocial well-being or experience adverse effects through the next care review. Approaches: Provide alternative methods of communication with family/visitors. In an interview on 12/16/2020 at 9:10 AM with Resident #12 said nobody told me my phone would be turned off and not working. She said my family usually called me every day, but I just thought they didn't have time for me. She said, I feel bad thinking like that now and it's even worse that I can't tell them how much I love them. Interview on 12/15/20 at 12:40 PM CNA S said since the new company took on 12/01/2020 the phones have been disconnected. She said she was not told to offer different phone options. She said she thought the SW was supposed to let the residents use her phone use her. When asked what the residents were supposed to do on the weekend she said she was not sure. She said there is no designated private phone that all residents can use. She said the phone located at the nurses' station is not private because it is adjacent to the resident TV area. Interview on 12/15/2020 at 12:47 PM with the SW said the phones in the resident rooms had been disconnected by the former owners of the facility on 12/01/2 020. She said normally family could call the main number and they would get transferred to the residents' room phone. She said the new owners were changing the phone system to a VOIP (Voice over Internet Protocol) phone system. She said this required a new type of installment unlike the traditional phone lines the residents used before the switch. She said the facility did not give residents and family prior notice the phones would be disconnected. She said the Administrator has been in contact with the new owners but is not sure when the phones will be set back up. She said residents were upset by not being able to contact their family member. She said we do not have Zoom (video call) since the new company took over 12/01/20 it is blocked. She said the nurse station phone is available. She was asked what the resident's do when the phone is in use by staff, and she said they would have to wait. She said window visits are not an option since the county and state said windows could not be raised for window visits. She said the county positivity rate for COVID-19 is high. She said Resident #36 has a lot of family that calls her. She said Resident #36 enjoys talking to her family because she does not participate in activities. Interview on 12/15/20 at 1:40 PM with Regional Director of Operation said the facility changed is changing to an internet-based system. She said we did not know if the residents were notified prior to the phones being disconnected. She was not able to explain why the residents' phones were disconnected and the staff phones services remained uninterrupted. She said the residents could uses the nurses' station phones. She said she had not been in the building and was not aware the phone at the nurses' station is near the resident common TV area. She said if residents are in the common area then they would need to leave to give the resident who wants to use phone privacy. Interview on 12/15/20 at 2:11 PM with the Administrator said there was a lack of communication between the former owner and the current owner regarding the phone. She said they noticed the phones were disconnected, after resident complaints over 12/1/2020 and 12/2/2020. She said she did not instruct staff to inform the residents of alternate options after the phones were disconnected. She said she was not aware that she needed to provide a private area for the residents to have access to a phone if their room phone were not working. Interview on 12/16/20 at 9:49 AM with the Administrator said after the company transfer the phones stopped working after two days. She said there was no plan to ensure residents had access to phone services and in a private area after they stopped. She said residents could use staff phones in their offices. She said she normally left the facility at 5pm. She could not explain how the residents would have reasonable access to use a phone in a private area after the staff with offices have left for the day. She said no resident had asked to use the phones. She said she was not aware that resident #29 talked to her spouse every evening around 6:00 pm or 6:30 pm. She said she was not thinking about telling each resident specifically that the phones stopped working. Interview on 12/16/2020 at 10:42 AM LVN D said Resident 29# and Resident #36 use the phone regularly and have not been able to call out since the phones were disconnected on 12/01/2020. She said it would have been helpful for Resident #36 to have a cordless phone because she does not like to come out of her room much. Interview on 12/16/2020 at 12:30 PM with the Administrator said it is important for residents to talk to family because they are not able to have in-person visits. The residents had expressed general frustration about not having access to a phone after 12/01/2020. She said there has been a lag time in notifying the residents and providing them with alternate options to a phone that can be used privately. She said she is ultimately responsible to ensure residents had access to a phone and in a private area. In an interview on 12/16/2020 at 8:40 AM with Resident #30 said the phones have not been working for over a week I like to talk to my church friends every day and pray with them, it's been so hard and depressing not being able to talk with anyone. In an interview on 12/17/2020 at 12:27 PM with DON said alternative methods of communication with family/visitor in resident care plans meant resident should have been given opportunities to talk to family/friends by phone. She said they did not know the phones would be turned off by the previous owners. She said they did not have an alternate plan, other than residents could use the nurse's stations phone. She said the nurses station phone is not private. She said they did not inform the residents that it was an option. She said they did not have a private designated area for residents to use the phone or a cordless phone. Record review of facility Grievance Log dated 1/1/2020 - 12/08/2020 revealed there were no documented grievances related to disconnected phones. Record review of facility Rights of the Elderly (revised 7/21/18) revealed in part the following: .An elderly individual is entitled to privacy while attending to personal needs and a private place .This right applies to .telephone conversation . Record review of facility Statement of Resident Rights (Texas) revealed in part the following: .You have a right to . 6. Privacy, including privacy during .telephone calls .

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 1 of 1 kitchen in that: Kitchen main drawers with serving utensils were dirty. Facility primary can opener blade was dirty and had food debris. Leftover Egg Omelet from breakfast in a plastic container with a temperature of 148 degrees stored in the walk-in refrigerator saved for later use. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings included: Observation of the facility 's kitchen and interview on 12/16/20 between 8:30 am and 8:40am with the Food Service manager revealed the following: The facility primary can opener blade was dirty and had food debris. The food Service Manager at this time said she will assign a staff to sanitize and wash the can opener blade. Kitchen main drawers with serving utensils were observed dirty. The Food Service Manager at this time said that she will assign a staff to wash and sanitize the drawer and the serving utensils. Observed leftover egg omelet from breakfast in a plastic container with a temperature of 148 degrees Fahrenheit stored in the walk-in refrigerator to be saved for later use will have temperature in the Danger Zone. (41degrees Fahrenheit - 140 degrees Fahrenheit.) Interview with the Food Service Manager on 12/16/20 at 8:35 AM revealed that the leftover egg omelet was not cooled off rapidly thus the food had a temperature 148 degrees Fahrenheit which did not allow food to cool rapidly to minimize the possibility of foodborne illness. She stated that she will discard the leftover food. Interview following the above observation on 12/16/20 at 8:45 am the Food Service Manager said that she was responsible for ensuring dietary requirements are met. Record review of facility's Dietary Dept. Sanitation not dated revealed that all utensils, counters, drawers, shelves and equipment shall be kept cleaned and sanitized. Record review of facility's Dietary Dept. Cooking, Cooling, & Reheating Foods not dated revealed that foods should be cooled properly to minimize the possibility of foodborne illness. Use an ice bath, stir foods as they cool to eliminate hot pockets, use shallow 2 inch pans to help food cool quickly, place pan on top shelves of the refrigerator due to the top of the refrigerator is usually colder, make sure air can circulate around pans to help cool foods quickly, and do not cover food until it is completely cool.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administration of all drugs or biologicals to meet the needs of each resident and ensure expired drugs or biologicals were not available in one of four medication carts (200 hall Medication Cart ) for 3 of 3 residents ( Resident #20, #23 and #35) reviewed Pharmacy Services. The facility failed to ensure that expired insulin was removed from nurse medication (med) cart located on Hall 200. The facility failed to ensure Residents (#23 and #35) [MEDICATION NAME] nebulizer inhalation (for wheezing and shortness of breath) without opened dates were removed from nurse med cart on Hall 200. These failures could affect the residents residing in Hall 200 and place them at risk of not receiving the intended therapeutic benefit of their medications. Findings included: Resident #20 Observation on 12/15/20 at 11:00 am of the nurse med cart located on Hall 200 revealed, Resident #20's Regular [MEDICATION NAME]vial open date 10/18/20 and was labeled use as directed per sliding scale, give before breakfast and before supper. Record review of Resident #20's clinical record revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed severely impaired with decision making and she required 1 person total assist most activities of daily living (ADLs). Record review of Care Plan last reviewed 10/06/20, revealed Resident #20 was insulin dependent diabetic and noted at risk for cardiac, renal, circulatory and healing issues. Further noted goal was to have her blood sugar (BS) maintained within acceptable levels, to reduce the risk of associated complications thru the next review period. Record Review of Resident #20's Consolidated Physician Order dated December 2020 revealed an active order for: Regular [MEDICATION NAME]subcutaneous (sq) as per sliding scale twice a day (BID) scheduled at 6:30 am and 4:30 pm. If BS 150-200, give 2 units; 201-250, give 4 units; 251-300, give 6 units; 301-350, give 8 units; 351-400, give 10 units. If BS < 60 or > 401 to call MD. Record review of Resident #20's Medication Administration Record [REDACTED]=298 before supper. Interview with LVN D on 12/15/20 at 11:00 am confirmed Resident #20's Regular [MEDICATION NAME]vial open date 10/18/20 and after 28 days should have been removed from nurse cart. LVN D further stated she did not administer Resident's Regular [MEDICATION NAME] insulin, since it was scheduled to give before supper. Resident #23 Observation on 12/15/20 at 11:00 am of the nurse med cart located on Hall 200 revealed two opened foil packages of [MEDICATION NAME] ([MEDICATION NAME]) nebulizer (neb) inhalation, without opened dates for Residents (#23 and #35). Record review of Resident #23's clinical record revealed a [AGE] years old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident's Care Plan dated 11/18/20 noted she has a history of [MEDICAL CONDITION] and at risk for shortness of breath (SOB). Further noted the goal to minimize risk of exacerbation of diagnosis. Record review of Resident #23's Consolidated Physician Order dated December 2020, revealed order for [MEDICATION NAME] ([MEDICATION NAME]) solution for nebulization (neb) 1 vial via neb every 4 hours as needed (prn) for wheezing and shortness of breath. During interview on 12/15/20 at 11:00 am LVN D stated both [MEDICATION NAME] nebulizer treatments will be discarded but will have to re-order from Pharmacy for Residents (#23 and 35). She stated the Physician order for [REDACTED]. During interview on 12/15/20 at 11:05 am DON stated nebulizer inhalation should have an opened date after each foil package was opened and nurses must pay attention to remove expired meds in the med cart. Resident #35 Record review of Resident #35's clinical record revealed [AGE] years old female was admitted to the facility on [DATE] and last month admitted to Hospice. Her [DIAGNOSES REDACTED]. Record review of Resident #35's Consolidated Physician Orders dated December 2020 revealed order for [MEDICATION NAME] ([MEDICATION NAME]) solution for nebulization 1 vial via neb every 4hrs as needed for wheezing and dyspnea (difficulty of breathing). During interview on 12/15/20 at 2:00 pm DON stated the ADON reviewed Consultant Pharmacist recommendations to follow-up with the Physician. She said medications when reviewed for irregularities were usually caught by the Pharmacist as well. During interview on 12/15/20 at 2:30 pm ADON stated Consultant Pharmacist conducted on-line monthly medication regimen review. ADON when asked, stated she did not know how the Pharmacist does it remotely but Pharmacist was at the facility two months ago. Record review of the facility policy entitled, Consultant Pharmacist Services Provider Requirements dated 11/2017, revealed to assist the nursing care center staff on development, implementation, evaluation and revision of pharmaceutical service procedures that address resident needs and follow the current standards of practice.

Based on interview and record review, the facility failed to ensure that residents receive treatments and care in accordance with professional standards of practice, the comprehensive person- centered care plan that will meet each resident's physical, mental, and psychosocial needs for 2 of 13 residents (CR #1 and #2) reviewed for quality of care, in that; CR #1 sustained a fall and complained that her was broken and pain to her leg. CR #1's physician ordered 3 x-rays' (femur, hips, and pelvis) but only one view of the ordered x- ray was completed. The facility nurse failed to communicate to administration, the physician, and family that all x-rays were not obtained. CR #1 continued to complain of pain and x-rays were not reordered until 4 days later and the resident was diagnosed with [REDACTED].#1 was admitted to the hospital where she underwent surgery to her hip and returned to the facility after surgery with a significant change in condition. CR #2 who exhibited self-harming behaviors of hitting her head on walker and her on bed rail, was not provided prompt intervention. CR#2 was transferred to the hospital where it was discovered she had a hair line neck fracture Facility staff failed to consult CR #2's physician , notify her family and administration of her self -harming behaviors to implement interventions. These failures affected two former residents whose health declined from diminished quality of care. Findings include: CR #1 Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged /deceased on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 5 indicating severely impaired cognition. The ADL assessment revealed CR #1 was independent and required setup only with eating and personal hygiene, she was continent of bowel and bladder. The Pain assessment for CR #1 revealed she had no pain issues and had not received scheduled or PRN pain medications within last 5 days of assessment. The fall assessment on the MDS revealed resident had no history of falls. Further review of the MDS revealed resident had clear speech and made herself understood, resident also had daily behaviors of rejecting care. Record review of CR #1's care plan dated [DATE] revealed hand-written additions, [DATE] resident was observed on floor in front of bed, denied pain, 30 minutes later yelling, my leg is broke. [DATE] Resident dragging her left foot when wheeling and some swelling and bruising to left hip - repeat x-ray show fracture to hip. Her interventions included: assist resident with transfers as needed, encourage resident to assume a standing position slowly, keep bed in lowest position with breaks locked, always keep call light in reach, keep personal items and frequently used items within reach. Notify MD and family as needed, Observe frequently and place in supervised area when out of bed. Obtain PT consult as ordered, place resident in a fall prevention program as needed, and provide proper, well maintained footwear. Refer to therapy as needed ([DATE]). Declined Reacher, refer to therapy ([DATE]), reminder sign in room ([DATE]), X-rays ordered no fracture shown ([DATE]). Record review of CR #1's care plan updated after [DATE] and last revised on [DATE] revealed resident was at risk for injuries from falls related to generalized weakness and refusals to allow staff to assist. Resident had a witnessed fall on [DATE] and refused to allow x-ray tech to complete x-rays, fracture was not determined until [DATE]. Her interventions included: Geri chair for comfort (does not prevent rising as resident stands), keep bed in lowest position with brakes locked, keep call light in reach at all times, keep personal items and frequently used items within reach, Notify MD and family as needed, Nursing staff to use Hoyer lift with 2 staff for transfers, (Therapy does not need to use Hoyer as they are working with me), OT and PT to work with me and follow P[NAME], and provide proper, well maintained footwear. Record review of CR #1's incident report dated [DATE] at 6:30AM revealed LVN #1 was called to resident room by a CNA, resident was yelling that bed was slick while sitting on the floor next to bed, she moved all extremities as usual no complaints of discomfort, yelling at staff to get out of her room. NP, RP, and care plan was reviewed and revised at 7:25AM. Progress note section for the event on [DATE] at 7:27AM revealed, called to resident room heard resident yelling at staff noted resident sitting on floor next to bed stated, the bed is slick yelling at staff to get out of her room assessment done no change in range of motion, no complaint of discomfort after resident calmed down assisted to wheel chair by staff X2 no red or discolored area noted. RP and PCP notified . Report was written by LVN#1. Record review of CR #1's significant change MDS dated [DATE] revealed a BIMS score of 4 indicating severely impaired cognition. The ADL assessment revealed CR #1 was totally dependent on staff and required assistance of ,[DATE] staff members, she was always incontinent of bowel and bladder. The Pain assessment for CR #1 revealed she had received PRN pain medications within last 5 days of assessment. The fall assessment on the MDS revealed resident had a fracture related to a fall within the last 6 months. Further review of the MDS revealed resident had clear speech and made herself understood, resident also had behaviors of rejecting care 4 - 6 days, but less than daily. Record review of MA #1 witness statement from CR #1's incident dated [DATE] revealed CR #1 had a fall check off list indicating: her call light was in place, she fell in her room, resident had no shoes or socks on, injury was seen, charge nurse was notified, and resident was alert and oriented. Further review of the statement revealed, Resident was sitting at the edge of bed, I was a few feet away. Resident who transfers self-slid out of bed onto the floor, called for charge nurse. Resident stated, I slipped out of bed on the slick floor. Record review of LVN #1 witness statement from CR #1's incident dated [DATE] revealed CR #1 had a fall check off list indicating: her call light was in place, she fell next to bed, resident was transferring, resident had no shoes or socks on, no injury was seen, charge nurse was notified, resident was alert and oriented, and resident was confused at times. Further review of the statement revealed, was called to resident room, noted resident siting on floor next to bed, resident told writer that bed is slick move all extremities yelling at other staff in room to get out, 0 signs/symptoms of discomfort noted . Record review of CR #1's nurses notes dated [DATE] at 6:40AM signed by LVN #1 revealed he was called to resident room and noted CMA in room resident sitting on floor next bed. Resident was yelling at staff to get out and told the nurse the bed was slick. The resident was assessed and was noted to move all extremities as usual with 0% discomfort. The staff assisted resident into her wheel chair and she propelled herself with feet. 30 - 45 minutes later the resident was yelling her leg was broken in 4 places. The doctor was called, and she gave order to get mobile x-ray to do x-rays for 2 views of hips, pelvis, and femur. Record review of CR #1's physician's telephone order dated [DATE] revealed, x-ray bilateral hips and femur [DIAGNOSES REDACTED]. Record review of CR #1's radiology report dated [DATE] at 5:50PM revealed examination of Hips Bilateral without pelvis 2 V with results of no acute osseous pathology. There were no X-ray results for the femur and pelvis as ordered. Review of CR #1's clinical record revealed no other x-rays (femur or pelvis) were completed on [DATE]. Record review of CR #1's nurses notes dated [DATE] with no time stamp signed by LVN #2 revealed, Resident follow up fall with no adverse reaction. Move all extremities well without difficulty up in wheelchair, self - propelling, x - ray results back and no fractures noted. Record review of CR #1's nurses notes dated [DATE] with no time stamp signed by LVN #1 revealed resident was in bed sleeping in intervals and had 0% discomfort at that time. She propelled in her wheelchair with feet and had no problems or delayed injuries from the fall. Record review of CR #1's nurse notes dated [DATE] for 10pm - 6am signed by LVN #3 revealed, Resident follow-up fall, neuros in progress and all within normal limits. Resident awake, alert. Crying out off and on. Requesting Tylenol. Give by mouth and taken with sips of water. Call light in reach. Will continue to monitor resident. Record review of CR #1's nurses noted dated [DATE] at 2:00AM signed by LVN #3 revealed, Resident quiet down and asleep at this time. Will monitor. Record review of CR #1's SBAR Communication Form started on [DATE] revealed resident had decreased 02 sat and had a temperature. The Form listed that resident had changes of a fall occurring on [DATE]. Resident's vitals were BP ,[DATE], P 81, Temp 101.4, O2 sat of 81% on room air. Resident mental status evaluation revealed she had decreased level of consciousness, increased confusion, and new memory loss. Residents functional status evaluation revealed decreased mobility, needs more assistance with ADL's, weakness, and fall that occurred on [DATE]. Resident pain evaluation revealed she had new pain in her leg related to fall that was rated at an 8. Resident's neurological evaluation revealed she had decreased level of consciousness with increased confusion and sleepiness. The Form further noted observations of resident, Resident in bed increased confusion, low saturation, and pain to lower extremities. Nursing note to close out form noted, Resident sent to hospital for evaluation T - 101.4, low O2 sat (81% on room air), increased confusion and pain to lower extremities. The Form was signed and dated [DATE] at 10AM by LVN #2 and noted CR #1's RP was at the bedside. Record review of CR #1's Patient Transfer Form dated [DATE] revealed resident was being transferred to the hospital for altered mental status, low O2 sat, status [REDACTED]. Notes revealed resident had a temp of 101.4. Record review of CR #1's physician telephone orders dated [DATE] at 11:55AM revealed an order to send resident to ER for evaluation. Record review of CR #1's nurses notes dated [DATE] at 12:55PM revealed per nurse at hospital resident was being admitted . Record review of CR #1's patient transfer form dated [DATE] revealed the resident was being transferred from the hospital back to the facility and she was diagnosed with [REDACTED]. Discharge medication list revealed for the resident to continue [MEDICATION NAME] tablet 325 MG as needed every 6 hours for a finding of chronic pain. Record review of CR #1's hospital records for discharge on [DATE] revealed no record of x-rays completed. Record review of CR #1's nursing notes dated [DATE] at 12PM signed by LVN #1 revealed resident was back from hospital with [DIAGNOSES REDACTED]. She was propelling herself in wheelchair with feet and was drinking water. Record review of CR #1's physician telephone order dated [DATE] revealed resident was readmitted to the facility from the hospital and for her to continue nursing home medications and treatment. Order also noted to add [DIAGNOSES REDACTED]. Record review of CR #1's nurses notes dated [DATE] from 10PM - 6AM revealed in part, .Resident complained of pain in legs, Medicated times 1 Tylenol 325MG by mouth. Note was written by LVN #3. Record review of CR #1's nurses notes dated [DATE] at 3:00AM revealed in part, .Resident was awakened and started yelling . Attempted to redirect resident no progress. Resident did quiet down eventually . Note was written by LVN #3. Record review of CR #1's notes dated [DATE] revealed in part, .11AM resident noted dragging left leg, MD made aware at this time awaiting response. Will continue to monitor . 11:45AM x-ray of bilateral femurs ordered at this . 4PM received x-ray results of left femur, resident refused to have right femur x-rayed. Report sent to doctor at this time awaiting orders. 4:30PM new orders received to send to ER . 6PM ambulance transported resident out of facility at this time. Record review of CR #1's x-ray results dated [DATE] at 2:31PM revealed an examination of left femur with results of acute intertrochanteric LEFT femoral fracture. Record review of CR #1's physician telephone orders dated [DATE] revealed order to x-ray bilateral femurs STAT. Record review of CR #1's physician telephone orders dated [DATE] revealed order to send to ER for treatment of [REDACTED]. Record review of CR #1's patient transfer form dated [DATE] revealed resident was transferred to hospital for fracture of left femur. Social information on the form revealed, Witnessed fall on [DATE], x-ray completed to pelvis, refused femur x-ray at that time per technician on [DATE]. Left femur x-rayed report attached. Record review of CR #1's hospital record revealed she was admitted to the hospital on [DATE] with an intertrochanteric fracture and had surgery procedure of open reduction and internal fixation using Ace [MEDICATION NAME] hip screw 90 X 135 with four - hole plate. Resident was discharged from the hospital back to the facility on [DATE]. Record review of CR #1's (MONTH) 2019 MAR indicated [REDACTED] [DATE] for complaint of general pain. [DATE] for complaint of general pain. [DATE] for complaint of leg pain. Record review of CR #1's (MONTH) 2019 MAR indicated [REDACTED] [DATE] Resident requested Tylenol . 30 minutes later requested 2nd Tylenol for complaint of general body aches. Record review of CR #1's (MONTH) 2019 TAR revealed an order for [REDACTED]. Interview on [DATE] at 2:27PM, CR #1's RP said on [DATE] around 7AM she got a call from LVN #1 saying CR #1 had fallen out of bed and they had ordered x-rays for her legs and hips. She said she spoke to LVN #1 several time that day and he reported the x-rays were completed with no findings. She said LVN #1 told her CR #1 was yelling that her leg was broken but said he did not know what was wrong with her because her x-rays were fine. The RP said it was then later reported to her the resident was fine and she was propelling herself around in wheelchair. She said the Saturday morning ([DATE]) around 9AM she went to the facility to visit the resident and when she got there she found CR #1 in bed curled up in a fetal position at the top of her bed. She said she tried to speak to the resident, but she would not respond and looked contorted. She went and found a nurse at the nurse's station who came in and assessed the resident and found that she was not responding to them either. She said the facility called an ambulance and the resident was sent to the ER where it was then reported to her the resident was just dehydrated and she was going to be fine. She said the hospital did not complete any x-rays while CR #1 was there and said the resident was not complaining of pain while at the hospital or when she saw her because the resident was unresponsive at the time from dehydration. She said she was assured by the facility staff and hospital the resident was fine and just needed an IV and the resident would be returned to the facility. The RP said her, and her family left to go on vacation with the reassurance that CR #1 was fine. She said next call she got was on Monday ([DATE]) from the DON saying CR #1 was at the ER and had a fracture. She said it was reported to her that a nurse went in to check on CR #1 and she found that her hip was swollen. The RP said it was explained to her that CR #1 had refused to have the first set of x-rays completed on [DATE] and only one view was completed. The RP said that it was reported to her by LVN #1 that all of CR #1 x-rays were done with no concerns and said that was the first time it was told to her that CR #1 had refused any of the x-rays. The RP said she had spoken to another nurse (LVN #3) who had reported to her CR #1 had been raising hell over the weekend complaining about having leg pain. The RP said she expected the facility to find the fracture before they did and to report to her that x-rays were not completed so a decision could be made of what to do next since it was clear the resident had sustained an injury. The RP said the next two months after the surgery were awful and said the resident was in a lot of pain and did not even talk to her anymore. She said the resident declined quickly after surgery and passed away within two months of having the surgery. Interview on [DATE] at 2:34PM, LVN #1 said he did not recall working on [DATE] when CR #1 fell but said he did remember the day she was transferred out on [DATE] and she had x-rays completed that confirmed she had a fracture. He said he could not recall if CR #1 had pain when she was sent out but said resident would occasionally ask for one Tylenol for general pain. Interview on [DATE] at 10:37AM, MA #1 said she witnessed CR #1 fall. She said she would go into her room early and get her things out and try and do what she needed to do because the resident did not like for people to be in her room and would not allow anyone to touch her. She said she stood at the end of the bed while the resident transferred herself to her wheel chair as she always did, and the resident suddenly slipped and fell to the floor. MA #1 said the resident fell hard. She said the resident just said, Oh I fell . The MA said she went to get LVN #1 who assessed the resident. The medication aide said the resident looked like she was hurt from the fall but had her usual behaviors of not wanting to be bothered or touched. The MA said the resident would sometimes ask for Tylenol for general pain but the next few days she saw the resident after the fall she said it was not the same pain she had complained of in the past. She said she observed the resident in bed and she seemed to be in pain and said, she looked bad. The MA clarified the observations she had of the resident not looking well was after the fall and before the surgery. Interview on [DATE] at 10:56AM, LVN #4 said she couldn't remember much about the incident with CR #1 but confirmed she wrote the nurses notes on [DATE] about resident dragging her leg in her wheel chair. She said the resident would usually propel herself in wheel chair with both legs but on this day, she saw the resident just pulling herself with one leg and not using the left leg causing it to drag. She said the resident did not complain of pain but said she did not think the resident would complain of pain even if she was in it. LVN #4 said she recalled that CR #1 had apparently refused to let the technician complete all of the first ordered x-rays on [DATE] so she told the technician to x-ray the leg she was complaining of first. The LVN could not remember any other details about CR #1 before she was transferred to the hospital on [DATE]. Interview on [DATE] at 12:02PM, LVN #2 said after CR #1 had her fall she stayed in bed most for most of the day. She denied the resident ever complained of pain. LVN #2 said it was not reported to her the x-ray technician had not completed all of CR #1's ordered x-rays. LVN #2 said she doesn't know if CR #1 had any bruising or swelling to the hip area because she had not observed the area. Interview on [DATE] at 4:00PM, the DON said LVN #1 was the nurse who was there when CR #1 had her fall on [DATE]. She said LVN #1 may not remember due to him recovering from serious medical condition that may have affected his recollection of events. She said she could not remember the incident clearly either but did not think the resident had complained of much pain and said she recalled the resident would not let the technician complete all of the ordered x-rays. She said they monitored the resident after the fall and then it started bruising on the leg and they ordered the x-rays again and that's when the fracture was found. The DON said she could not recall if they were made aware of all the x-rays not being completed before [DATE]. The DON could not recall if the physician or family was notified of the x-rays not being completed on [DATE]. The DON said the resident had a right to refuse the x-rays but could not speak on what was done after the x-rays were refused to ensure the resident was not injured besides do neuros and monitor the resident . CR #2 Record review of CR #2's face sheet revealed a [AGE] year-old female admitted on [DATE] and discharged on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's quarterly MDS dated [DATE] revealed a BIMS score of 8 indicating moderate impaired cognition. Further review of the MDS revealed resident had no behavior or mood issues and resident only required supervision with ADL's. Record review of CR #2's care plan last updated on [DATE] revealed resident was currently taking antipsychotic medication for [MEDICAL CONDITION] with hallucinations. Resident was currently participating in the psychiatric program, taking antidepressant and antianxiety medication. [DATE] resident yells, curse, screams, and threatens staff when they redirect her. [DATE] resident was observed by staff while in dining room grab her walker and hit herself in the head, staff intervened and stopped the behaviors. Later in the day resident was in her room laying in bed and was rocking side to side and hit her head on the enabler bar, the nurse aide placed a pillow between the rail and resident. [DATE] standing on chair in dining room, staff finally able to talk her out and help her down. Her interventions included: Neuros initiated, enabler bar removed from bed, seen by physician, ordered to send to geriatric psychiatric facility, remind resident behavior is inappropriate and stop me, administer medication as per physicians orders, monitor and record displayed behavior and or mood problems, monitor and record any displayed behavior and/or mood problems, monitor and record any adverse effects of the medications, encourage appropriate behavior, monitor effectiveness of [MEDICAL CONDITION] medications, notify physician with any adverse reactions and/or no improvement in behavior/mood. Record review of CR #2's provider investigation report dated [DATE] revealed CR #2 had an injury of unknown source. CR #2's was observed by a housekeeper hitting herself in the head with her walker and was redirected. The Housekeeper notified a CNA who then notified a nurse who assessed the resident and identified a small bruise to her forehead. The Nurse notified the MD and RP and the MD ordered to monitor for any more unusual behaviors, especially those that might involve self - harm. Later in the day on [DATE] during the evening shift a CNA was in the room with CR #2 and observed her rocking back and forth in bed and hit her head on the assist bar on the bed. The nurse on duty was notified and she assessed the resident. The MD and RP were notified and due to her previous behaviors that day the resident was transferred to a behavior hospital. The facility social worker escorted the resident to the behavioral hospital. It was noted the resident denied pain during assessments and during the transition to the hospital. Resident was transferred from the behavioral hospital to a hospital in Houston because their CAT scan machine was down. The resident was diagnosed at the hospital with a hair line neck fracture. The injury was noted to be, Nondisplaced fracture of indeterminate age extending through the [MEDICATION NAME] process into the [MEDICATION NAME] foremen on the right C4. Record review of CR #2's nurses notes dated [DATE] for 6am - 2pm shift revealed, 8AM resident up in dining room attempting to stand in the chair. When redirected screamed at staff and cursed them out. Started fighting when staff attempted to help her out the chair. RP here and notified of resident outburst and behavior. Record review of CR #2 nurses' notes dated [DATE] for 6am - 2pm shift revealed resident continued on behavior monitoring and she attempted to exit the doors yelling and screaming at staff, she refused to be redirected. Record review of CR #2 nurses' notes dated [DATE] and [DATE] revealed the resident was observed walking with and without walker but no other behaviors were noted. Record review of CR #2's SBAR communication Form dated [DATE] at 3:50PM revealed resident was banging her head on bed rail and walker and resident had pulled her tooth out. It was noted that resident had behaviors before but zero self - harm before. Skin evaluation revealed resident had a bruise to her forehead where she was banging her head, but resident had no pain. The physician was notified on [DATE] at 2:50PM and order to refer her to behavioral hospital or other geriatric psych facility for evaluation. Record review of CR #2's nurses notes dated [DATE] at 6:25PM revealed resident had left the facility to go to behavioral hospital. Interview on [DATE] at 12:41PM, the social worker said CR #2 was calm when she first came to the facility, but she did have some hallucinations. She said CR #2 was going to a psychiatric program at the hospital but would refuse to go some days. She said she stayed in the program longer than most because she was not consistent with going and said it was normally a 60 - 90-day program. The social worker said CR #2 had just completed the program and was about to have her start on the facility's telehealth psych services. The social worker said the resident always had behaviors, mostly just verbal where she would walk without her walker and would get mad if she was redirected but the week leading up to [DATE] the resident's behaviors had increased. She said the resident was yelling, cursing, dancing around and away from her walker, opening cabinets, standing on tables, etc. She said the day of [DATE] was the first time she had self-harm type of behaviors and said she had hit her head on walker and bed rail, then pulled her tooth out of her mouth. She said the resident had a tumor behind her eye, so it was difficult to determine what was swelling from her hitting head or if it was swelling from her tumor. She said she also felt the tumor was slightly discolored so hard to determine bruising. She said she transported CR #2 to the behavioral hospital on [DATE] and observed the resident had bruising in the middle of her forehead from hitting her head on walker. She said she met up with the RP at the behavioral hospital and then left to go back to the facility. The social worker said throughout her time with the resident she never complained of pain. Interview on [DATE] at 1:06PM, CNA #1 said on [DATE] a housekeeper came and got her and told her CR #2 was hitting her head on her walker. She said when she walked up to resident she wasn't hitting her head anymore. She said she did notice resident's forehead was reddened. She said she alerted the nurse (LVN #5) about the resident hitting her head and he assessed the resident. She said she did not see the resident again after that for the shift. She said it was around breakfast time when the incident happened, so she guessed it was about 7AM. The CNA said the resident had a lot of behaviors and did not think the facility was the place for CR #2. She denied the resident was ever physically abusive to anyone but said she was verbally abusive to her family and staff. The CNA she had observed the resident have self - harming behaviors one other time. She said she was walking down the hallways and heard a banging noise coming from CR #1's room. She said she went into her room and found the resident laying in bed crying banging her head on the bed rail. She said she gave the resident the call light and left to go get a nurse. She said the resident's forehead was reddened. She said she notified a nurse but could not remember who and did not go back in the room with them to the resident, but she assumed the nurse went in to assess the resident after she told them about the incident. The CNA clarified that the observation of resident banging her head on the bed rail and crying was not on [DATE]. She could not recall which date it was but said it was probably a day or two before she was sent out. CNA #1 said she worked the 6am - 2pm shift. Interview on [DATE] at 1:29PM, LVN #5 said he could not remember if he assessed CR #2 after she hit her head with the walker on [DATE]. He said he did remember CNA #1 notifying him of CR #2 hitting her head on her bed rail. He said when he went into the room she had already stopped, so he did not observe her doing that. He said the resident was crying say she didn't want to here and wanted to go home. He told the resident he would talk to the doctor. He said he did assess the resident and she had no injuries or bruising he had observed. He could not remember what day this incident had happened but did not think it was the same day she was transferred out of the facility. He said he remembered hearing she had some similar behaviors before, but he had never observed any. LVN #5 clarified that he worked the 6am - 2pm shift. Interview on [DATE] at 2:01PM, CNA #2 said she worked the 2pm - 10pm shift on [DATE] and it was reported to her when she came in CR #2 was observed banging her head on her walker. She said she had observed CR #2 in bed rocking from side to side as she usually does, and she bumped her head twice on the side rail. She said placed a pillow there and went got the nurse (LVN #6) who assessed the resident. CNA #2 said also observed CR #2 lying in bed and said, oh baby this tooth and just pulled her tooth out of her mouth and handed it to her. She said she went to the nurse's station and notified (LVN #6) about the resident pulling out her tooth. CNA #2 said she could not recall if the two-incident happened on the same day. Interview on [DATE] at 2:18PM, housekeeper said on [DATE] she observed CR #2 hitting her head on her walker. She said she went over to the resident and told her to stop and went told a CNA (CNA #1) about what happened. The housekeeper said the resident was hitting her head pretty hard and had hit it several times before she got her to stop. She said she had never seen her do that before. She the resident already had a knot and bruising on her forehead and said it was not from her tumor. She said would see CR #2 all the time and knew what her tumor looked like and what she observed that morning was not swelling or discoloration from her tumor. The housekeeper said it was early in the day when she made the observation, she guessed it was may

Based on observation, interview, and record review the facility failed to ensure a resident whose assessment did not reveal or who does not have a [DIAGNOSES REDACTED]. condition demonstrates that development of such a pattern was unavoidable for one of two resident (Resident #1) reviewed for behavioral health. The facility failed to address Resident #1's exhibited psychosocial concerns and mood changes following several life challenging experiences . The facility failed to develop and implement a care plan that addressed Resident #1's exhibited psychosocial concerns and mood changes . Resident #1 became depressed, disinterested in things previously enjoyed, and verbalized no interest in staying at the facility. These failures affected 1 resident and placing him at risk of a decreased mental health and a diminished quality of life. Findings include: Resident #1 Record review of Resident #1's Face Sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Admission MDS assessment dated [DATE] revealed a BIMS score of 12 indicating moderately impaired cognitive skills. The mood section indicated a score of 0. He only required assistance with personal hygiene and bathing. A discharge plan had not been developed and his expectation for placement was unknown. The question Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? was coded with the answer no. Observation and interview on 8/13/19 at 8:50 p.m. revealed Resident #1 sitting outside, unattended, smoking a cigarette. He was wearing a long sleeve flannel, an undershirt, jeans, and socks. He appeared very thin with swollen feet. He said he had been outside for about 2.5 hours. He said following a hospitalization he was brought to the facility and was only supposed to be there for 21 days but had been living in the facility for 3 months. He said he got tired of being in that building but was happy that guy let me come outdoors. See a little piece of the world. He said everyday he asks the Lord to somehow get me out of this place. He said he got tired of seeing all the residents in the facility sitting around in wheelchairs and made him not want to live anymore. He said he did not even have a television in his room. He then talked about his girlfriend selling his truck without his consent for $1,000. He said the girlfriend brought the money to the facility after law enforcement got involved and the office kept it. When asked if he had access to it he said he did not know, and they told him he owed them money. Record review of Provider Investigation Report dated 6/11/19 revealed the facility called the police department regarding the unauthorized sale of Resident #1's truck. The report summary revealed the girlfriend owed Resident #1 $732. She brought $600 to the Administrator on 6/12/19 and the remaining $132 on 6/14/19. -Truck sale: $1,000 -The girlfriend gave him $268 -The facility received $600 on 6/12/19 -The facility received $132 on 6/14/19 Observation and interview on 8/14/19 at 8:35 a.m. revealed Resident #1 dressed and groomed sitting in his wheelchair with his feet on the bed looking out the window. When asked how he was doing he said, I'm okay I guess. When asked what was wrong he said, a lot of things wrong since I'm in here. There was no television in his room. Record review of Resident #1's Clinical Chart revealed he was admitted on [DATE]. The undated Resident Inventory revealed he had a cell phone and cowboy hat. During an interview on 8/14/19 at 10:30 a.m., the BOM said Resident #1 gave consent for the money to be applied to his bill. During an interview on 8/14/19 at 10:40 a.m., CNA #1 said all residents must provide their own TVs unless they are on the therapy side. She said Resident #1 wanted to be independent and did not like assistance. She said He doesn't wanna be here but there was no one to take care of him at home. During an interview on 8/14/19 at 11:40 a.m. the BOM and Administrator were present. They said $600 was applied to Resident #1's bill with a handwritten consent. The consent was requested. The document was not received before exit. During an interview on 8/14/19 at 11:50 a.m., when asked about the situation with Resident #1's truck, the Social Worker said, the whole scenario was a sore spot for him. She said he and his girlfriend were together for [AGE] years and she sold his truck for $1,000 without permission. She said his girlfriend also refused to let him come stay with her following his 21 days of rehab. He was very upset about it. He felt like she had dumped him. He did a lot for her and bailed her out of a lot. She said what made him mad was whenever he brought her the money after selling his truck, she only gave him $170. Once the Social Worker and the police got involved she brought an additional $130 and then $600 on another visit. She said, Not only did he realize he couldn't go back (to his girlfriend's) but his heart was broken. When asked if he gave consent for the money to be applied to his bill she said It was verbal between him and the business office manager. He wasn't happy about it. She said, when they told me they put it on his account I said 'what?' She said she did not think that was a good idea. When asked about his mood she said, In general he's been bummed since he got here. said Resident #1 really doesn't like being here. When asked why the mood section on the MDS assessment did not indicate that, she said he might have been good on the day he was assessed. When asked how they were addressing his mood she said she talked to his family and encouraged the continue to do weekend things. She said his family member would get him on the weekend and take him to his house and played dominoes. She said he did not want to participate in activities and declined psychiatry and a telehealth counselor. She said she had been working on a discharge plan, but none of Resident #1's family wanted to let him stay with them. She said Everybody told him no. She said she was working on getting him into the Money follows the person program and made the referral last week. She said he should be seen on 8/20/19. Once in the program she would begin looking for placement at either an independent living facility or an assisted living facility. When asked if she tried any other interventions to improve his mood she said I think the only thing we can do is get him out of here. That's the only thing that's gonna make him happy. When she was informed that Resident #1 did not have a television and asked if that would be helpful she said, I don't think he can really afford it. She said Resident #1's happy day was watching the day go by smoking his cigarettes. She said the past couple of weeks became a pattern of being outside more. She said he received $60 a month from his social security but $60 doesn't really go far when you smoke cigarettes. She said if he could, he would smoke 2 cigarettes at all 7 smoke breaks, but he had been running out. She said, This month it really hit him that he didn't have cigarette money. She said Resident #1 used the $130 that he received from the unauthorized sell of his truck to buy cigarettes. Resident #1's care plan was requested from the Administrator on 8/14/19 at 12:35 p.m., but not received prior to exit. During an interview on 8/14/19 at 3:00 p.m. the ADON said Resident #1 was down when he was first admitted but seemed to perk up now that he knew more people.

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident #2) reviewed for pain management, in that : Resident #2 complained of hip pain which was not effectively managed . Resident #2 was diagnosed to have a [MEDICAL CONDITION]. This failure affected one resident and placed her at risk of unnecessary pain and mental anguish. Findings include: Resident #2 Record review of Resident #2's Face Sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and recently readmitted from a hospital stay on 7/29/19. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severely impaired cognition. She was coded as having no behaviors. She required extensive to total assistance of 1 - 2 staff with all ADL care except for eating which she was independent. Resident #2 was pain assessment indicated no pain presence in the last 5 days. The MDS indicated staff assessment for pain was not conducted. Record review of Resident #2's Care Plan dated 7/29/19 revealed On 7/24/19 I started experiencing pain to my left hip area and was transferred to the hospital for evaluation where it was determined I had a left [MEDICAL CONDITION]. I had not demonstrated any symptoms before being up in the geri chair nor had I fallen or been known to do anything that could have resulted in this injury. The goal was the hip would heal without complications. Interventions included pain medication as needed and transfers via hoyer lift. Record review of Resident #2's X-Ray dated 7/24/19 revealed Intertrochanteric [MEDICAL CONDITION] hip with marked coxa vara deformity. Record review of Resident #2's Incident Report dated 7/24/19 revealed Resident sitting up in geri chair in dining room complaining of left hip pain unrelieved with pain medication. After assessing area the area to the left hip noted to have swelling. Physician notified and order received to send to hospital for evaluation. It was signed by LVN #1. During a telephone interview on 8/14/19 at 1:40 p.m., LVN #1 said Resident #2 sometimes yells and screams a lot. She said on 7/24/19 around 7 a.m. when doing rounds she noticed Resident #2 was complaining of hip pain and said, it really hurts. She said she assessed Resident #2 and barely touched her hip and it hurt her. She said she gave PRN pain medication and informed the DON who sent Resident #2 out to the hospital. She said she was not informed by CNA #2 that Resident #2 had complaints of pain. Record review of Provider's Investigation Report dated 7/30/19 revealed the findings were inconclusive. The summary said Resident is an [AGE] year old female with BIMS score of 4. Her [DIAGNOSES REDACTED]. Resident is up in geri-chair when she is not in bed. Radiology report that resident shows intertrochanteric [MEDICAL CONDITION] him with marked coxa vara deformity and old left inferior pubic ramus fracture. Further review revealed summary of investigation findings revealed it was inconclusive. Record review of Resident #2's MAR for (MONTH) 2019 revealed on 7/16/19 and 7/18/19 she received a PRN Tylenol #3 300 mg due to complaints of hip pain. It did not indicate which hip was hurting. The pain assessment completed at every shift indicated no pain other than the evening on 7/13/19 and the morning shift on 7/29/19. Further review revealed on 7/24/19 she was given PRN Tylenol #3 300 mg due to complaints of left hip pain at 8 a.m. There was no follow-up on if the medication was effective. Observation and interview 8/14/19 at 9:40 a.m. revealed Resident #2 was tearful, lying in her bed, and receiving medication from an unidentified staff member. The unidentified staff member tried talking with her and she became more tearful and confused. She wiped her tears with the cover and the unidentified staff member walked out of the room. An interview was attempted with Resident #2, but she was hard to understand. During an interview on 8/14/19 at 10:40 a.m., CNA #1 said close to lunch time on 7/24/19 Resident #2 was hollering that her leg was hurting her and could barely move it. She said she was not assigned to her that day but saw her earlier sitting in her geri chair. During an interview on 8/14/19 at 10:50 a.m., CNA #2 said she was assigned to Resident #2 on 7/24/19. She said that morning, before 7 a.m., when getting her up, she didn't help roll like she usually did. She said it was typical for her to holler and cry. CNA #2 immediately told LVN #1 she's hurting/something is wrong. She said Resident #2 was still able to bear weight at the time. LVN #1 gave Resident #2 medication for pain. During an interview on 8/14/19 at 10:55 a.m., the Treatment Nurse said on 7/24/19 , she was summoned by CNA #2 to assess Resident #2 around 10:30 am because her nurse was on break. She said Resident #2 was sitting in her geri-chair in the dining area. She said Resident #2 could not verbalize pain, but her facial expressions would indicate pain. She said she checked the MAR and realized LVN #1 had given her PRN Tylenol at 8 a.m. She then informed the DON and ADON that there was something wrong because she was unable to perform ROM and they did an assessment and sent Resident #2 out to the hospital. Record review of Resident #2's nursing note dated 7/24/19 revealed CNA summoned this nurse to evaluate resident for left hip pain. Resident c/o acute left hip pain unable to perform ROM. No recent falls noted. ADON and DON made aware. 911 called and r/p made aware. NP made aware. 11:35 EMS arrived. Signed by Treatment Nurse. Record review of Resident #2's nursing note revealed no note was written by LVN #1. During an interview on 8/14/19 at 2:30 p.m., Physician said she was made aware of Resident #2's hip pain on 7/24/19, she could not remember the time she was notified of the pain but said it was before Lunch on 7/24/19. She said gave order to send her out. She further said she was not aware the resident had hip pain on 7/16/19 and 7/18/19. Record review of Resident #2's Progress Note dated 8/8/19 revealed she underwent intertrochanteric [MEDICAL CONDITION] repair on the left side on 7/24/19 and returned on 7/29/19. Signed by physician. During an interview on 8/14/19 at 3:00 p.m., the ADON said on 7/24/19 she and the DON were informed by staff that Resident #2's hip was hurting around 10:30am. The Treatment Nurse did an assessment and then she completed one. She said Resident #2 could not move her leg. She said she expected nurses to assess a resident's pain and assess the resident prior to administering pain medication. A follow-up interview was attempted with LVN#1 on 8/14/19 at 3:15 p.m. She did not answer or return the phone call. During an interview on 8/14/19 at 3:35 p.m. the ADON and the Administrator were present. When asked if the hip pain on 7/16 and 7/18 were for the left or right hip, they were unsure. The ADON said Resident #2 had a previous surgery on her left hip. When asked who completed the investigation they said it was the DON who was not in the facility due to a doctor's appointment. Record review of the facility's Pain Management Policy dated 8/2009 revealed To evaluate residents who are experiencing pain and provide pain management interventions to increase the resident's quality of life. Further review revealed Behavioral responses: These include altered body position, moaning, signing, grimacing, withdrawal, crying, restlessness, muscle twitching, and immobility.

Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 residents (Resident #2) reviewed for quality of care. The facility failed to timely assess Resident #2's when she indicated she had hip pain and failed to immediately notify Resident #2's physician of her complaint of left hip pain. Resident #2 was sent out to the hospital 4.5 hours after her first compliant of pain and was diagnosed with [REDACTED]. This failure affected 1 resident and placing her at risk of delayed treatment and diminished quality of life. Findings include: Resident #2 Record review of Resident #2's Face Sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and recently readmitted from a hospital stay on 7/29/19. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severely impaired cognition. She was coded as having no behaviors. She required extensive to total assistance of 1 - 2 staff with all ADL care except for eating which she was independent. Resident #2 was pain assessment indicated no pain presence in the last 5 days. The MDS indicated staff assessment for pain was not conducted. Record review of Resident #2's Care Plan dated 7/29/19 revealed On 7/24/19 I started experiencing pain to my left hip area and was transferred to the hospital for evaluation where it was determined I had a left [MEDICAL CONDITION]. I had not demonstrated any symptoms before being up in the geri chair nor had I fallen or been known to do anything that could have resulted in this injury. The goal was the hip would heal without complications. Interventions included pain medication as needed and transfers via hoyer lift. Record review of Resident #2's X-Ray dated 7/24/19 revealed Intertrochanteric [MEDICAL CONDITION] hip with marked coxa vara deformity. Record review of Resident #2's Incident Report dated 7/24/19 revealed Resident sitting up in geri chair in dining room complaining of left hip pain unrelieved with pain medication. After assessing area the area to the left hip noted to have swelling. Physician notified and order received to send to hospital for evaluation. It was signed by LVN #1. During a telephone interview on 8/14/19 at 1:40 p.m., LVN #1 said Resident #2 sometimes yells and screams a lot. She said on 7/24/19 around 7 a.m. when doing rounds she noticed Resident #2 was complaining of hip pain and said, it really hurts. She said she assessed Resident #2 and barely touched her hip and it hurt her. She said she gave PRN pain medication and informed the DON who sent Resident #2 out to the hospital. She said she was not informed by CNA #2 that Resident #2 had complaints of pain. Record review of Provider's Investigation Report dated 7/30/19 revealed the findings were inconclusive. The summary said Resident is an [AGE] year old female with BIMS score of 4. Her [DIAGNOSES REDACTED]. Resident is up in geri-chair when she is not in bed. Radiology report that resident shows intertrochanteric [MEDICAL CONDITION] him with marked coxa vara deformity and old left inferior pubic ramus fracture. Further review revealed summary of investigation findings revealed it was inconclusive. Record review of Resident #2's MAR for (MONTH) 2019 revealed on 7/16/19 and 7/18/19 she received a PRN Tylenol #3 300 mg due to complaints of hip pain. It did not indicate which hip was hurting. The pain assessment completed at every shift indicated no pain other than the evening on 7/13/19 and the morning shift on 7/29/19. Further review revealed on 7/24/19 she was given PRN Tylenol #3 300 mg due to complaints of left hip pain at 8 a.m. There was no follow-up on if the medication was effective. Observation and interview 8/14/19 at 9:40 a.m. revealed Resident #2 was tearful, lying in her bed, and receiving medication from an unidentified staff member. The unidentified staff member tried talking with her and she became more tearful and confused. She wiped her tears with the cover and the unidentified staff member walked out of the room. An interview was attempted with Resident #2, but she was hard to understand. During an interview on 8/14/19 at 10:40 a.m., CNA #1 said close to lunch time on 7/24/19 Resident #2 was hollering that her leg was hurting her and could barely move it. She said she was not assigned to her that day but saw her earlier sitting in her geri chair. During an interview on 8/14/19 at 10:50 a.m., CNA #2 said she was assigned to Resident #2 on 7/24/19. She said that morning, before 7 a.m., when getting her up, she didn't help roll like she usually did. She said it was typical for her to holler and cry. CNA #2 immediately told LVN #1 she's hurting/something is wrong. She said Resident #2 was still able to bear weight at the time. LVN #1 gave Resident #2 medication for pain. During an interview on 8/14/19 at 10:55 a.m., the Treatment Nurse said on 7/24/19 , she was summoned by CNA #2 to assess Resident #2 around 10:30 am because her nurse was on break. She said Resident #2 was sitting in her geri-chair in the dining area. She said Resident #2 could not verbalize pain, but her facial expressions would indicate pain. She said she checked the MAR and realized LVN #1 had given her PRN Tylenol at 8 a.m. She then informed the DON and ADON that there was something wrong because she was unable to perform ROM and they did an assessment and sent Resident #2 out to the hospital. Record review of Resident #2's nursing note dated 7/24/19 revealed CNA summoned this nurse to evaluate resident for left hip pain. Resident c/o acute left hip pain unable to perform ROM. No recent falls noted. ADON and DON made aware. 911 called and r/p made aware. NP made aware. 11:35 EMS arrived. Signed by Treatment Nurse. Record review of Resident #2's nursing note revealed no note was written by LVN #1. During an interview on 8/14/19 at 2:30 p.m., Physician said she was made aware of Resident #2's hip pain on 7/24/19, she could not remember the time she was notified of the pain but said it was before Lunch on 7/24/19. She said gave order to send her out. She further said she was not aware the resident had hip pain on 7/16/19 and 7/18/19. Record review of Resident #2's Progress Note dated 8/8/19 revealed she underwent intertrochanteric [MEDICAL CONDITION] repair on the left side on 7/24/19 and returned on 7/29/19. Signed by physician. During an interview on 8/14/19 at 3:00 p.m., the ADON said on 7/24/19 she and the DON were informed by staff that Resident #2's hip was hurting around 10:30am. The Treatment Nurse did an assessment and then she completed one. She said Resident #2 could not move her leg. She said she expected nurses to assess a resident's pain and assess the resident prior to administering pain medication. A follow-up interview was attempted with LVN#1 on 8/14/19 at 3:15 p.m. She did not answer or return the phone call. During an interview on 8/14/19 at 3:35 p.m. the ADON and the Administrator were present. When asked if the hip pain on 7/16 and 7/18 were for the left or right hip, they were unsure. The ADON said Resident #2 had a previous surgery on her left hip. When asked who completed the investigation they said it was the DON who was not in the facility due to a doctor's appointment. Record review of the facility's Pain Management Policy dated 8/2009 revealed To evaluate residents who are experiencing pain and provide pain management interventions to increase the resident's quality of life. Further review revealed Behavioral responses: These include altered body position, moaning, signing, grimacing, withdrawal, crying, restlessness, muscle twitching, and immobility.

Based on observations, interviews and record reviews, the facility failed to ensure residents had the right to manage their finances for 1 of 1 resident (Resident # 1) reviewed for personal funds, in that: Resident #1's truck was sold without his consent while living in the facility. When the money was returned, the facility took $600 of the $732 returned and applied it towards his bill without his consent. Resident #1 was saddened by this, became disinterested in things previously enjoyed, no longer wanted to stay at the facility and was unable to afford desired things that comforted him. This failure affected 1 resident and placed him at risk of low self-esteem, depression, and diminished quality of life. Findings included: Record review of Resident #1's Face Sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Admission MDS dated [DATE] revealed a BIMS score of 12 indicating he had moderately impaired cognitive skills. The mood section had a score of 0 indicating no mood presence. Observation and interview on 8/13/19 at 8:50 p.m., revealed Resident #1 sitting outside, unattended, smoking a cigarette. He was wearing a long sleeve flannel, an undershirt, jeans, and socks. He appeared very thin with swollen feet. He said he had been outside for about 2.5 hours. He said following a hospitalization he was brought to the facility and was only supposed to be there for 21 days but had been living in the facility for 3 months. He said he got tired of being in that building, but was happy that guy let me come outdoors. See a little piece of the world. He said everyday he asks the Lord to somehow get me out of this place. He said he got tired of seeing all the residents in the facility sitting around in wheelchairs and made him not want to live anymore. He said he did not even have a television in his room. He then talked about his significant other selling his truck without his consent for $1,000. He said the significant other brought the money to the facility after law enforcement got involved and the office kept it. When asked if he had access to it he said he did not know, and they told him he owed them money. Record Review of Resident #1's Smoking Safety Evaluation dated 5/1/19 revealed he demonstrated he was able to safely smoke with minimal supervision. Record review of Provider Investigation Report dated 6/11/19 revealed the facility called the police department regarding the unauthorized sale of Resident #1's truck. The report summary revealed the significant other owed Resident #1 $732. She brought $600 to the Administrator on 6/12/19 and the remaining $132 on 6/14/19. -Truck sale: $1,000 -The significant other gave him $268 -The facility received $600 on 6/12/19 -The resident received $132 on 6/14/19 Record review of Resident #1's (MONTH) Bill revealed a balance of $2,728 on 6/5/9. There was a $600 payment via money order dated 6/12/19. Observation and interview on 8/14/19 at 8:35 a.m. revealed Resident #1 dressed and groomed sitting in his wheelchair with his feet on the bed looking out the window. When asked how he was doing he said, I'm okay I guess. When asked what was wrong he said, a lot of things wrong since I'm in here. There was no television in his room. Record review of Resident #1's Clinical Chart revealed he was admitted on [DATE]. The undated Resident Inventory revealed he had a cell phone and cowboy hat. During an interview on 8/14/19 at 10:40 a.m., CNA #1 said all residents must provide their own TVs unless they were on the therapy side of the facility . During an interview on 8/14/19 at 11:40 a.m. the Business Office Manager (BOM) and Administrator were present. They said $600 was applied to Resident #1's bill with a handwritten consent. The consent was requested, but not received before exit. They said the remaining $132 was given to Resident #1. During an interview on 8/14/19 at 11:50 a.m. when asked about the situation with Resident #1's truck the Social Worker said, the whole scenario was a sore spot for him. She said he and his significant other were together for [AGE] years and she sold his truck for $1,000 without permission. She said his significant other also refused to let him come stay with her following his 21 days of rehab. He was very upset about it. He felt like she had dumped him. He did a lot for her and bailed her out of a lot. She said what made him mad was whenever she brought him the money after selling his truck, she only brought him $268. Once the Social Worker and the police got involved she brought an additional $130 and then $600 on another visit. She said, Not only did he realize he couldn't go back (to his significant other's) but his heart was broken. When asked if he gave consent for the money to be applied to his bill she said It was verbal between him and the Business Office Manager but he wasn't happy about it. She said, when they told me they put it on his account I said 'what?' She said she did not think that was a good idea. When asked about his mood she said, In general he's been bummed since he got here. said Resident #1 really doesn't like being here. When asked why the mood section on the MDS assessment did not indicate that, she said he might have been good on the day he was assessed. When asked if his current mood was captured on any other MDS assessments she said it would had not been significant enough to flag as a concern. When asked how they were addressing his mood she said she talked to his family and encouraged the continue to do weekend things. She said his family member would get him on the weekend and take him to his house to play dominoes. She said he did not want to participate in activities and he declined psychiatry and a telehealth counselor. She said she had been working on a discharge plan, but none of Resident #1's family wanted to let him stay with them. She said Everybody told him no. She said she was working on getting him into the Money follows the person program (money follows the person is a federal Medicaid program designed to move elderly nursing homes residents out of nursing homes and back into their own homes or into the homes of their loved ones) and made the referral last week. Once in the program she would begin looking for placement at either an independent living facility or an assisted living facility. She said he should be seen on 8/20/19. When asked if she tried any other interventions to improve his mood she said I think the only thing we can do is get him out of here. That's the only thing that's gonna make him happy. When she was informed that Resident #1 did not have a television and asked if that would be helpful she said, I don't think he can really afford it. She said Resident #1's happy day was watching the day go by smoking his cigarettes. She said the past couple of weeks became a pattern of being outside more. She said he received $60 a month from his social security but $60 doesn't really go far when you smoke cigarettes. She said if he could, he would smoke 2 cigarettes at all 7 smoke breaks, but he had been running out. She said, This month it really hit him that he didn't have cigarette money. She said Resident #1 used the $130 that he received from the unauthorized sell of his truck to buy cigarettes. During an interview on 8/14/19 at 12:35 p.m., the Administrator provided two $300 money orders signed by Resident #1. She said when Resident #1's significant other brought the money it was in cash and they did not want to turn away the cash so the facility had Resident #1 turn the cash into money orders. Resident #1's care plan was requested but not received prior to exit. A follow-up interview was attempted on 8/14/19 at 3:20 p.m. with Resident #1 but an identified staff member said he was still out at a doctor's appointment from the morning. During an interview on 8/14/19 at 3:35 p.m. the Administrator and ADON were present. When asked if Resident #1 was given options on what to do with the $600 the Administrator said, I think three options would have been presented. He could keep the money, put it towards his bill, or put in the trust fund. When asked who gave him the options she said, I don't remember honestly. Record review of the facility's policy on Resident Rights dated (MONTH) 2014 revealed Each resident and their family will be told of their rights upon admission to the nursing facility. The policy did not address the resident's rights to manage their funds.

Based on observation , interview and record review, the facility failed to ensure that residents receive treatments and care in accordance with professional standards of practice, the comprehensive person- centered care plan that will meet each resident's physical, mental, and psychosocial needs for one of six residents (CR#1) reviewed for quality of care, in that; CR#1 identified with behavior of kicking out at things was not provided adequate intervention to prevent her from injury. CR#1's care plan for behavior of kicking out was not updated with new and effective intervention. CR #1 was found with fracture to her right foot. These failures affected one resident and placed her at increased risk of more injuries ,health decline and diminished quality of life. CR #1 Record review of CR #1's face-sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Annual MDS dated [DATE] revealed a BIMS score of 5, indicating severely impaired cognition. Further review revealed CR #1 had physical behaviors directed towards others. Further review of CR #1's MDS revealed CR #1 required extensive assist of one staff for bed mobility, transfers, dressing and toilet use. Record review of CR #1's care-plan (Target date: 10/12/19) revealed: Problem start date: 6/14/17: Category: behavioral symptoms: I am physically aggressive during care. Hitting, kicking, and slapping staff, pulling back during transfer attempts and hollering out if they just touch my arm/leg, telling staff they hurt me. I have been kicking the bottom side of the footrest of the geri-chair, the underneath part of the table causing bruising and increasing the risk for more serious injury. 5/31/19 my family refused psychiatrist recommendations. Approach: Assist rails were removed from bed as I would bang my head against them and bang on them. Psychiatrist consult per PCP was obtained. Assess whether the behavior endangers me and/or others. Intervene if necessary. Document behaviors. Get assistance during care, 2 staff during ADL care. Praise me when behavior is appropriate. Provide consistency in approaching me. Set expectations and limits for me. Explain why and what is being done is important and how it will help me. Problem start date: 7/11/19: I have a hairline fracture of my right distal fibula at the ankle, my third and fourth right foot phalanges. Approach start date: administer medications as ordered as needed. Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge. Handle gently and try to eliminate any further damage to fractured areas. Monitor and record any complaints of pain. Monitor and record any non-verbal signs of pain. Problem Start date: 7/11/19: I have [MEDICAL CONDITION]/osteopenia and I am at risk for fractures related to falls or other spontaneous fractures. Approach start date: Give medications per physician's orders [REDACTED]. Report results to physicians. Encourage me to exercise and attend activities as tolerated. Remind me to call for assistance with my ADLs as needed. Observation and interview with CR #1 and family member on 7/12/19 at 5:30 PM. Observation made at hospital, CR #1 in room, lying in bed, dressed appropriately, and groomed. CR#1 was asleep. Family member at bedside. Family member stated that on 7/11/19, she came to the facility to visit CR #1, she proceeded to look at CR #1's foot, removed CR #1's sock, and noticed CR #1 had a large bruise to the top of the foot. Family member stated she asked LVN #1 about the bruise, and LVN #1 stated she did not know where the bruise came from, she did not see the bruise when she worked the previous day, and there were no incidents during the previous day. Family member stated LVN #1 proceeded to call CR #1's physician who gave an order to send CR #1 to the ER to x-ray the foot. Family member stated CR #1 was sent to the ER where the x-ray was completed, and she was informed the x-ray showed a [MEDICAL CONDITION] foot. Family member proceeded to show surveyor CR #1's foot. Observation of CR #1's right foot revealed a purplish/blue colored bruise to the top and outer right side of CR #1's foot. Further observation revealed when Family member lifted CR #1's leg to show the surveyor the bottom of the foot, CR #1 proceeded to kick her legs in the air and moaned out loud. Further observation revealed CR #1's hospital bedrails were padded with white towels. Family member stated it was to protect CR#1 when she would kick her legs around. Record review of CR #1's hospital x-ray result: Exam date: 7/11/19 History: [AGE] year-old female who presents with right foot pain. Comment: Frontal, oblique, and lateral radiographs of the right foot were examined. There are subtle findings of hairline fracture seen in the proximal phalanges of the third and fourth toes in the oblique projection. Impression: Findings suspicious for [MEDICATION NAME] fractures of the proximal phalanges of the third and fourth toes is suspected. Interview with DON on 7/12/19 at 6:37 PM, DON stated CR #1 was sent to the ER for an x-ray to the foot. DON explained that CR #1's foot was red and swollen, and that CR #1 was seen by the MD the day before and MD stated it was [MEDICAL CONDITION] and ordered antibiotics. DON explained that at the time CR #1 was not complaining of pain. DON stated on 7/11/19 , staff informed her that CR #1's leg was swollen compared to how it was during the previous day. X-Ray at the hospital showed a hairline fracture. DON stated she talked to the facility staff about CR #1's foot, and that CR #1 was combative with care, and would kick and hit the staff. DON explained that she investigated and talked to staff and they informed her that CR #1 kicks her legs against the geri-chair and she also kicks the staff .DON further stated she had still not reported the bruise because I'm pretty sure it's from hitting and kicking. Interview with DON on 7/12/19 at 6:40 PM, DON stated during interviews with facility staff she was informed that CR #1 had the behavior of kicking her legs against the geri-chair and kicking the staff. DON further stated facility staff were aware of CR #1's behaviors, and would try to calm the resident down as an intervention for her kicking. Interview with CNA #1 on 7/15/19 at 1:17 PM, CNA#1 stated on 7/11/19, she worked the 6AM - 2 PM shift, and it was CR #1's shower day. CNA #1 explained that upon undressing CR #1 for her shower, she saw the discoloration to the resident's leg. CNA#1 said she did not give CR#1 shower that day and immediately told LVN #1 . LVN #1 proceeded to come to the room to look at CR #1's leg. CNA #1 stated CR #1 was complaining of pain and asked CNA#1 to not touch her legs. CNA #1 further stated it was unusual because CR #1 would usually try to kick her but on that day the resident did not try to kick her. CNA #1 stated she did not see the resident kick her geri-chair on that day and did not know where the bruise came from. CNA #1 stated on 7/11/19 she did not see CR #1 kick the geri-chair, but that usually when CR #1 would start kicking, staff would give the resident space to not make the behavior worse, and staff would also try to calm CR #1 down. Interview with LVN #1 on 7/15/19 at 1:23 PM, LVN #1 stated on 7/11/19, she worked the 6am - 2 pm shift, and went to see CR #1's leg, and saw that it was red as if it was inflamed, she proceeded to complete CR #1's treatment to the heel. LVN #1 stated she did not see the bruise or anything unusual. LVN #1 stated CR #1 did complain of pain during the treatment, but that the resident usually complained of pain. LVN #1 stated she proceeded to call the MD for stronger pain medication. This occurred during the morning shift ( 6am- 2pm) . Interview with CNA #2 on 7/15/19 at 1:51 PM, CNA #2 stated she worked on 7/11/19, but was not assigned to CR #1. CNA #2 stated she was helping CNA #1 so CR#1 was brought over to her hall. CNA #2 stated while CR #1 was on her hall, she saw the bruise to CR #1's ankle and it went up on the leg. CNA# 2 stated she proceeded to call LVN #1 because she thought CR #1's leg was broken, and LVN #1 came over to look at it. CNA #2 stated she had not worked with CR #1 in over a month and did not know what happened or why the resident's foot was bruised. Interview with LVN #2 on 7/15/19 at 1:57 PM, LVN #2 stated she worked the 2pm - 10 pm shift on 7/11/19 and received report from LVN #1 who stated that CR #1 complained of pain, and that she called the MD for pain medications. LVN #1 also gave report that CR #1's leg was red, and that CR #1 had been diagnosed the previous day with [MEDICAL CONDITION]. LVN #2 further stated she went to assess the resident, and when she removed CR #1's socks, she saw a bruise, she called the ADON who came in to the resident's room with her then proceeded to look at the bruised area, and called the MD. Interview with MD on 7/15/19 at 2:06PM, MD stated on 7/10/19 she examined CR #1 and looked at the resident's heels and legs due to [MEDICAL CONDITION]. MD stated during the examination there was no bruising or swelling to CR #1's foot or ankle. MD further stated that on 7/11/19 the nurse sent her a picture of CR #1's foot which showed the foot was purple. MD stated she proceeded to order an x-ray and for the resident to be sent to the ER. MD stated CR #1 can be combative with staff during care, and that the resident lifts her legs a lot when she's in the geri-chair. MD stated her suspicion was that CR #1 may have banged her leg on something while being moved, but that she did not know for sure. Interview with ADON on 7/15/19 at 2:41 PM, ADON stated she was in the facility on 7/11/19, the day the bruise was found on CR #1's foot. ADON stated LVN #2 informed her of the bruise to CR #1's foot, and she went to assess the resident with LVN #2. ADON stated it was dark dark dark blue, and that the MD was notified and an order for [REDACTED].#1 was kicking her leg and complaining of pain. ADON further explained that LVN #2 received the x-ray report via fax and informed me of the results. ADON further stated that the DON and Administrator were not in the facility on that day, but that she informed them of the x-ray results via phone. ADON stated she had no idea how the bruise could have happened, she only knew that CR #1 had a history of [REDACTED]. Interview with Administrator on 7/15/19 at 2:54 PM, Administrator stated a lot of CR #1's behaviors had been verbal, and that it wasn't until the last two to three weeks that the resident had been in the geri-chair that the kicking had started. Administrator further stated she was unaware of any specific interventions that were put in place for the resident while on the geri-chair, but that she spoke to CR #1's MD on 7/15/19 about soft wrapping the geri-chair. Administrator stated she was unaware of anything else that could have been done to keep CR #1 from kicking and getting injured. Facility's policy on quality of care requested at this time was not provided prior to exit .

Based on observation, interview, and record review the facility failed to ensure that one of 13 residents (Resident #29) maintained acceptable parameters of nutritional status, body weight and protein levels and received a therapeutic diet when there was a nutritional problem as evidenced by: Resident #29 experienced a significant weight loss in a three month period when the dietician's recommendations for nutritional supplements was not implemented. This failure affected one resident and placed seven additional residents with significant weight loss or gain at risk of their nutritional needs not being met which could lead to decreased independence, the inability to heal, and a decline in overall health. Findings include: Record review of Resident #29's face sheet revealed an [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #29's MDS assessment dated [DATE] revealed a BIMS score of 03 which indicated she had severely impaired cognitive functioning. Further review of the same MDS revealed Resident #29 needed supervision and set up assistance only for eating. Record review of Resident #29's care plan dated 10/05/15 revealed the following: 1. Supervise during meal service. 2. Encourage resident to eat slowly. Record review of Resident #29's Admission Data Summary dated 9/21/15 revealed the following: Prior level of functioning - Eating: Required some assistance/cueing Activities of Daily Living - Eating: Required some assistance/cueing Record review of Resident #29's clinical record revealed an occupational therapy evaluation dated 10/08/15 that revealed the following: Self-Feeding: Supervision (Needs verbal cueing but no physical assist) Further review of the same record revealed no further occupational therapy screenings or evaluations to address Resident #29's self-feeding for possible solutions or interventions. Observation and interview on 04/12/16 at 12:15 P.M. during the lunch meal revealed Resident #29 in the dining room feeding herself lunch using only her hands. Resident #29 was served spaghetti and pudding. Resident #29 was not provided with appropriate hand hygiene prior to meal service and was not encouraged by staff to use her silverware. Staff walked past her as she attempted to feed herself by scooping food with her cupped hands, spilling most of the food on her face, neck, shirt, and then lap. Resident #29 was unable to answer the surveyor's questions. Observation on 04/13/16 at 8:00 A.M. during the breakfast meal revealed Resident #29 was served breakfast in her room unsupervised. Resident #29 did not consume her breakfast meal. Observation on 04/13/16 at 12:15 P.M. during the lunch meal revealed Resident #29 in the dining room feeding herself lunch using only her hands. Resident #29 was served tamales with gravy and refried beans. Resident #29 was not provided with appropriate hand hygiene prior to meal service and was not encouraged by staff to use her silverware. Staff would walk past her as she attempted to feed herself by scooping food with her cupped hands, spilling most of the food on her face, neck, shirt, and then lap. Observation on 04/14/16 at 8:00 A.M. revealed Resident #29 was served breakfast in her room unsupervised. Resident #29 did not consume her breakfast meal. Record review of the facility's Weight Variance Report revealed the following weights for Resident #29: January 7, 2016 128.60 .9% February 4, 2016 109.00 15.2% March 3, 2016 110.00 9% April 3, 2016 112.00 1.8% Record review of Resident #29's Nutrition assessment dated [DATE] revealed the following: Weight: 109 Height: 64 inches Ideal Weight: 120 Resident's Eating Ability: Assisted Nutritionally Pertinent Labs: None Skin Concerns: Non healing skin tear Notes: Resident weight 109 BMI 17 very low. Resident weight has decreased 19 pounds in 30 days. Resident weight loss is not beneficial. Resident has non healing skin tear to lower leg. Current goal is skin healing and weight gain. Recommend: 1. Add 30cc prostat AWC daily for 30 days. 2. Add house shake 1 carton TID for weight gain. Record review of Resident #29's physician orders [REDACTED]. During an interview on 04/14/16 at 9:30 A.M., the Occupational Therapist (OT) was asked if Resident #29 was screened for occupational therapy services after 10/08/15. The OT stated Resident #29 did not have another occupational therapy screening after the initial evaluation. During an interview on 04/14/16 at 9:55 A.M., the MDS staff was asked if Resident #29 was screened for occupational therapy services after the initial evaluation on 10/08/15. The MDS staff stated Resident #29 had not been screened. When asked if any lab work had been ordered by the physician after the weight loss had been identified, the MDS staff stated that no lab work had been ordered. When asked if the dietician's recommendations in February had been followed, the MDS staff stated she had no knowledge of the dietician's recommendations. The MDS staff stated the dietician filed the Nutritional Assessments in the residents' clinical records without communicating these recommendations with facility staff. Interview on 04/14/16 at 10:45 A.M. the DON and the Administrator stated the dietitian did not let them know when recommendations were put in Resident #29's chart concerning her weight loss. They only found out about them when they were later found in the chart. The DON stated Resident #29's physician was contacted today for an order for [REDACTED]. Record review of the facility's Care Plan policy dated 10/2012 read in part .6. Approach/Plan. a. List care to be provided for the problem listed. The care must be necessary and appropriate to accomplish the goal listed. b. Coordinate care to be provided to the resident for the most effective, efficient utilization of resources. c. Individualize care for the unique needs of the resident. d. Communicate vital information to staff providing direct resident care. Record review of the facility's Weight policy dated 03/2012 read in part .It is the policy of this home that a resident must have significant weight loss of 10% or more of body weight, be below Ideal Body Weight, and/or with BMI of less than 19, and after having unsuccessfully tried all reasonable interventions to increase caloric intake, as listed below, before an appetite stimulant order should be initiated .Interventions that should be tried before initiating an order for [REDACTED]. The CMS form 672 dated 04/14/16 revealed eight residents with unplanned significant weight loss or gain.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent the development of and promote the healing of pressure sores for one of two (Resident #41) who were reviewed for pressure sore care. Resident #41 was not provided proper wound care to promote healing. The resident also developed multiple areas to his sacrum from a sticky dressing used to cover the wound which ripped off his skin when removed. This failure affected one resident and placed four other residents with pressure sores at risk of worsening of the sores, decrease of new skin growth and infections. Findings included: Record review of Resident #41 ' s face sheet revealed a [AGE] year old admitted to the facility on [DATE] and readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident # 41 ' s MDS dated [DATE] revealed he was severely impaired cognitively and dependent on staff with all ADLs. resident #41 was incontinent of bowel and had a urinary catheter. The MDS also revealed Resident # 41 had one stage II pressure ulcer. Record review of Resident #41's care plans dated from 2/27/2015 to the latest dated 5/22/2015 revealed no care plan for the sacral wound. Record review of Resident # 41 ' s physician's orders [REDACTED]. Cleanse area on coccyx with normal saline, pat dry and apply Duoderm every three 3 days and as needed until healed. Observation on 5/27/15 at 10:32 p.m., during wound care, Resident # 41 had a foul odor, and had multiple stage IIs on his sacral area. The Sacral areas were dark with black dead skin peeling off. Resident # 41 had a duoderm dressing to his sacral area with the middle part of the dressing melted and edges stuck to the skin on Resident # 41 ' s left and right buttocks. Several attempts were made to remove the duoderm dressing without success. The area was then saturated with normal saline and left for hours to loosen up. Resident #41 ' s wound was last cleaned three days prior, and the wound had a foul smell. Interview on 5/27/15 at 10:32 p.m., LVN # 4 agreed the wound had a foul smell. She expressed she just came in today to help. She was not the regular wound care nurse. LVN #4 said she was not comfortable carrying on with the current wound care order. She stated she wanted to notify the physician of the wound condition. LVN # 4 did not think Duoderm every three days was the proper treatment for [REDACTED]. Record review of Resident #41 ' s physician's orders [REDACTED]. cleanse open areas to coccyx with wound cleanser , apply [MEDICATION NAME] ointment to wound bed, cover with [MEDICATION NAME] and then 4 by 4 gauze, secure with tape daily ,every shift and as need and obtain a wound culture. Observation on 5/27/15 at 2:30 p.m., LVN # 4 following the new order performed wound care. LVN # 4 reported the wound culture would be done by the 6-2 shift the next day. LVN # 4 said the charge nurses do wound care. The facility did not have a designated wound care nurse. Record review of Resident # 41 ' s skin assessment revealed none had been completed. After repeated requests none were provided for review. Interview on 5/28/15 at 6:48 p.m., the DON said she was aware of the resident wounds issues yesterday. She said she saw the wound this morning and it did not smell that much. The DON said the [MEDICATION NAME] ointment treatment ordered was initiated yesterday. Record review of facility policy skin integrity monitoring revised 3/12 revealed goal was prevent the development of pressure ulcers by performing routine skin assessments on all residents at admission and specified intervals with appropriate interventions as per policy to prevent tissue destruction, accurately identifying existing destruction and optimize healing by utilizing consistent treatment. All resident with a disruption of skin integrity will be evaluated on a weekly basis with specific attention given to the evaluation , treatment and management of the skin alterations., This evaluation will be documented using the skin assessment flow sheet-pressure ulcer. Facility CMS form 672 dated 5/28/15 listed 51 residents in the facility and 5 residents had pressure ulcer.