Every finding on record at Avir at La Grange

Based on observation, interview, and record review, the facility failed to make sure that drugs are stored in locked compartments and only authorized persons have access for 1 of 3 medication carts (Medication Cart #1) reviewed for drug storage and labeling.The facility failed to ensure Medication Cart #1 was locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included:Observation on 05/26/2026 at 10:49 a.m., revealed the locking mechanism protruding outward (indicated the medication cart was unlocked) on Medication Cart #1 near the nurses desk. The drawers of the medication cart were facing toward the entrance to 300 hall. There were no nurses or staff near Medication Cart #1. During an interview LVN A on 05/26/2026 at 11:05 a.m., she said she had been trained on medication storage. LVN A stated the person assigned to a medication cart was responsible for locking the medication cart. She stated if the medication cart was left unlocked and unattended a resident could obtain any type of medication. LVN A stated if a resident ingested the medication there was a potential a resident may become severely ill and need to be hospitalized . She stated all staff monitored to ensure the medication carts were locked. She stated staff monitored through observation. She stated she left the medication cart unlocked because she got distracted by another staff. LVN A stated she had been in-service on locking medication cart. During an interview with LVN B on 05/26/2026 at 11:20 a.m., LVN B stated the medication carts were expected to be locked any time staff walked away from the cart. She stated the nurse was responsible for locking the medication cart. She stated if the medication cart was left unlocked and unattended a resident could access the medication and ingest the medications and cause the resident become sick and may need to be assessed at the hospital, or medications could be stolen. She stated she had been in-service on locking medication carts, however, she did not recall the date or time.During an interview with the DON on 05/27/2026 at 1:00 p.m., she stated the policy for medication carts was that the carts should always be locked. The DON stated the nurses were responsible for locking the medication carts. She stated if the medication cart was left unlocked and unattended a resident or visitor could get into the cart and take medication. She stated if a resident ingested a medication there was a potential a resident may be allergic to the medication and may need to be assessed at the hospital. She stated there was a possibility staff or a visitor could remove the medications from the medication cart. The DON stated all nurses had been in-service on locking medication cart. She did not recall the date and time of the last in-service of locking medication cart. The DON stated LVN A had been an employee at the facility a few months and she received training on administering medication and locking medication cart during orientation. During an interview with the Administrator on 05/27/2026 at 1:10 pm, she stated the policy for the medication carts was that the cart was to be locked when the nurses were not working on the carts. She stated if the medication cart was left unlocked and unattended it could cause drug diversion; missing medication and the residents could take medications. The Administrator stated if a resident ingested medications and the resident had an allergic reaction there was a possibility a resident may need to be hospitalized . She stated the Nurse Supervisor, ADON and DON made routine checks during the day to ensure the medications carts were locked. She stated she did not know why LVN A left the medication cart unlocked.Record review of Medication Labeling and Storage Policy dated 02/2023 revealed The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 13 of 64 days (first quarter of 2026) reviewed in that: The facility failed to ensure they had a RN on duty daily for 13 days of the 64 days in the first quarter from 01/2026 through 03/2026.This deficient practice placed residents at risk of missing nursing assessments, resident supervision, and skilled nursing treatment. Findings included:Review of the facility's RN staffing hours for the months of January, February, and March of 2026 revealed no RN hours for the following days: 01/11/2026 (SU); 01/24/2026 (SA); 01/25/2026 (SU); 02/01 (SU); 02/07 (SA); 02/08 (SU); 02/14 (SA); 02/15 (SU); 02/16 (MO); 02/21 (SA); 02/22 (SU); 02/28 (SA); 03/01 (SU).During an interview with the ADON on 03/05/2026 at 10:03 a.m., it was revealed she had been doing the nursing schedule. She said the policy for RN coverage was facility did not have an RN on staff all the time because the NP came in the facility frequently. She said an RN was supposed to be scheduled everyday but because of licensing the facility did not have to have an RN. She said she thought the facility had applied for a waiver. She said she was responsible for making sure there was an RN every day. She said if the facility did not have an RN every day it could only affect the resident as far as if a resident passed away. She said the RN could pronounce someone dead. She said the ADM and DON monitored to ensure there was an RN on schedule. She said there were only two RN that worked at the facility. She added she did not know why the facility had not had RN coverage. During an interview with the DON on 03/05/2026 at 10:14 a.m., it revealed she had been trained on nursing schedule requirements. She said she did not know the policy for RN scheduling requirements. She said she did not know that the facility needed to have an RN 8 hours a day every day. The ADON is responsible for doing the schedule. She said it could affect the residents if there is something that is out of scope of practice for the LVN that an RN can like pronounce a resident. She said she and the ADM monitors to ensure there is an RN on schedule 7 days a week. She said they mentioned the scheduling in the QAPI meeting. She said they monitored by having a meeting with the staff in the mornings. She said she did not know why there were no RN coverage for the 13 days. During an interview with the ADM on 03/05/2026 at 10:22 a.m., she said that she had been trained on the nursing requirements related to scheduling. She said the policy for RN hours was 8 hours a day 7 days a week. She said the ADON was responsible for ensuring that the facility had an RN 8 hours a day 7 days a week. She said if an RN was not scheduled it could delay RN care to a resident in need of an RN. She said HR and corporate monitored to ensure the facility had an RN 8 hours a day. She said HR and corporate monitored by following up to make sure the schedule was accurate. She said the facility did not have an RN for 10 days out of February due to an RN that resigned. She said the facility had two RN positions open and did not have success in hiring an RN.Record review of Staffing, Sufficient and Competent Nursing Policy dated 08/2022 revealed Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.Review of the TAC Title 26 S554.901 of this chapter (relating to Quality of Care) reflected . (2) Registered nurse. (A) The facility must use the services of a registered nurse for at least eight consecutive hours a day, seven days a week, except when waived under paragraph (5) or (6) of this subsection.

Based on observations, interviews, and record reviews, the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during the survey for five of five residents reviewed for resident council. The facility failed to provide the Resident Council with a private meeting area to conduct their meetings. This failure could place residents at risk of not being able to voice concerns due to a lack of privacy. Findings included: A confidential group interview and observation in facility dining room were conducted on 3/04/2026 at 2:00 PM with five residents. During this confidential group interview the meeting was interrupted by facility staff three times within a thirty-minute time span. Three of the residents stated the interruptions sometimes occur during Resident Council meetings, because the meetings are held in the dining room.Interview conducted with ACTD on 3/03/2026 at 1:48 PM. The ACTD stated that the Resident Council Meeting can be held privately in the dining room. She reported that she had signs that would be posted on the doors. Interview conducted with ACTD on 3/05/2026 at 11:39 AM. The ACTD stated she has been employed at the facility for two years and is familiar with the Resident Council policy. She reported that Resident Council meetings are held in the dining room with the doors closed. When told about staff walking in and out during the meetings, the ACTD stated the dining room is the only available area to hold the meetings. When asked how staff are made aware that the meeting is private, she stated staff are informed by word of mouth and that she has told staff not to enter during the meetings. The ACTD further stated she has not previously requested another meeting location that would provide more privacy but would consider requesting one. The ACTD stated that not having a private space for meetings could prevent residents from voicing their concerns.Interview conducted with DON on 3/05/2026 at 11:59 AM. The DON stated she recently began working at the facility and has not yet had the opportunity to review the facility's Resident Council policy. The DON stated the Resident Council policy requirements are generally universal and that residents must have a private space to meet without interruptions. She stated one must be invited to attend. The DON stated that a lack of privacy during Resident Council meetings could have a negative impact on residents. She explained that residents may feel they could not speak freely if staff were present or interrupt the meeting, and they may fear retaliation. The DON stated the Resident Council meeting should be a safe place for residents to express their concerns.Interview conducted with ADM on 3/05/2026 at 12:26 PM. The ADM stated she has been at the facility since July 2025. The ADM stated the dining room has two doors that can be closed to allow the Resident Council meeting to be held privately. The ADM stated there was a lack of communication the previous day regarding the meeting. She stated that Resident Council meetings are typically held on the second Tuesday of the month unless the schedule changes. The ADM stated information about the Resident Council meeting is usually communicated during morning meetings with staff. The ADM further stated the kitchen has a separate exit that does not lead into the dining room. The ADM acknowledged that residents have the right to meet privately. She stated the potential effect of staff entering during meetings could cause residents to feel they cannot freely express their opinions and could interfere with their privacy.Review of facility policy revised February 2021, named Resident Council reflected: Policy statement The facility supports residents' rights to organize and participate in the resident council. Policy Interpretation and Implementation1. The purpose of the resident council is to provide a forum for:a. residents, families and resident representatives to have input in the operation of the facility;b. discussion of concerns and suggestions for improvement;c. consensus building and communication between residents and facility staff; andd. disseminating information and gathering feedback from interested residents.2. All residents are eligible to participate in the resident council. The facility staff encourages residents who are willing to participate. Staff, visitors, or other guests may attend resident council meetings if invited by the respective resident group.3. The resident council group is provided with space, privacy and support to conduct meetings.

Based on observation, interview and record review the facility failed to ensure residents received care consistent with professional standards of practice, to ensure necessary treatment and services to promote healing for two of three residents reviewed for pressure ulcers. (Resident #8 and Resident #27) A) The facility failed to ensure the ADON followed standard precautions during wound care for Resident #8's unstageable deep tissue injury (DTI) right heel pressure ulcer (is a full-thickness injury whose depth cannot be determined because the wound bed is obscured by necrotic tissue, slough, or eschar) on 03/04/2026 when she failed to clean the unstageable pressure ulcer in a manner that did not contaminate the wound. She further failed to apply the dressing to the wound as to not cause unnecessary pressure, or trap air and moisture which could hinder the healing process. B) The facility failed to ensure the ADON followed standard precautions during wound care for Resident #27's Stage III coccyx pressure ulcer (a full-thickness skin loss potentially extending into the subcutaneous tissue layer. Wounds often present with granulation tissue and epibole (rolled wound edges) and may have slough and/or eschar.) on 03/04/2026 when she failed to use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. She further failed to apply the wound treatment and wound care products to the wound in a manner that ensured the product was able to work as intended to promote healing. These failures could cause severe pain, and lead to systemic infections causing harm or death for residents that have or are at risk for pressure ulcers. Findings: A) Review of Resident #8's face sheet reflected a [AGE] year old female admitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Rhabdomyolysis (a condition characterized by the breakdown of muscle fibers leading to the release of harmful substances into the blood stream) and osteoarthritis (the protective cartilage that cushions the ends of the bones wears down over time leading to pain). Review of Resident #8's Annual MDS dated [DATE] reflected that she did not have a BIMS conducted indicating she had severe cognitive impairment. Further review of her MDS reflected that she was assessed to have unhealed pressure ulcers and was assessed to have an unstageable deep tissue injury (DTI). Review of Resident #8's comprehensive care plan reflected a focus area dated 01/21/2026 The resident has a deep tissue injury to right heel. Pressure ulcer. Interventions included Administer treatment as ordered and monitor for effectiveness.Follow facility policies/ protocols for the prevention/ treatment of skin breakdown. Review of Resident #8's consolidated physician orders dated 03/04/2026 reflected an order dated 02/25/2026 Cleanse right heel with wound cleanser, pat dry, apply xeroform and cover with a silicone bordered gauze. Observation on 03/04/2026 at 10:41 AM revealed the ADON outside of Resident #8's room to prepare the treatment supplies. After opening and shutting the treatment cart drawers' multiple times and touching various surfaces with her hands, without hand hygiene and no gloves she got out gauze and placed on a piece of wax paper, the xeroform dressing and a silicone boarded dressing. She placed an entire bottle of wound cleanser on the wax paper. The ADON entered the room with the supplies and without cleaning the overbed table placed the treatment supplies on the overbed table (she obtained the overbed table from the resident's roommates' side of the room). The ADON then without hand hygiene she donned gloves. The ADON removed the dirty dressing from Resident #8's right heel, without changing gloves or hand hygiene she sprayed wound cleanser on the gauze brought in and cleaned the unstageable DTI by swiping up and down and across the wound (which could cause any bacteria from the surrounding tissue to be brought into the wound). Without changing gloves or hand hygiene she removed the xeroform gauze from the package and gathered up into a slight ball and placed on the wound (which can cause pressure issues, trapped air and moisture which can hinder the healing process, it is recommended to apply xeroform gauze to avoid wrinkles, it is recommended to use by applying smoothly to wound bed (www.woundsource.com)). The ADON then applied the silicone outer dressing over the balled up xeroform. She took off her gloves and took the wound cleanser and placed it back into her cart without wiping it done. No hand hygiene was performed after the wound treatment. B) Review of Resident #27's face sheet dated 03/05/2026 reflected an [AGE] year old male admitted on [DATE] with the following diagnoses, pressure ulcer unstageable to sacral area (is a full-thickness injury whose depth cannot be determined because the wound bed is obscured by necrotic tissue, slough, or eschar), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) and CHF (congestive heart failure)(long-term condition in which your heart can't pump blood well enough to meet your body's needs.). Review of Resident #27's Quarterly MDS assessment dated [DATE] reflected he was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #27 was further assessed to have a Stage III pressure ulcer. Review of Resident #27's comprehensive care plan reflected a focus area dated 02/21/2026 Resident has Stage III sacral wound. Pressure ulcer. Interventions included Administer treatment as ordered and monitor for effectiveness.Follow facility policies/ protocols for the prevention/ treatment of skin breakdown. Review of Resident #27's consolidated physician orders reflected an order dated 02/21/2026 Cleanse sacral wound with wound cleanser. Apply collagen particles and calcium alginate and cover with silicone bordered super absorbent dressing. Observation on 03/04/2026 at 2:48 PM revealed the ADON outside of Resident #27's room to gather supplies. She placed all the supplies (gauze, calcium alginate, collagen powder and boarded silicone dressing) on a piece of wax paper on her cart. The ADON then went down the hall (two doors down) and used the hand sanitizer on the wall (turning her back on her supplies). The ADON then returned to the cart, got her supplies and entered the resident's room and placed the wax paper on the resident's overbed table that she did not clean (It was observed to have two water rings and food particles on the table). The ADON then left the room stating she was going to get a gown. When she re-entered the room without hand hygiene, she donned gloves. She then shut the door with her gloved hands. She then grabbed the dirty overbed table with her gloved hands to bring it closer to her. At that point someone knocked on the resident's door and with her gloved hands she opened the door then re-shut the door. Without hand hygiene or a glove change she had the two staff members in room assisting to turn Resident #27 on his side. She removed his old dressing to reveal a Stage III pressure ulcer to his coccyx with 3 cm depth (the wound was clean with no signs of infection) she continued her treatment with the same gloves by cleaning the wound across the top of the wound from the outside across the wound. The ADON did not clean the inside of the wound, only across the open area. The ADON swiped across the wound multiple times from the outside in. After cleaning across the wound she let go of this left buttock which she was holding to have access to his wound and the extra skin of his left buttock fell over the wound while she obtained the other wound care supplies (contaminating the area) without recleaning or performing hand hygiene or changing her gloves she applied the collagen to the outside of the wound not the inside wound bed and placed a calcium alginate over the tunnelling, none placed inside with 3 cm depth of the wound. The ADON then covered the wound with the outside silicone dressing. (No glove changes or hand hygiene performed at any time during the wound care) she removed her gloves and took her supplies to the cart. No hand hygiene was performed after the treatment. In an interview on 03/04/2026 at 2:56 PM the ADON stated she did not know she needed to clean the over bed tables before putting down the wax paper. She stated she did use hand sanitizer out in the hall before she started gathering her treatment supplies. She stated she did not wash her hands or change gloves during the treatment with Resident #8 when moving from clean to dirty and stated, If I washed my hands that many times, I would not have hands. The ADON was not sure regarding the application of the xeroform whether she did it right or not and stated that it was the way she was taught. She stated on Resident #27 she used the hand sanitizer in the hall but stated she did not wash her hands or use gloves in the room. When asked about her wound cleaning techniques and application of the wound dressings for Resident #27 she stated, What was I supposed to do, have one of the aides hold it? She stated she applied the dressing to his wounds the way she was taught. In an interview on 03/05/2026 at 10:00 AM the DON stated she expected the nurses to wash their hands before going into the room and when they come out. When asked about the facility policy regarding hand washing, she stated yes staff should clean hands before and during wound care when going from dirty to clean, when asked about cleaning the table she stated Yes it should be cleaned. The DON stated resident wounds should be cleaned thoroughly from the inside out and wound care products should be used as recommended to promote healing. In an interview on 03/05/2026 at 10:05 AM the RNC stated nurses should clean wounds from the center out and around not back and forth and the staff should have assistance in the room to help hold the resident in a position when effective wound care can be done. The RNC stated dressings should be applied smooth, without any wrinkles to prevent pressure or wound damage and the wound care products should be used as recommended and the entire wound should be treated. Review of the facility's policy Wound Care dated (2001) reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached.2. Wash and dry your hands thoroughly. 3. Position resident. If necessary, place disposable cloth next to residents (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing.5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly (hand sanitizer can be used). 6. Put on gloves. Gown as indicated based on EBP definition. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use tongue blades and applicators to remove ointments and creams from their containers. 16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard them into designated container. Wash and dry your hands thoroughly. Review of the facility's policy Handwashing/ hand hygiene dated (2001) reflected This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of five residents (Resident #8 and Resident #27) reviewed for infection control practices. A) The facility failed to ensure the ADON followed standard precautions during wound care for Resident #8's unstageable right heel pressure ulcer on 03/04/2026 when she failed to perform hand hygiene during wound care, set up a clean wound dressing field without cross contamination, use enhanced barrier precautions on a chronic wound per facility policy, or use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer. B) The facility failed to ensure the ADON followed standard precautions during wound care for Resident #27's Stage III coccyx pressure ulcer on 03/04/2026 when she failed to perform hand hygiene during wound care, set up a clean wound dressing field without cross contamination and failed to use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. This failure placed residents at risk for developing wound infections, and at risk for healthcare associated cross-contamination and infection.Findings included: A) Review of Resident #8's face sheet reflected a [AGE] year old female admitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Rhabdomyolysis (a condition characterized by the breakdown of muscle fibers leading to the release of harmful substances into the blood stream) and osteoarthritis (the protective cartilage that cushions the ends of the bones wears down over time leading to pain). Review of Resident #8's Annual MDS dated [DATE] reflected that she did not have a BIMS score conducted indicating she had severe cognitive impairment. Further review of her MDS reflected that she was assessed to have unhealed pressure ulcers and was assessed to have an unstageable deep tissue injury (DTI). Review of Resident #8's comprehensive care plan reflected a focus area dated 01/21/2026 The resident has a deep tissue injury to right heel. Pressure ulcer. Interventions included Administer treatment as ordered and monitor for effectiveness.Follow facility policies/ protocols for the prevention/ treatment of skin breakdown. Review of Resident #8's consolidated physician orders dated 03/04/2026 reflected an order dated 02/25/2026 Cleanse right heel with wound cleanser, pat dry, apply xeroform and cover with a silicone bordered gauze. Observation on 03/04/2026 at 10:41 AM reveled the ADON outside of Resident #8's room to prepare the treatment supplies. After opening and shutting the treatment cart drawers' multiple times and touching varies surfaces with her hands, without hand hygiene and no gloves she got out gauze and placed on a piece of wax paper, the xeroform dressing and a silicone boarded dressing. The resident did not have an EBP sign on the door and the ADON did not don PPE prior to entering the room. She placed an entire bottle of wound cleanser on the wax paper. The ADON entered the room with the supplies and without cleaning the overbed table placed the treatment supplies on the overbed table (she obtained the overbed table from the resident's roommates' side of the room). The ADON then without hand hygiene she donned gloves. The ADON removed the dirty dressing from Resident #8's right heel, without changing gloves or hand hygiene she sprayed wound cleanser on the gauze brought in and cleaned the unstageable DTI by swiping up and down and across the wound (which could cause any bacteria from the surrounding tissue to be brought into the wound). Without changing gloves or hand hygiene she removed the xeroform gauze from the package and gathered up into a slight ball and placed on the wound (which can cause pressure issues, trapped air and moisture which can hinder the healing process, it is recommended to apply xeroform gauze to avoid wrinkles, it is recommended to use by applying smoothly to wound bed (www.woundsource.com). The ADON then applied the silicone outer dressing over the balled up xeroform. She took off her gloves and took the wound cleanser and placed it back into her cart without wiping it done. No hand hygiene was preformed after the wound treatment. B) Review of Resident #27's face sheet dated 03/05/2026 reflected an [AGE] year old male admitted on [DATE] with the following diagnoses pressure ulcer unstageable to sacral area (is a full-thickness injury whose depth cannot be determined because the wound bed is obscured by necrotic tissue, slough, or eschar), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) and CHF (long-term condition in which your heart can't pump blood well enough to meet your body's needs.). Review of Resident #27's Quarterly MDS assessment dated [DATE] reflected he was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #27 was further assessed to have a Stage III pressure ulcer. Review of Resident #27's comprehensive care plan reflected a focus area dated 02/21/2026 Resident has Stage III sacral wound. Pressure ulcer. Interventions included Administer treatment as ordered and monitor for effectiveness.Follow facility policies/ protocols for the prevention/ treatment of skin breakdown. Review of Resident #27's consolidated physician orders reflected an order dated 02/21/2026 Cleanse sacral wound with wound cleanser. Apply collagen particles and calcium alginate and cover with silicone bordered super absorbent dressing. Observation on 03/04/2026 at 2:48 PM revealed the ADON outside of Resident #27's room to gather supplies. She placed all the supplies (gauze, calcium alginate, collagen powder and boarded silicone dressing) on a piece of wax paper on her chart. The ADON then went down the hall (two doors down) and used the hand sanitizer on the wall (turning her back on her supplies) The ADON then returned to the cart got her supplies and entered the resident's room and placed the wax paper on the residents overbed table that she did not clean (It was observed to have two water rings and food particles on the table) The ADON then left the room stating she was going to get a gown. When she re-entered the room without hand hygiene she donned gloves. She then shut the door with her gloved hands. She then grabbed the dirty overbed table with her gloved hands to bring it closer to her. At that point someone knocked on the resident's door and with her gloved hands she opened the door then re-shut the door. Without hand hygiene or a glove change she had the two staff members in room assisting to turn Resident #27 on his side. She removed his old dressing to reveal a Stage III pressure ulcer to his coccyx with 3 cm depth (the wound was clean with no signs of infection) she continued her treatment with the same gloves by cleaning the wound across the top of the wound from the outside across the wound. The ADON did not clean the inside of the wound, only across the open area. The ADON swiped across the wound multiple times from the outside in. After cleaning across the wound she let go of this left buttock which she was holding to have access to his wound and the extra skin of his left buttock to fell over the wound while she obtained the other wound care supplies (contaminating the area) without recleaning or performing hand hygiene or changing her gloves she applied the collagen to the outside of the wound not the inside wound bed and placed a calcium alginate over the tunnelling, none placed inside with 3 cm depth of the wound. The ADON then covered the wound with the outside silicone dressing. (No glove changes or hand hygiene performed at any time during the wound care) she removed her gloves and took her supplies to the cart. No hand hygiene was performed after the treatment. In an interview on 03/04/2026 at 2:56 PM the ADON stated she did not know she needed to clean the over bed tables before putting down the wax paper. She stated she did use hand sanitizer out in the hall before she started gathering her treatment supplies. She stated she did not wash her hands or change gloves during the treatment with Resident #8 when moving from clean to dirty and stated, If I washed my hands that many times, I would not have hands. The ADON was not sure regarding the application of the xeroform whether she did it right or not and stated that it was the way she was taught. She stated Resident #8 was not on EBP she stated that Resident #8's wound was chronic, but she did not think the resident needed to be on EBP. She stated on Resident #27 she used the hand sanitizer in the hall but stated she did not wash her hands or use gloves in the room. When asked about her wound cleaning techniques and application of the wound dressings for Resident #27 she stated, What was I supposed to do have one of the aides hold it She stated she applied the dressing to his wounds the way she was taught. In an interview on 03/05/2026 at 10:00 AM the DON stated she expected the nurses to wash their hands before going into the room and when they come out. When asked about the facility policy regarding hand washing, she stated yes staff should clean hands before and during wound care when going from dirty to clean, when asked about cleaning the table she stated Yes it should be cleaned. The DON stated resident wounds should be cleaned thoroughly from the inside out and wound care products should be used as recommended to promote healing. She further stated Resident #8's wound was chronic but was not sure if she needed to be on EBP. In an interview on 03/05/2026 at 10:05 AM the RNC stated nurses should clean wounds from the center out and around not back and forth and the staff should have assist in the room to help hold the resident in a position when effective wound care can be done. The RNC stated dressings should be applied smooth without any wrinkles prevent pressure or wound damage and the wound care products should be used as recommended and the entire wound should be treated. The RNC stated regarding Resident #8's EBP, that the wound was chronic, and the policy states she should be on EBP, and she would ensure that she is placed on EBP moving forward. Review of the facility's policy Enhanced Barrier Precautions dated (2001) reflected Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:. h. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.a. Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears. Review of the facility's policy Wound Care dated (2001) reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached.2. Wash and dry your hands thoroughly. 3. Position resident. If necessary, place disposable cloth next to residents (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing.5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly (hand sanitizer can be used). 6. Put on gloves. Gown as indicated based on EBP definition. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use tongue blades and applicators to remove ointments and creams from their containers. 16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard them into designated container. Wash and dry your hands thoroughly. Review of the facility's policy Handwashing/ hand hygiene dated (2001) reflected This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e.f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility for 42 residents reviewed for pests.The facility failed to ensure the facility was free of pests in the dining room.This failure could place residents at risk of increased exposure to pests and vector-borne diseases and infections.Observation on 03/03/2026, at 9:21 AM this Surveyor observed 2 large size dead cockroaches in a silver pan behind the ice machine in the dining area.Observation on 03/04/2026, at 11:52 AM this Surveyor observed 2 large size dead cockroaches in a silver pan behind the ice machine in the dining area.During confidential interviews between 03/3/2026 and 03/05/2026, residents complained about roaches they observed throughout the facility (no specific dates/times provided).During an interview with HSK Dir, on 3/04/2026, at 3:17 PM, he stated the pest control company comes out every 60 days or as needed for problems that occur. Also, he stated the building is known to have a problem with water bugs AKA cockroaches, but no other problems. However, if he sees problems, he will address them, and if it happens more than once, he will call the professional pest control company to come out and handle the issue.During an interview with Dietary MNG on 03/05/2026, at 9:30 AM she revealed that she has not personally seen any roaches in the kitchen but when she took over as Dietary manager, she started her own Pest Sighting Log.During an interview with HSK D, on 03/05/2026, at 10:18 AM he stated he has seen bugs on cockroach traps in residents' rooms and usually where there is water standing. He also revealed the facility had a bug inspector out a week ago, but he was not aware of a logbook to report sightings.During an interview with ADM on 03/05/2026 at 1:09 PM she stated she has never seen signs of pests in the building but if she did, she would log this in the binder. She stated the building is checked monthly and the kitchen also has a schedule inspection in March. In the past residents have reported scratching sounds, but this has been logged and checked by maintenance.Record review of pest control log on 3/5/2026, revealed the pest control technician completed their last monthly service on 2/5/2026. It also revealed several reports of roaches at the facility. Record review on 3/5/2026 reveals a pest control invoice dated 2/5/2026, the invoice has the message attached. The hazmat closet, kitchen, nurses' station, med room, and room [ROOM NUMBER] all with reported gnats. The technician walked to the facility to treat the hallways and common area and noticed gnats down every hallway on walls. The technician reported to the Administrator and showed her months of reports regarding the lack of cleanliness in the kitchen and the information was relayed to the kitchen staff and Dietary Manger. Review of the facility's policy titled, Pest Control and Sanitization revealed: Pest ControlPolicy StatementOur facility shall maintain an effective pest control program.Policy Interpretation and Implementation1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Pest control services are provided by. Windows are screened at all times.Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas.Garbage and trash are not permitted to accumulate and are removed from the facility daily.Maintenance services assist, when appropriate and necessary, in providing pest control services. SanitizationPolicy StatementThe food service area is maintained in a clean and sanitary manner.Policy Interpretation and Implementation All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.

Based on observation, interview, and record review, the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and included the appropriate expiration dates to preserve their integrity for medications stored, and to store medications properly to prevent deterioration for one of three medicaiton carts reviewed. The facility failed to ensure expired medications were removed from the 200 hall medication cart. These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or contaminated medication.Findings Included: Observation on 03/04/2026 at 11:34 AM revealed the facility Unit 2 Medication cart with a bottle of Benadryl expired on 01/2026, a bottle of Meclizine expired on 01/2026, and a bottle of normal saline eye drops expired 05/2025. In an interview on 03/04/2026 at 11:36 AM MA B stated the bottle medication Benadryl, Meclizine and normal saline on the 200 hall cart were expired and should not have been on the cart. MA B stated everyone who works on the carts were responsible to look for expired medication. She stated they just got missed. In an interview on 03/04/2026 at 11:20 AM the DON stated after looking at the medication that they were expired and should not be on the medication cart. She stated it was everyone's responsibility to look for and remove expired medications. Review of the facility's Policy Medication labeling and storage dated February 2023 reflected Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observations, interviews and record reviews, the facility failed to provide bedrooms that measured at least 80 square feet per resident in multiple resident bedrooms for 12 of 30 resident rooms (Rooms 202, 204, 207,401,403,407,501,503,504,507,509, and 510) reviewed for environment.The facility failed to ensure resident bedrooms rooms, 202, 204, 207,401,403,407,501,503,504,507,509, and 510 measured at least 80 square feet per resident.This failure could place residents at risk by limiting the amount of resident care equipment and personal belongings that could be accommodated in the resident's room. This may restrict the resident's' ability to move about the room freely and could negatively affect the residents' quality of life.The findings include: Observations conducted on 3/3/25 during the initial pool screening beginning at 8:55 AM revealed 12 resident rooms did not have the required amount of living space for each resident.Interview conducted with ADM on 3/03/2026 at 3:43 PM, she stated that she had not been successful in locating a room waiver for the facility.Observation and interview conducted 3/05/2026 at 12:11 PM. The HSK Dir measured room [ROOM NUMBER]. The area for bed A measured 75 square feet and the area for bed B measured 76 square feet. The HSK Dir stated he had assumed the director position one week prior. He stated he did not recall the required square footage for residents' rooms. The HSK Dir stated he remembered measuring the rooms approximately four years ago for a surveyor. Interview conducted with the DON on 3/05/2026 at 12:04 PM. The DON stated she was not aware of the specific square footage requirements for residents' rooms. She stated this was the first facility where she had worked in which resident rooms did not appear to meet the required room size. She stated the potential effect on the residents is that limited room space could restrict residents from having additional personal belongings, which could affect their pride.Interview conducted with ADM on 3/05/2026 at 12:21 PM. The ADM stated she has been at the facility for approximately seven months and was not aware the resident rooms did not meet regulatory room size requirements. The ADM stated she located documentation that indicated a request for a room size waiver was submitted in December 2024; however, she was unable to determine the status of that request. The ADM stated she is currently in the process of requesting a room size waiver. She stated the potential effect on residents could include decreased comfort and limited ability to arrange or maintain personal belongings within their rooms.Record review of the room roster provided by the facility on 03/03/2026 revealed 24 residents lived in Rooms 202, 204, 207,401,403,407,501,503,504,507,509, and 510 .No facility policy for regarding required resident room size or square footage was provided to survey team upon exit.

Based on interviews and record reviews, the facility failed to consult with the resident's physician when there was a need for an in and out catheter and a foley catheter for 1 (Resident #1) of three residents reviewed for physician notification. 'The facility failed to notify Resident #1's provider of the need for in and out catheter and for a foley catheter on 12/21/2025.This failure could result in decreased continuity of care, and a delay in needed treatment and services. Findings include:Record review of Resident #1's face sheet, dated 1/13/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included chronic kidney disease, stage 3B ( kidneys had moderate to severe damage, filtering blood at 30-44% of normal, indicated by an eGFR of 30-44 ml/min, requiring closer management to slow progression, with potential symptoms such as: swelling, fatigue, or changes in urination, and increased risk of complications of blood pressure), gout due to renal impairment, multiple sites ( a form of arthritis caused by the accumulation of uric acid crystals in several joints of the body, where the root cause of this buildup is a problems with the kidney's ability to filter out uric acid), and vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (caused by damage to blood vessels in the brain which disrupts blood flow and deprives brain cells of oxygen and nutrients without any behavior symptoms). Record review of Resident #1's Quarterly MDS Assessment, dated 10/22/2025, reflected Resident #1 had a BIMS score of 99, which indicated Resident #1 was unable to complete the interview. He had poor short- and long-term memory recall. Resident #1's decision making ability was severely impaired. He was dependent on staff with hygiene, showers, dressing, and transfers. Resident #1 was incontinent of bowel and bladder.Record review of Resident #1's Comprehensive Care Plan, reflected Resident #1 had chronic kidney disease and at risk for kidney failure, fluid overload, and electrolyte imbalance. Interventions: Diet as ordered. Monitor labs per orders and report to Medical Doctor. Provide good skin care. Weigh Resident #1 per orders. Resident #1 had hypertension (abnormally high blood pressure) and was at risk for renal failure ( when your kidneys can no longer effectively filter waste, extra fluid, and minerals from your blood, leading to dangerous buildup in the body), and was at risk renal failure ( when your kidneys can no longer effectively filter waste, extra fluids, and minerals from blood). Interventions: Encourage adequate fluid intake and a healthy diet. Give medications as ordered. Monitor and document any edema ( swelling caused by excess fluid). Monitor and document abnormalities for urinary output. Report significant changes to the MD. Monitor, document and report to MD as needed any signs and symptoms of dizziness, fainting, lack of concentration, blurred vision, nausea, fatigue, and/or cold clammy pale skin. Monitor/ document/ report to MD as needed any signs or symptoms of hypertension, headache, confusion, lethargy, vomiting, and/or irritability. Resident #1 had potential fluid volume deficient related to inadequate intake, reduced activity, and fluid loss. Intervention: Encourage fluids. Evaluate and administer IV hydration as prescribed. Monitor intake/output and hydration markers. Labs per orders. Record review of Resident #1's nurses notes, dated 12/21/2025 at 3:14 p.m., reflected collected U/a ( collected urine) using sterile technique, using in and out catheter; Resident #1 noted to have 1000ml of tea color urine with sediment and odor; 16 Fr with 10 mL balloon inserted at this time. Will continue with plan of care. Signed by RN A.Record review of Resident #1's nurses notes, dated 12/21/2025 at 6:57 p.m., reflected Resident #1 had output in foley catheter 400 mL of amber urine with mucus; will continue with plan of care.Record review of Resident #1's physician orders for the month of November and December 2025 reflected Resident #1 did not have a physician order or an in and out catheter or for a foley catheter.Record review of Resident #1 nurses' notes dated 12/21/2025 at 2:47 pm, reflected on call physician was contacted and new orders received to collect U/A.Interview on 01/13/2026 at 9:55 a.m., RN A stated Resident #1 needed an in and out catheter to obtain urine for U/A. She stated Resident #1 was having difficulty with the in and out catheter and she inserted a foley catheter. RN A stated she did not contact the physician for the in and out catheter or the foley catheter. She stated this was a protocol to contact the physician anytime a resident may need a catheter. RN A stated she made a mistake, and she had been in-service on obtaining physician orders anytime a resident needed an IV, catheter or any type of new treatment. RN A stated there was a possibility Resident #1 did not need a catheter or the physician may have wanted another type of treatment. She did not recall the date of the in-service. Interview on 01/13/2026 at 1:30 p.m., the ADON stated RN A was expected to contact the physician to obtain a physician order for the in and out catheter and the foley catheter. She stated the physician orders were to ensure care was not missed and possibly the care may need to be monitored, and this would need to be documented on the physician order. The ADON stated anytime a resident needed any type of medical device the physician was to make that decision upon what the nurse reported to the physician about the resident's physical status. She stated there was not a physician order for an in and out catheter or for a foley catheter and there was not any documentation indicated the physician was contacted about Resident #1 needing catheters.Interview on 01/13/2026 at 3:15 pm the Medical Doctor stated Resident #1 health was declining and if he was transferred to the hospital any sooner it would not have made a difference in his overall physical condition. He stated antibiotics would not have helped him with UTI (urinary tract infection and sepsis) his diagnosis when he was admitted to the hospital on [DATE]. He stated he was not notified of Resident #1 needing any type of catheter. The Medical Doctor did not respond to any further questions about the catheters.Record review of the facility's Policy on Physician Orders, dated 2001, reflected The purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services. Physician orders are essential for the comprehensive care of the residents.

Based on interview and record review the facility failed to ensure, a resident based on comprehensive assessment of a resident, that the resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan, and the residents' choices for one of four residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 had orders for in and out catheter and a foley catheter when resident began retaining urine on 12/21/2025. This deficient practice could place residents at risk of not receiving adequate care, harm, or injuries. Findings include:Record review of Resident #1's face sheet, dated 1/13/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included chronic kidney disease, stage 3B ( kidneys had moderate to severe damage, filtering blood at 30-44% of normal, indicated by an eGFR of 30-44 ml/min, requiring closer management to slow progression, with potential symptoms such as: swelling, fatigue, or changes in urination, and increased risk of complications of blood pressure), gout due to renal impairment, multiple sites ( a form of arthritis caused by the accumulation of uric acid crystals in several joints of the body, where the root cause of this buildup is a problems with the kidney's ability to filter out uric acid), and vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (caused by damage to blood vessels in the brain which disrupts blood flow and deprives brain cells of oxygen and nutrients without any behavior symptoms).Record review of Resident #1's Quarterly MDS Assessment, dated 10/22/2025, reflected Resident #1 had a BIMS score of 99, which indicated Resident #1 was unable to complete the interview. He had poor short- and long-term memory recall. Resident #1's decision making ability was severely impaired. He was dependent on staff with hygiene, showers, dressing, and transfers. Resident #1 was incontinent of bowel and bladder.Record review of Resident #1's Comprehensive Care Plan, reflected Resident #1 had chronic kidney disease and at risk for kidney failure, fluid overload, and electrolyte imbalance. Interventions: Diet as ordered. Monitor labs per orders and report to Medical Doctor. Provide good skin care. Weigh Resident #1 per orders. Resident #1 had hypertension (abnormally high blood pressure) and was at risk for renal failure ( when your kidneys can no longer effectively filter waste, extra fluid, and minerals from your blood, leading to dangerous buildup in the body), and was at risk renal failure ( when your kidneys can no longer effectively filter waste, extra fluids, and minerals from blood). Interventions: Encourage adequate fluid intake and a healthy diet. Give medications as ordered. Monitor and document any edema (swelling caused by excess fluid). Monitor and document abnormalities for urinary output. Report significant changes to the MD. Monitor, document and report to MD as needed any signs and symptoms of dizziness, fainting, lack of concentration, blurred vision, nausea, fatigue, and/or cold clammy pale skin. Monitor/ document/ report to MD as needed any signs or symptoms of hypertension, headache, confusion, lethargy, vomiting, and/or irritability. Resident #1 had potential fluid volume deficient related to inadequate intake, reduced activity, and fluid loss. Intervention: Encourage fluids. Evaluate and administer IV hydration as prescribed. Monitor intake/output and hydration markers. Labs per orders.Record review of Resident #1's nurses notes, dated 12/21/2025 at 3:14 p.m., reflected collected U/a (collected urine) using sterile technique, using in and out catheter; Resident #1 noted to have 1000ml of tea color urine with sediment and odor; 16 Fr with 10 mL balloon inserted at this time. Will continue with plan of care. Signed by RN A.Record review of Resident #1's nurses notes, dated 12/21/2025 at 6:57 p.m., reflected Resident #1 had output in foley catheter 400 mL of amber urine with mucus; will continue with plan of care.Record review of Resident #1's physician orders for the month of November and December 2025 reflected Resident #1 did not have a physician order or an in and out catheter or for a foley catheter. Record review of Resident #1 nurses' notes dated 12/21/2025 at 2:47 pm, reflected on call physician was contacted and new orders received to collect U/A. Interview on 01/13/2026 at 9:55 a.m., RN A stated Resident #1 needed an in and out catheter to obtain urine for U/A. She stated Resident #1 was having difficulty with the in and out catheter and she inserted a foley catheter. RN A stated she did not contact the physician for the in and out catheter or the foley catheter. She stated this was a protocol to contact the physician anytime a resident may need a catheter. RN A stated she made a mistake, and she had been in-service on obtaining physician orders anytime a resident needed an IV, catheter or any type of new treatment. RN A stated there was a possibility Resident #1 did not need a catheter or the physician may have wanted another type of treatment. She did not recall the date of the in-service.Interview on 01/13/2026 at 1:30 p.m., the ADON stated RN A was expected to contact the physician to obtain a physician order for the in and out catheter and the foley catheter. She stated the physician orders were to ensure care was not missed and possibly the care may need to be monitored, and this would need to be documented on the physician order. The ADON stated anytime a resident needed any type of medical device the physician was to make that decision upon what the nurse reported to the physician about the resident's physical status. She stated there was not a physician order for an in and out catheter or for a foley catheter and there was not any documentation indicated the physician was contacted about Resident #1 needing catheters.Interview on 01/13/2026 at 3:15 pm the Medical Doctor stated Resident #1 health was declining and if he was transferred to the hospital any sooner it would not have made a difference in his overall physical condition. He stated antibiotics would not have helped him with UTI (urinary tract infection and sepsis) his diagnosis when he was admitted to the hospital on [DATE]. Record review of the facility's Policy on Physician Orders, dated 2001, reflected The purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services. Physician orders are essential for the comprehensive care of the residents.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 medication carts ( Medication Cart #1) reviewed for medication storage. The facility failed to ensure Medication Cart #1 was locked and medications were secure and not accessible to other staff, residents or visitors.This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications. Findings include:Observation on 01/13/2026 at 8:35 AM revealed medication cart #1 was unlocked against the wall near the entrance to the dining room. The back of the cart was against the wall with the drawers facing the hallway. The locking mechanism was protruding outward on the medication cart. The State Surveyor opened the drawers and captured photos. The nurse responsible (RN A) for the medication cart was in the dining room passing out meal trays to residents and unable to view the medication cart.Observation on 01/13/2026 at 8:43 a.m. revealed RN A walked from the dining room toward the unlocked medication cart #1. There were visitors walking down the hall near the unlocked medication cart #1.Interview on 01/13/2026 at 8:45 a.m., RN A stated she thought she had locked the medication cart before she entered the dining room to assist with the breakfast meal. She stated she could not believe the cart was unlocked. RN A stated she had the only set of keys for that cart. She stated residents and visitors had access to the medications in the medication cart. RN A stated if a resident had ingested another residents' medications there was a possibility the resident may overdose, have an allergic reaction, and may require further care at the hospital. RN A stated there was a possibility a resident may die from ingesting another residents' medication. She stated she was in-serviced on locking medication carts when she was not obtaining medications from the cart. RN A stated she did not recall the date of the in-service.Interview on 01/13/2026 at 3:15 p.m., the Director of Nurses stated the medication carts were expected to be locked unless the nurse was standing at the cart administering medications. She stated if the medication carts were in the hallway and the nurse was not standing at the medication cart there it was expected to be locked, no exceptions. She stated a resident had the opportunity to take medications out of the medication cart and if the resident ingested the medications there was a potential a resident may be allergic or overdose on another resident's medications. The Director of Nurses stated there was a possibility the medication could have an interaction with the current medication the resident had been prescribed and may cause a resident to need hospitalization for further assessment and treatment. She stated it was a possibility a resident may die if they were severely allergic to the medication. She stated the staff were in-serviced on locking medication carts. She did not recall the date of the in-service.Record review of the facility's policy on Medication Labeling and Storage, dated 2001, reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen and 1 of 1 emergency food storage room reviewed for kitchen and food sanitation. 1. The facility failed to dispose of a bag labeled lunch meat with a manufacture expiration date of [DATE]. 2. The facility failed to safely store all food items to prevent contamination or spoilage; a bag of pancakes and a bag of waffles were each in a torn bag exposed in the freezer on [DATE]. 3. The facility failed to ensure dietary staff followed handwashing procedures on [DATE]. 4. The facility failed to ensure 8 gallons of expired water (expired [DATE]) in emergency storage were cycled out and removed and 3 additional separate damaged gallons of water removed. These failures could place residents at risk for food contamination and foodborne illness. Findings included: During the initial tour of the kitchen on [DATE] at 09:03 AM the following were observed: - Reach in refrigerator contained a clear zip seal bag that was labeled lunch meat with marker and had a printed manufacturer expiration date of [DATE]. The bag also had writing on it with marker that said it was opened [DATE]. - In the reach in freezer there was two separate boxes, one contained frozen pancakes and the other frozen waffles. Each box had one bag of each item that had its contents exposed (one bag of waffles, and one bag of pancakes) due to being in a torn bag exposing the contents. During a tour of the separate emergency food storage area on [DATE] at 09:25 AM the following were observed: - Eight single gallon bottles of water were observed with a printed expiration date of [DATE]. - Three single gallon bottles of water were observed in a box, all three single-gallon bottles were damaged, caved in, and punctured causing leakage. During a follow up visit to the kitchen for puree observation [DATE] at 11:49 AM DC A was observed removing his gloves and placing them in the trash can, touching the trash can by pushing them in, then putting on gloves and going to work on the single serve cakes. Moments later as his gloves appeared to stick to the saran wrap, he removed the gloves and continued to touch the single serve cakes. He was then observed leaving the kitchen area and returning to food preparation multiple times. DC A did not at any point during this time wash his hands after touching the trash can or leaving the kitchen and returning to food preparation. In an interview on [DATE] at 09:31 AM with the DM, she stated that it was her expectation that food products are not used past the manufacturer expiration date. She stated the lunch meat that was dated with an open date of [DATE] and a printed manufacturer expiration date of [DATE] was opened and used past the manufacturer expiration date and should not have been used. The DM stated it was her expectation that dietary staff check daily for expired products and dispose of them and ensure all items opened and placed back in the refrigerator/ freezer are properly sealed in a zip seal bag or airtight container. The DM stated the emergency food storage is checked on a weekly basis and that it is her expectation that expired items are removed. The DM stated the expired water in the emergency supply was overlooked and should have been removed along with the damaged bottles. She stated a potential negative outcome of expired items being served is it could make residents sick. The DM stated that items which are not sealed and stored in the refrigerator/ freezer could have freezer burn, affect the food quality, and lead to spoilage. In an interview on [DATE] at 12:03 PM with DC A, he stated he did not think to wash his hands but that a potential negative outcome of not washing his hands after handing contaminated items would be could lead to cross contamination of the food. In an interview on [DATE] at 01:30 PM with the ADM, she stated it was her expectation for dietary staff to recognize, keep up with, and prevent expired food items. She stated it was her expectation that items stored in the freezer/ refrigerator were dated and labeled and can be stored in a zip seal bag if it is sealed properly. She stated dietary staff should be washing their hands after touching dirty surfaces. The ADM stated a negative outcome to items not sealed would cause the food to be compromised, the food would not be palatable, and could make residents sick. She stated if dietary staff failed to wash their hands after touching a contaminated item it would result in cross contamination of food. Record review of the Food Storage policy dated [DATE] revealed: Policy: The consultant dietician will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe for consumption. All food will be stored according to the stated and federal food codes. Dry storage rooms: The first in first out rotation method is used. Packages are dated and added items are placed behind existing supplies so that older items are used first. Freezers: Frozen foods are stored in moisture proof wrap or containers that are labeled and dated. Record review of the Employee Sanitation policy dated [DATE] revealed: Policy: The nutrition and food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes to minimize the risk of infection and food borne illness. Handwashing Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times: - Immediately before engaging in food preparation . - During food preparation as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. - After engaging in other activities that contaminate the hands. Use of gloves - Gloves are not a substitute for thorough and frequent hand washing. When using gloves always wash hands before touching or putting on new gloves. Review of the 2022 U.S. Food and Drug Administration Food Code revealed: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen (2) Is in a container or PACKAGE that does not bear a date or day; P or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in ,d+[DATE].17(A). ,d+[DATE].11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph ,d+[DATE].15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.

Based on interview and record review the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #34) of 1 resident reviewed for trauma informed care. The facility failed to ensure that Resident #34 diagnosis of Post-Traumatic Stress Disorder (PTSD) potential triggers were identified, and care planned. The facility failed to ensure that Resident #34 received psychiatric services based on his current diagnosis to evaluate and plan for his care needs. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Record review of Resident #34's face sheet dated 12/12/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of other schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms such as depression, and mania), bipolar disorder (chronic mood disorder that causes intense shifts in mood, energy levels and behavior)-current episode-depressed-severe-with psychotic features, major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest)-single episode-unspecified, generalized anxiety disorder, post-traumatic stress disorder-chronic (mental health condition that can develop after someone experiences or witnesses a traumatic event), and assault by unspecified means. Record review of Resident #34's Admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating cognition intact. Section I Active Diagnosis revealed checked for anxiety disorder, depression, bipolar disorder, schizophrenia, and Post Traumatic Stress Disorder. Section N of the MDS revealed the resident was taking an antidepressant. The MDS revealed that Resident #34 did not exhibit any behaviors indicating rejection of care. Record review of Resident #34's care plan last revised 12/05/24 revealed problem identified Resident #34 has diagnosis of PTSD and is at risk for anxiety, hallucinations, irritability, difficulty sleeping, lack of interest in activities, easily startled/ frightened, and loss of memory with interventions administer medications per MD orders, allow extra time for communication as resident may have difficulty expressing thoughts/ needs, encourage resident to express/ talk about feelings as needed, facilitate access to community resources as needed for emotional/ behavioral support, monitor/ document behaviors per facility policy, provide extra time to address resident slowly and calmly to attempt to decrease risk of startling resident. The care plan did not identify any triggers for resident #34 related to the PTSD diagnosis. Additionally, the care plan also identified: - Resident #34 has a diagnosis of depression and is at risk of signs and symptoms of distress, symptoms of depression, insomnia, anxiety or sad mood with interventions. - Resident #34 has schizoaffective disorder and is at risk for disorganized thinking, hallucinations, paranoia, insomnia, and delusions with interventions. - Resident #34 has a diagnosis of bipolar and is at risk for impaired thought process, manic episodes, major depressive episodes, abnormal elevated moods, suicidal episodes, insomnia, significant weight loss/gain with interventions. - Resident #34 has anxiety and is at risk for feelings of fear, worry, irritability, fatigue, restlessness, insomnia, panic attacks, and isolation with interventions. Record review of Resident #34's physician orders revealed an order start date of 09/17/24 for aripiprazole 10mg tablet, 1 tablet oral, at bedtime for diagnosis of other schizoaffective disorder and trazodone tablet, 50mg, 1 tablet, oral at bedtime for diagnosis bipolar disorder, current episode depressed, severe, with psychotic features. Record review of Resident #34's ordered behavior checks with a start date of 10/24/24 for delusions and agitation revealed no behaviors identified. Record review of Resident #34's psychoactive medication therapy consents revealed a consent form dated 09/17/24 for trazodone marked ordered for depression and antidepressant. A second consent form was also reviewed for aripiprazole 10 mg by mouth a day for schizoaffective disorder, bipolar disorder with psychotic features, and mood instability. Resident #34 did not have psych consultations/ assessments for review on 12/12/2024. In an interview on 12/12/24 at 10:22 AM with the DON, she stated Resident #34's PTSD diagnosis was pulled from the last facility he came from and when he was admitted to this facility, he did not exhibit any behaviors that would have caused them to request a psych evaluation. The DON stated that it had been mentioned in the care plan meetings to the resident and his family but stated that despite all his current diagnosis related to mood/behavior disturbances that he is not receiving any psych consultations and they do not know what his PTSD triggers are. When asked if she (the DON) was qualified to evaluate someone as a mental health authority and make that judgement she stated she was not qualified to do that. The DON stated that a potential negative outcome to a resident having multiple diagnosis of mental health disorders that did not have PTSD triggers identified or evaluations by a mental health professional would be he could be missing out on potential resources that could be provided. A policy for trauma informed care was requested from the DON 12/12/24 at 10:30 AM, she stated there was no specific policy for trauma informed care or PTSD. In an interview on 12/12/24 at 1:30 PM with the ADM she stated it was her expectation that PTSD triggers for a resident be identified through verbal education, care plans, and charts. After reviewing Resident 34's diagnosis with the ADM, she stated that she would have reached out to psych services and said a potential negative outcome of a resident not being evaluated by psych services would be the potential for them to miss out on needed services.

Based on observation, interview, and record review the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 2 residents (Resident #37) reviewed for personal privacy and confidentiality of records. The facility failed to protect the personal healthcare information of Resident #37 which was visible on a computer screen in the hallway while LVN A went into his room to preform wound care on 12/11/2024. This failure could place residents at risk for loss of privacy and dignity. Findings included: Review of Resident #37's face sheet dated 12/12/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses acute kidney failure (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.), Diabetes Mellitus Type II (A condition results from insufficient production of insulin, causing high blood sugar.) and Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.). Review of Resident #37's Admission MDS dated [DATE] reflected he was assessed to have a BIMS score of eight indicating moderate cognitive impairment. Resident #37 was assessed to have physical and verbal behaviors 1 to 3 days during the assessment period. Resident #37 was assessed to require moderate to dependent assist with all ADLs. Resident #37 was assessed to be at risk for pressure ulcers and was assessed to have MASD. Review of Resident #37's comprehensive care plan dated 11/07/2024 and revised 12/06/2024 reflected no entries related to protection of personal health information. Observation on 12/11/2024 at 11:25 AM LVN A left the screen open on her computer screen outside Resident #37's room while she went inside his room to perform wound care. The computer screen exposed Resident #37's personal healthcare information including his wound care orders. In an interview on 12/11/2024 at 11:30 AM LVN A stated she should not have left the computer screen open that it could lead to Resident #37's confidential information being exposed, and it was a HIPPA violation. In an interview on 12/12/2024 9:34 AM the DON stated it was her expectation that residents' health information is be keep private to prevent HIPPA violations. The DON stated the nurse should have ensured the computer screen was not visible to passersby. Review of the facility's Policy Resident Rights dated 12/01/2018 reflected A person living in a nursing home or assisted living facility has the same rights as any other resident of Texas and the United States under federal and state laws. These include the right to: Privacy; Confidentiality of records . 49048

Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 2 residents (Resident #9) assessments reviewed for PASARR evaluations. The facility failed to refer Resident #9 to the appropriate, State-designated authority when she was diagnosed [DATE] with psychotic disorder with delusions due to known physiological condition and psychotic disorder with hallucinations due to know physiological condition. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a decline in mental health. Findings included: Record review of Resident #9's face sheet dated 12/12/24 revealed an [AGE] year-old female admitted to the facility 09/19/23 with a diagnosis of psychotic disorder with delusions due to known physiological condition, psychotic disorder with hallucinations due to known physiological condition, unspecified mood [affective] disorder, cognitive communication deficit (communication difficulty caused by a cognitive impairment), and generalized anxiety disorder (mental health condition that causes people to experience excessive and uncontrollable worry about everyday events or activities). Record review of Resident #9's annual comprehensive MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Section I of the MDS assessment also indicated the resident had an active diagnosis of anxiety disorder and psychotic disorder. Record review of Resident #9's care plan revealed the following problems identified: - Psychotropic drug use- Resident #9 was at risk for adverse consequences related to receiving antipsychotic and depressant medication for the treatment of anxiety, depression, delusional disorder, and psychotic disorder with interventions. - Resident #9 has episodes of disruptive behavior symptoms as evidence by: screaming, shouting, yelling, hollering with interventions. - Resident #9 is at risk for social isolation related to anxiety with interventions. Record review of Resident #9's EMR revealed a 1012 form Mental illness/ Dementia Resident Review completed 10/05/23 that revealed it was marked No, the individual does not have a dementia diagnosis or had a dementia diagnosis, but it is not primary Section C of the form Mental Illness Indication was marked Panic or Other Sever Anxiety Disorder, yes, date of onset: 09/19/23 and any other disorder, yes, date of onset: 09/27/23- Delirium due to known physiological condition to which the form instructed If any of the responses are YES, the nursing facility needs to complete a new PL1 and sections D and E for the form, A full PASRR Evaluation will be conducted after the nursing facility submits the new positive PL1. Section D of the form Nursing Facility Action was marked A new positive PL1 was submitted on [date left blank] according to the instructions in section C with DLN [left blank]. Record review of Resident #9's EMR did not reveal a PASRR Evaluation was completed. In an interview on 12/12/24 at 10:09 PM with MDS B she stated the 1012 form to prompt a PASRR evaluation was not submitted. MDS B stated the resident should have a primary diagnosis of Dementia [the record did not show Dementia as a primary diagnosis]. MDS B stated that based on her current listed diagnosis, there should have been another PL1 done so PASRR could have come out to see if she would have qualified for services. MDS B stated that a potential negative outcome of not having completed that form is the resident could be missing out on mental health services and PASRR services if so indicated. In an interview on 12/12/24 at 1:30 PM with the ADM, she stated that the resident who is PASRR positive should be referred to services as a precaution and that a potential negative outcome of not sending the referral is behaviors could increase. The PASRR policy was requested from the DON 12/12/24 at 10:30 AM, she stated there was no PASRR policy and that they just follow PASRR guidelines.

Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 treatment carts reviewed for medication storage. The facility failed to ensure the treatment / nurse cart was locked while unattended by LVN A on 12/11/2024. This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles. Findings included: Observation on 12/11/2024 at 11:25 AM LVN A left the treatment/ nurse cart unlocked and unattended outside of room [ROOM NUMBER] while she performed wound care. In an interview on 12/11/2024 at 11:30 AM LVN A stated she did forget to lock her cart. LVN A stated the cart should have been locked to prevent residents from getting in the cart and having had access to harmful items, like medications and needles. She stated as the nurse/ treatment cart the cart had treatment supplies and medications. In an interview on 12/12/2024 at 9:34 AM the DON stated she expected staff to ensure medication and treatment carts were locked to maintain medication security and prevent residents from having had access to harmful items. Review of the facility's policy medication storage dated 12/2018 reflected It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse . 49048

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for one of one resident reviewed for pressure ulcers wound care. (Resident #37). The facility failed to ensure the LVN A followed standard precautions during wound care on 12/11/2024 for Resident #37's stage II right buttock pressure ulcer when she failed to set up a clean field for treatment supplies, used a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. These failures could place residents at risk for developing wound infections. Findings included: Review of Resident #37's face sheet dated 12/12/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses acute kidney failure (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and include unexplained fatigue and headache.), Diabetes Mellitus Type II (A condition results from insufficient production of insulin, causing high blood sugar.) and Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.). Review of Resident #37's Admission MDS dated [DATE] reflected he was assessed to have a BIMS score of eight indicating moderate cognitive impairment. Resident #37 was assessed to have physical and verbal behaviors 1 to 3 days during the assessment period. Resident #37 was assessed to require moderate to dependent assist with all ADLs. Resident #37 was assessed to be at risk for pressure ulcers and was assessed to have MASD. Review of Resident #37's comprehensive care plan reflected a problem dated 11/02/2024 Resident #37 had a pressure ulcer related to MASD interventions included Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin weekly. Keep clean and dry as possible. Minimize skin exposure to moisture . Further review of Resident #37's comprehensive care plan reflected a problem dated 11/01/204 Resident #37 requires EBP during contact care related to wounds. Interventions included .Staff to provide/utilize appropriate PPE along with standard precautions while providing resident care. (i.e.: ADLs (dressing, grooming, personal hygiene, transfers, linen changes), incontinent care/toileting, wound care . Review of Resident #37's consolidated physician orders reflected an order dated 11/19/2024 Cleanse stage 2 right buttock with normal saline, apply hydrocolloid dressing once a day on Monday and Friday. Observation on 12/11/2024 at 11:27 AM revealed LVN A outside of Resident #37's gathering supplies for his wound care. She placed all the items on a piece of wax paper and brought them into Resident #37's placing them on his overbed table without moving his personal items or cleaning the table. LVN A further brought in an entire box of gloves from her treatment cart and placed them on the table. LVN A then turned Resident #37 to his left side to reveal a stage II pressure ulcer to his right buttock. LVN A using gauze soaked with normal saline cleaned across the pressure ulcer then patted all around the wound and surrounding skin. LVN A then let go of the right buttock allowing the loose skin to fall over the pressure ulcer. LVN A then lifted Resident #37's right buttock again and using a dry gauze patted at the pressure ulcer and without recleaning the pressure ulcer applied the hydrocolloid dressing. In an interview on 12/11/2024 at 11:35 AM LVN A stated she did not clean the overbed table prior to putting her supplies on the table she stated she thought the wax paper was enough. She stated she did not know she could not take the box of gloves out of the room once she brought them in. She stated the gloves would be contaminated once brought into the room and should not be brought back to the cart. She stated she should have cleaned the wound by starting in the center and moving outward. She stated she did not realize she cleaned across the wound. She stated she should have had someone in there to help her because the right buttock did fall back over the wound, and she stated she did not reclean it and should have. LVN A stated by not recleaning the wound after the unclean skin met the wound it became contaminated and could lead to infections. In an interview on 12/12/2024 at 9:34 AM the DON stated it was her expectations for staff to perform wound care in an aseptic (free from contamination by harmful bacteria, viruses, or other microorganisms) in a manner that does not contaminate the wound. She stated once items are brought into the room they are contaminated and should not be put back on the carts. Review of the facility's policy infection control- standard precautions dated 12/2018 reflected It is the policy of this home that staff members will use standard precautions when providing resident care or when there is the potential of coming into contact with contaminated items. The facility's policy did not address infection control in wound care. 49048

Based on interview and record review the facility failed to ensure that 49 of 49 resident rooms met the required square footage in that: All forty-nine resident rooms were less than the required space of eighty square feet in multiple resident rooms or 100 square feet for single resident rooms. This included rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 201, 202, 203, 204, 205, 206, 207, 208, 209, 301, 302, 303, 304, 305, 306, 401, 402, 403, 404, 405, 406, 407, 501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 601, 602, 603, 604, 605, 606, 607, 608. This failure could restrict the amount of resident care equipment and residents' personal effects that could be accommodated in these resident rooms, limit the ability of the residents to move about the room, and decrease residents' quality of life. Findings included: During an interview on 12/12/2024 at 9:00 AM, the Administrator stated they had requested a waiver for room size in the past, she did not have a physical copy, and the facility would request a waiver again. A record review of the facility's CMS form 2567 dated 9/26/2022 reflected We request a waiver for F912. A record review of the facility's CMS form 672 titled Resident Census and Conditions of Residents dated 10/11/2023 reflected a census of thirty-eight.

Based on observation, interview and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 3 (Resident #19, Resident #32, and Resident #36) of 8 residents reviewed for accommodation of needs. The facility failed to ensure Resident #19, Resident #32, and Resident #36 had call lights within their reach. These failures placed residents at risk of not having their needs met. Findings included: A record review of Resident #19's face sheet dated 10/12/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dementia (symptoms affecting memory and thinking), muscle weakness, bipolar disorder (mental disorder), age-related debility (weakness), hypertension (high blood pressure), muscle wasting and atrophy (muscle loss), unspecified abnormalities of gait and mobility, and lack of coordination. A record review of Resident #19's MDS assessment dated [DATE] reflected a BIMS of 15, which indicated intact cognition. A record review of Resident #19's care plan last revised on 7/20/2023 reflected she had impaired visual function and was at risk for falls. Interventions included staff were to keep Resident #19's call light within reach. A record review of Resident #32's face sheet dated 10/12/2023 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of dementia (symptoms affecting memory and thinking), major depressive disorder (depression), protein-calorie malnutrition, history of transient ischemic attack (brief stroke), type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), muscle wasting and atrophy (muscle loss), muscle weakness, unsteadiness on feet and abnormalities of gait and mobility. A record review of Resident #32's MDS assessment dated [DATE] reflected a BIMS of 3, which indicated severely impaired cognition. A record review of Resident #32's care plan last revised on 9/27/2023 reflected he had incontinence and was at risk for falls. Interventions included staff were to keep Resident #32's call light within reach. A record review of Resident #36's face sheet dated 10/12/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of chronic kidney disease, muscle wasting and atrophy (muscle loss), muscle weakness, reduced mobility, hypertension (high blood pressure), anemia (blood disorder), schizophrenia (mental disorder), mild intellectual disabilities, glaucoma (eye disease leading to vision loss) and major depressive disorder (depression). A record review of Resident #36's MDS assessment dated [DATE] reflected a BIMS of 15, which indicated intact cognition. A record review of Resident #36's care plan last revised on 10/03/2023 reflected he had impaired visual function and was at risk for falls. Interventions included staff were to keep Resident #36's call light within reach at all times. During an observation and interview on 10/10/2023 at 4:12 p.m., Resident #32 was observed lying in bed. Observed Resident #32's call light to be wrapped around itself in a circular direction and hung on the wall. Resident #32 stated he knew how to use the call button but he could not reach it. During an observation and interview on 10/10/2023 at 4:24 p.m., MA C stated no Resident #32's call light was not within reach, she did not know who had put it up there, and I can't control where people put the call light. Observed MA C unwrap Resident #32's call light as she placed it within reach of the resident. During an observation and interview on 10/12/2023 at 9:19 a.m., Resident #36 was observed lying in bed and his call light was on the floor. Resident #36 stated I can't reach it and asked if the surveyor could pick it up for him. Resident #36 said the call light had been on the floor all night. During an observation and interview on 10/12/2023 at 9:27 a.m., Resident #19 was observed lying in bed and her call light was on the floor. Resident #19 asked if the surveyor could pick it up for her. During an interview on 10/12/2023 at 9:29 a.m., CNA A stated both Resident #19 and Resident #36 knew how to use the call light and used it. During an interview on 10/12/2023 at 9:32 a.m., Resident #19 stated she did not know how long the call light had been on the floor but that her hands were sore. During an observation and interview on 10/12/2023 at 9:33 a.m., CNA A stated no that Resident #19 could not reach her call light and it's on the floor. Observed that CNA A asked Resident #19 why her call light was on the floor and Resident #19 told CNA A she needed some kind of fastener for the light but that she would stick it under her pillow for now. During an interview on 10/12/2023 at 9:34 a.m., CNA A stated Resident #19 did not have a clip on her call light. During an interview on 10/12/2023 at 4:14 p.m., the ADON stated the facility's policy on call lights included making sure they were in reach. The ADON stated CNAs monitored to ensure call lights were in reach and nurse managers rounded to monitor CNAs. The ADON stated staff were trained on call light placement via in-services and through verbal one on one trainings. The ADON stated yeah that staff had been trained on call light placement and said, I talk to staff all the time. The ADON stated if call lights were not in reach, residents would not be able to ask for help. During an interview on 10/12/2023 at 4:55 p.m., the Administrator stated the facility's policy on call lights was for them to be at bedside. The Administrator stated CNAs monitored to ensure they were within reach and regarding how CNAs were monitored, it's a facility effort. The Administrator stated housekeepers and department head monitored through Ambassador Rounds-the Administrator explained this meant rounding on rooms. The Administrator stated staff had been trained on call light placement through in-services, education, and computerized trainings, and all staff had been trained to her knowledge. The Administrator stated if call lights were not in reach, it could result in residents waiting longer for CNAs to respond. The Administrator stated, it could be something serious that happened and residents would not be able to notify CNAs. A record review of the facility's admission packet dated 12/01/2018 reflected the following: STATEMENT OF RESIDENT RIGHTS You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. You have all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States (Rule S 19.402 (a) & (b) Texas Administrative Code and S I 02.003 (a) Human Resources Code). Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate, or retaliate against you for exercising your rights. You have a right to: 1. ll care necessary for you to have the highest possible level of health A record review of the facility's in-service dated 2/17/2023 reflected staff were trained on the facility's call light policy. A record review of the facility's in-service dated 6/13/2023 reflected staff were trained on customer service instructed not to forget to always put the call light within resident's reach. A record review of the facility's in-service dated 9/06/2023 reflected staff were trained on customer service instructed not to forget to always put the call light within resident's reach. A record review of the facility's in-service dated 10/10/2023 reflected staff were trained on the facility's call light policy. A record review of the facility's policy titled Call Light - Use of dated October 2020 reflected the following: Policy It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use. Procedure 1. All nursing personnel must be aware of call lights at all times. 8. [NAME] providing care to residents, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. 12. Be sure call lights are placed near the resident, never on the floor or bedside stand.

Based on observation, interview and record review, the facility failed to maintain comfortable sound levels for 7 (Resident #1 and six anonymous residents) of 8 residents reviewed for homelike environment. The facility failed to ensure Resident #22 did not upset other residents in the dining room with his yelling and behaviors during meals. This failure place residents at risk of not having comfortable sound levels. Findings included: A record review of Resident #1's face sheet dated 10/12/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of congestive heart failure, angina (chest pain), Alzheimer's disease (neurodegenerative disease), dysphagia (difficulty swallowing), muscle weakness and osteoporosis (skeletal disorder). A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS of 12, which indicated moderately impaired cognition. A record review of Resident #1's care plan last revised on 10/10/2023 reflected he had moderately impaired hearing. Interventions included staff were to speak clearly and distinctly. A record review of Resident #22's face sheet dated 10/12/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of malignant neoplasm of brain (brain tumor), dementia (symptoms affecting memory and thinking), cerebral infarction (stroke), dysphagia (difficulty swallowing), pain, and aphasia (difficulty communicating). A record review of Resident #22's MDS assessment dated [DATE] reflected a BIMS of 3, which indicated severely impaired cognition. A record review of Resident #22's care plan last revised on 10/05/2023 reflected he had significant weight loss related to poor intake and spitting out everything he puts in his mouth. Resident #22's care plan reflected he could be sitting in the hall in wheelchair or in dining room and starts yelling and hollering. Interventions included a psych eval, relaxation music and hands on assistance during meals. During a confidential meeting of residents, six out of six residents reported Resident #22 screamed and hollered during meals and it bothered them. Two of seven residents said Resident #22 spat his food out on the table. One of seven residents stated the new administrator was nice and tried a radio, but nothing worked. An observation on 10/10/2023 at 12:50 p.m. revealed residents, including Resident #1, were eating lunch in the dining room. There was country music playing on a boombox in the dining room. Resident #22 was sitting at a table with the SLP and kept yelling hurry, hurry! During an interview on 10/11/2023 at 8:15 a.m., the SLP stated they were trying to figure out why Resident #22 had had an increase of vocalizations in the last couple of weeks. The SLP stated she did not know whether things were too stimulating for him, and the facility was looking into noise cancelling headphones. The SLP said Resident #22's yelling had been going on for a couple of weeks and him spitting out his food started the last week of September 2023. During an observation and interview on 10/11/2023 at 1:02 p.m., CNA B stated Resident #22's yelling had been going on for months, but she did not know exactly how long. CNA B stated yes the yelling was mostly during mealtimes. Observed Resident #22 sitting in his room with CNA B present and Resident #22 was yelling out Ahhh! CNA B stated someone in therapy would talk with Resident #22 and she thought it was the SLP. CNA B stated she would have to ask the nurse regarding other interventions the facility had tried. CNA B stated the ADON had asked her to go in and observe Resident #22 during lunch that day, but she did not typically work that hallway. During an observation and interview on 10/12/2023 at 8:22 a.m., the SLP was in Resident #22's room encouraging him to eat breakfast. During an observation and interview on 10/12/2023 at 9:47 a.m., Resident #1 was lying in bed. Resident #1 stated Resident #22's yelling had been going on for at least a couple of months. When asked if it was mostly during meals, Resident #1 stated, yeah and it bothers my [family member]. Resident #1 stated Resident #22 yelled and cussed during meals, it bothered him, made him nervous, and said he may get a nervous breakdown. Resident #1 stated we have all complained about it and the supervisor knows. Resident #1 stated nothing would help except for putting Resident #22 in his room. During an interview on 10/12/2023 at 1:55 p.m., the Medical Director stated either himself or one of three other providers visited the facility once monthly. The Medical Director stated, after reviewing notes from Resident #22's last four visits on 9/03/2023, 9/12/2023, 9/27/2023 and 10/12/2023, he did not see any notes about Resident #22's behaviors. The Medical Director stated just because it was not documented, it did not mean the facility did not call them-he stated they did not always put things in the computer. The Medical Director stated the last time he visited Resident #22 was on 7/23/2023 and there was nothing unusual for him. A record review of the facility's in-services from January through October 2023 reflected no in-services on homelike environment. A record review of the facility's resident council minutes titled Resident Council Meeting Form dated 9/12/2023 reflected the following: Nursing: Concern with one resident in dining room yelling constantly and disturbing others eating. Nursing: Concern on one resident [Resident #22] always yelling in dining room for all meals. This document reflected a handwritten note under the nursing concern which read working on concern with the ADON's signature underneath. A record review of the facility's resident council minutes titled RESIDENT COUNCIL MINUTES dated 10/10/2023 reflected Concerns-the yelling in dining room-Nursing. A record review of the facility's grievance titled Grievance/Complaint Report dated 9/12/2023 reflected the following: [Resident #1] is upset that a fell ow resident (@ times) makes unnecessary noise. It bothers him. Describe the incident as provided by the resident/individual: [Resident #22] keeps too much 'ruckus'. All that hollering bothers me. Describe your findings of the incident: Uncertain of cause, but resident does speak to himself @ times during meals. Recommendations/corrective action taken: Purchase radio for dining room to drown out noise; suggested meals in room; contact resident physician to advise. This grievance reflected it was resolved to the satisfaction of all concerned and marked as resolved on 9/15/2023. During an interview on 10/12/2023 at 4:20 p.m., the ADON stated she was not 100% sure what the facility's policy was on homelike environment when it came to sound levels. The ADON stated they usually monitored every meal and addressed concerns, so residents had a peaceful meal. The ADON stated to address Resident #22's yelling, they had tried earphones for him, he worked with the SLP, they had a radio in the dining room, they tried putting warm clothes on him, lighting, one on one sometimes. The ADON stated herself and the previous DON, whose last day was Monday 10/09/2023, were responsible for monitoring staff to ensure they provided a comfortable environment for residents. The ADON stated most of the time the nurses go around and ask if things are okay during meals. The ADON stated staff helped with interventions she put in place and communicated if they were not working as well. The ADON stated Resident #22's behaviors had been going on for a month or a month and a half, and just Resident #1 had complained about it. The ADON stated if one resident yelled, cursed, and spat during mealtimes, it would not make it a peaceful meal. During an interview on 10/12/2023 at 4:55 p.m., the Administrator stated, we try to accommodate all residents with sound levels. The Administrator stated they noticed Resident #22's yelling so she purchased a radio for mealtimes. The Administrator stated the next intervention was to remove Resident #22 from the dining room but said he was a member of the community, and they did not want to isolate him. The Administrator stated the facility tried earmuffs for Resident #22 to see if he was overstimulated in the dining room. The Administrator stated after trying interventions, she thought they would care plan him to eat in his room. The Administrator stated staff ensured a homelike environment during dining through guidance and education, and through their expectations as a company. The Administrator stated herself and department heads were responsible for monitoring staff to ensure they provided a comfortable environment for residents. The Administrator stated staff were trained on homelike environment through in-services. When asked how other residents may have been affected by one resident who yelled during mealtimes, the Administrator stated, most of them are compassionate and considerate with what's going on with him health-wise. The Administrator stated, then there are some like [Resident #1] who it bothers them, and we have to address it. A record review of the facility's in-services from January 2023 - October 2023 reflected no in-service trainings on homelike environment. A record review of the facility's policy titled Environment dated December 2017 reflected the following: Policy It is the policy of this home to maintain a homelike environment for its residents. Environment The facility will provide: The facility will maintain comfortable sound levels.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment was as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 4 of 15 residents (Resident #s 48, 13, 103, and 153) whose care was reviewed in that: 1. The facility failed to implement individualized interventions for Resident #48 to prevent further falls. Resident #48 sustained 9 falls from 6/1/19 to 7/30/19, 3 of which involved hitting his head. Fall risk evaluations were not completed and new interventions were not put in place after each fall as per facility policy. Resident #48 was sent to out to the hospital for a laceration to the back of his head on 7/22/19 which required staples. He had 3 more falls after the fall on 7/22/19. 2. The facility failed to perform a fall risk evaluation and put new interventions in place for Resident #13 after he fell on [DATE] and sustained a head injury. 3. The facility failed to implement individualized interventions for Resident #103 to prevent further falls. Resident #103 sustained 5 falls within a week. New interventions were not put in place after each fall as per facility policy. These deficient practices resulted in an Immediate Jeopardy (IJ) situation identified on 8/2/19. While the IJ was removed on 8/5/19, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy with a scope identified as pattern until all staff were in-serviced. 4. CNA D did not hold and guide Resident #153 to the wheelchair while transferring him with a mechanical lift. These deficient practices could affect all residents at risk for falls and with recent falls and all residents who were transferred with a mechanical lift by placing them at risk for recurrent falls with/without injury and could result in further neglect, injury, or harm. The findings were: 1. Record review of Resident #48's face sheet (dated 7/25/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #48's significant change MDS dated [DATE] revealed that he was unable to complete the BIMS (indicating severe cognitive impairment); understood and could sometimes understand; had highly impaired vision without corrective lenses; had short and long-term memory problems; had inattention and disorganized thinking; had delusions; had physical and verbal behaviors directed toward others that had gotten worse since the prior assessment; had no wandering behaviors; rejected care daily; needed the extensive assistance of 2 staff for bed mobility and transfers; only walked once or twice with setup help and one-person physical assistance; and was unsteady. A wheelchair was checked as a mobility device. He was not on a toileting program and was always incontinent of bowel and bladder. He was on as-needed and schedules pain medication. He had 2 or more falls since the previous assessment - 2 or more with minor injury and 2 or more with no injury. He received antidepressants 7 days during the lookback period, antianxiety medications 7 days during the lookback period, and antipsychotic medications 7 days within the lookback period. Therapy services were not provided. Record review of Resident #48's electronic care plan (dated 7/23/19) revealed Resident #48 had an actual fall with: No injury d/t (due to) Poor balance, Poor communication/comprehension, and Unsteady gait with interventions of Continue interventions on the at-risk plan; Provide activities that promote exercise and strength building where possible; Provide 1:1 activities if bedbound; and PT (physical therapy) consult for strength and mobility. Record review of Resident #48's fall risk evaluations revealed that he scored a 16 on 6/1/19; a 25 on 6/16/19; and a 23 on 6/25/19 with scores of 10 or above indicating high fall risk. Record review of Resident #48's fall risk evaluation done on 7/23/19 (after surveyor intervention) revealed that he scored a 16 with scores of 10 or above indicating high fall risk. Record review of Resident #48's incident/accident reports from 6/1/19 to 7/23/19 revealed: 6/1/19 - unwitnessed fall in resident's room - resident found next to recliner - resident complained of pain to mid back with no acute findings note - later complained of right arm/shoulder pain - abrasion noted to right mid back measuring 8.5 x 2.5 centimeters 6/4/19 - unwitnessed fall in resident's room - family member of another resident heard him call out - no injuries 6/16/19 - unwitnessed fall (location not specified) - resident found laying on stomach with rolling walker at side - blood dripping from face - laceration to left eyebrow - able to see skull measuring 3.5 cm - resident sent to ER (emergency room ) for evaluation and treatment - rolling walker noted to be the cause of fall 6/17/19 - unwitnessed fall in dining room - resident sat down on floor - no injuries - resident noted with recent falls and increased weakness 7/5/19 - witnessed fall in resident's room - resident was standing behind wheelchair and lost balance and sat on the floor next to his bed - red blanchable area .8 x 3.5 centimeters noted to his left upper back 7/20/19 - unwitnessed fall in hallway - resident wandering into the rooms of other residents while carrying his fall mat - another resident yelled for staff - staff found Resident #48 on his fall mat - abrasion to right side of head and reddened area to right shoulder There were no post-fall interventions specified on the above incident/accident reports. Record review of Resident #48's progress notes revealed that there was also a fall on 6/29/19 for which an incident/accident report had not been completed. The 6/29/19 fall was witnessed and occurred when he was ambulating with his walker. There was no injury. Record review of Resident #48's post-fall notes from 6/1/19 to 7/23/19 (provided by the DON after the surveyor questioned the lack of post-fall interventions on the incident/accident reports) revealed: 6/1/19 fall (revision made 7/1/19) - interventions: x-rays performed with no abnormal results; resident has behavioral issues often refusing care and attempting to swing at staff while assisting; staff allows time for resident to process thoughts, will give step by step instructions of what they are going to do before performing care; resident has memory impairment; wound care monitoring and treating skin tears; resident refuses therapy - conclusion: staff continues to attempt care, educate on fall precautions, and monitoring resident 6/4/19 fall (revision made 7/1/19) - interventions: resident impulsive, unaware of safety limitations, memory impairment d/t (due to) dementia with behavioral disturbance and recent changes in medications; medications reviewed with no change; room free of environmental hazards; increased rounding; choosing not to allow staff to perform toileting schedule; placed in room with high staff presence and door kept open whenever possible for monitoring in room; choosing not to participate in therapy; unable to recall teachings concerning fall precautions and refusing staff to assist with ADLs/transfers; resident curses staff while attempting to assist; nurse monitoring closely to ensure safety with staff increasing rounds - conclusion: increased rounding has prevented several falls; staff allowing resident time to process thoughts, maintaining personal boundaries while ensuring safety 6/16/19 fall (revision made 7/1/19) - interventions: resident sent to (hospital) and returned approximately 4 hours later; resident has very weak BLE (bilateral lower extremity) strength, very unsteady gait and balance, and noncompliant using call light before transferring; removed rollator due to weak BLE strength and using WC (wheelchair); 6 stitched to forehead, no abnormal results from test; resident very weak, requires increased help with ADLs; began decline in ADLs before fall; therapy to evaluate and treat 6/17/19 fall (revision made 7/23/19) - interventions: resident impulsive, unaware of safety limitations and very weak BLE (bilateral lower extremity) strength; rollator removed with resident in WC (wheelchair) d/t (due to) unsteady gait and balance; fall precautions in place with safety main goal d/t memory impairment and aggressive behaviors; resident continues refusing assistance with ADLs, transferring, and using restroom; increased rounding, bed in low position, call light next to resident, non-slip socks and shoes, staff attempted toileting schedule - resident becomes combative; door kept open whenever possible for monitoring and room free of environmental hazards - conclusion: increased rounding and WC preventing several falls 7/5/19 fall (revision made 7/23/19) - interventions: resident with memory impairment, impulsive, unaware of safety limitations, very weak BLE (bilateral lower extremity) strength and has behavioral issues becoming agitated frequently when staff attempts to assist; fall interventions - non-slip socks and shows, bed in low position with floor mat while in bed, door kept open whenever possible for monitoring, increased rounding, room free of environmental hazards, staff assisting with toileting needs whenever resident allows; staff allows resident time to process thoughts, speaks in a calm reassuring voice, and respects resident boundaries while ensuring resident's safety; while in WC (wheelchair), staff increases monitoring keeping resident close; resident will self-propel in WC; when resident attempts to stand and staff attempts to help resident, he becomes aggressive, attempting to hit staff, starts yelling and cursing; while attempting to stand from bed, has same behaviors, becoming aggressive, yelling, and cursing; staff preventing multiple falls; with all fall interventions in place and resident's behaviors, unaware of safety limitations, and memory impairment, main goal is to prevent injuries - conclusion: increased rounding with door kept open preventing several falls; staff closely monitoring while in WC to prevent resident from falling, attempting to stand; speaking to resident in calm, reassuring voice and aiding in redirection 7/20/19 fall (revision made 7/23/19) - interventions: resident high fall risk with fall precautions in place; bed kept in low position with floor mat next to bed while in bed, door kept open whenever possible for monitoring, increased rounding, room free of environmental hazards, staff assisting with toileting needs, snacks and fluids offered and constant monitoring; after pain, med (medication) are administered; very weak BLE (bilateral lower extremity) strength, very unstable gait/balance and using WC (wheelchair); staff closely monitoring - conclusion: nursing and staff preventing several falls with increased rounding There was no post-fall note for Resident #48's 6/29/19 fall. Record review of Resident #48's therapy notes revealed that he was screened on 6/17/19. On Resident #48's 6/17/19 therapy screen was written Pt (patient) resists attempt to get up and observe walking. Observation of Resident #48 lying in his bed with his eyes closed in his room at 9:21 a.m. on 7/22/19 revealed that he was yelling out Help me!. His fall mat was propped up against the other bed in his room. CNA H entered the room and said that Resident #48 sometimes yelled Help me! in his sleep and said that she had already been in the room [ROOM NUMBER] times. Observation of Resident #48 lying in his bed in his room at 3:50 p.m. on 7/22/19 revealed that he was yelling out Help me!. Resident #48 was requesting to be covered and said he was cold. The surveyor went to the hallway to get a staff member. Cook Q was mopping in the hallway and said she would get someone. The surveyor returned to Resident #48 in his room. Resident #48 was trying to get out of bed and was agitated. His fall mat was in place. Resident #48 pulled his call light behind his head. The surveyor asked him to use it to call for help, but he was unable to. At 3:52 p.m. on 7/22/19, the surveyor pressed Resident #48's call light for him. At 3:56 p.m. on 7/22/19, the DON entered Resident #48's room. The surveyor then left Resident #48's room and walked to the end of the hall. The surveyor returned to Resident #48's room at 3:59 p.m. on 7/22/19, and no staff were present. Resident #48 was sitting up and his legs were hanging off the side of his bed. The DON was coming down the hallway with thickened water in his hand. The DON left Resident #48 alone when he was in an agitated state. Observation of Resident #48 lying in the other bed (not his) in his room at 11:45 a.m. on 7/23/19 revealed that his call light was attached to him. The bed was not in a low position, and there was no fall mat beside it. During an interview with the DON at 11:47 a.m. on 7/23/19 (the surveyor saw him in the hallway and asked him what was going on with Resident #48 because Resident #48 wasn't in his bed), he confirmed that Resident #48 was lying in a bed that was not his, that the bed was not in a low position, and that the fall mat was not down. The DON said that Resident #48 fell the night before, had to be sent out to the hospital, and got staples to the back of his head. Record review of Resident #48's 7/22/19 6:18 p.m. progress note revealed that he was pushing his wheelchair by the doorway of his room and fell backwards. The fall was witnessed by staff, but he had regular socks and no shoes on. During an interview with CNA J at 12:03 p.m. on 7/23/19, she said that she did not put Resident #48 into the bed he was currently in. CNA J said that she put Resident #48 into bed after breakfast - around 9:20 a.m. - and saw him up in his wheelchair at the nurses' station about 30 minutes later. CNA J said that she didn't know who got Resident #48 out of bed, put him in his wheelchair, and wheeled him to the nurses' station. CNA J said that she had been off the last 4 days and stated Before I had off, he could probably get into his wheelchair himself, but I heard he had gotten unsteady. CNA J said that, when she put Resident #48 in bed, she put his wheelchair at the foot of his bed so that he wouldn't reach for it. CNA J said that she passed by Resident #48's room before her break - about 10:55 a.m. - and that he was in his wheelchair that was positioned between the 2 call light outlets on the wall. CNA J said that she went into Resident #48's room at 10:55 a.m. and asked him what he needed - the bathroom? to be put back in bed? He said no. I put the call light on him. I tried to talk him into going to the nurses' station, but he said 'I'm an old man! I know what I need!' so I left him alone. CNA J said that staff tried to keep an eye on Resident #48 at all times. During an interview with the DON at 1:38 p.m. on 7/23/19, when asked what was meant by Continue interventions on the at-risk plan for Resident #48, he stated Low beds, fall mats, taking them to the bathroom, call light in place, things like that. When asked how CNAs and other staff knew what fall prevention interventions were in place for each resident, the DON stated Word of mouth. The DON said that the at-risk plan was general and not specific to certain residents. The DON said that Resident #48 could sometimes use his call light and that, even if he couldn't, staff were still advised to keep it in his reach. When asked what was meant by increased rounding, the DON stated Ideally, at least every 30 minutes. He's on a busy hall. We tried to move him to another room, but that confused him. I'd like to do 1:1, but that's not possible. During an interview with CNA H at 9:24 a.m. on 7/24/19, she said that there was no written place where CNAs could go to see what each resident's specific care needs were. CNA H stated We know because we know the residents. She said that new employees learned by word of mouth. CNA H confirmed that Resident #48's fall mat was not down and should have been when the surveyor observed him with her at 9:21 a.m. on 7/22/19 and stated My fault - I got busy. CNA H said that she did not know where Resident #48's wheelchair should be placed when he was in bed but that she put it out of his reach and sight to prevent him from trying to get into it. When asked if she felt that Resident #48 was capable of self-transferring to a bed that was not in a low position, CNA H stated No, but he will try. During an interview with the corporate RN at 2:56 p.m. on 7/24/19, she said that all falls were evaluated and that interventions were to be care-planned. The surveyor informed the corporate RN that Resident #48's fall interventions were not care-planned, and she said that she unaware that fall interventions were not being care-planned. The surveyor showed the corporate RN Resident #48's incident/accident reports with no post-fall action taken, and she said that she informed the DON to provide the surveyor with fall conclusion notes. The surveyor showed the corporate RN the post-fall notes provided by the DON and expressed concern with increased rounding as the main, reoccurring intervention. The corporate RN confirmed that increased rounding was not working since Resident #48 continued to fall. She said that she would get with the DON to determine what had been done to prevent Resident #48's falls. The corporate RN said that staff met every morning to discuss falls and then met once a week for risk management meetings. During an interview with the corporate RN and the ADON/Treatment Nurse at 4:03 p.m. on 7/24/19, they said that fall interventions for Resident #48 included shoes and socks, a low bed, and a fall mat. When the surveyor expressed concern about Resident #48's repeated head hits, the corporate RN said that a helmet wouldn't work for him because he would take it off and hit someone with it. The corporate RN said that Resident #48 was on several medications for his behaviors. When asked if Resident #48's medications had been evaluated as a possible cause of his falls, the corporate RN stated They say that they have faxed the doctor for a medication review, but we're looking for that. I don't see it. During an interview with the DON and the corporate RN at 10:15 a.m. on 7/24/19, the DON said that Resident #48 was seen by a psychiatrist until his primary care physician was in the building at a time when he was having behaviors and adjusted his medications without consulting with his psychiatrist first. Resident #48's psychiatrist then backed out of his care. At 11:35 a.m. on 7/25/19, the corporate RN presented the surveyor with a handwritten timeline of Resident #48's falls to show what interventions were implemented after each one. The following information was provided: 6/1/19 - Educate on fall precautions; Monitoring 6/4/19 - Medication review with no change; Environment free of hazards; Increased rounding 6/16/19 - Removed rollator; Wheelchair in place; New shoes in place 6/17/19 - Mat at bedside; Increased rounding; Wheelchair in place 7/5/19 - Door kept open; Increased rounding; Mat in place 7/20/19 - Bed in low position; Mat in place; Increased rounding; Non-slip socks 7/23/19 - Medication review; [MEDICATION NAME] decreased to 75 milligrams from 150 milligrams During an interview with the corporate RN at 12:44 p.m. on 7/25/19, the surveyor compared the post-fall notes presented by the DON with the timeline presented by her. The corporate RN confirmed that many of the interventions on the timeline (the fall mat implemented on 6/17/19, the door kept open implemented on 7/5/19, the bed in low position implemented on 7/20/19, etc.) were not new and were already supposed to be in place. During further interview with the corporate RN at 12:44 p.m. on 7/25/19, she said that care-planned fall interventions popped up on CNA point-of-care kiosks to inform them of what interventions they needed to make sure were in place. The corporate RN confirmed that, if the fall interventions were not care-planned (as they were not care-planned for Resident #48), they would not pop of up on the CNA point-of-care kiosks. The corporate RN confirmed that staff could not determine what fall interventions had already been put in place and what new fall interventions could be tried with the facility's current system. The corporate RN confirmed that Resident #48's care plan to address falls were general and was not specific to him. Record review of the facility's incident/accident reports from 7/25/19 through 8/2/19 revealed that Resident #48 fell on [DATE], 7/29/19, and 7/30/19. The fall on 7/30/19 resulted in injury - discoloration to his skin. Record review of the facility's pharmacy reviews revealed that Resident #48 was not on the list of residents whose medications were reviewed in May, June, or (MONTH) of 2019. During an interview with LVN B and ADON S at 2:25 p.m. on 8/2/19, LVN B said that fall risk interventions for Resident #48 were a low bed, a floor mat, frequent checks, and if we start noticing him trying to get out of bed, we get him up. ADON S stated If (Resident #48) is overly agitated, we have meds - [MEDICATION NAME] and [MEDICATION NAME]. He always appears very agitated. When asked what was meant by frequent checks, LVN B and ADON S both stated constantly. They said that if Resident #48 was agitated and trying to get up, he should be moved to the nursing station. During an interview with Resident #48's Hospice social worker at 2:47 p.m. on 8/2/19, she said that Resident #48 had physically declined in the last 2 weeks and was now being seen more often by Hospice staff. During an interview with the DON at 9:00 a.m. on 8/3/19, he said that Resident #48 passed away in his sleep at 6:05 a.m. on 8/3/19. 2. Record review of Resident #13's face sheet (dated 7/25/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #13's 6/6/19 incident/accident report revealed that he fell in his bathroom and hit the top of his head, sustaining a 3 x 4 centimeter gash. Due to the fall, Resident #13 was transferred to the local acute hospital emergency room and had to get sutures. Record review of Resident #13's 5/20/19 fall risk evaluation revealed that he was at high risk for falls. There were no other fall risk evaluations for Resident #13. Record review of Resident #13's care plan (initiated 5/3/19) revealed that his fall risk was addressed with interventions of Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Ensure that the resident is wearing appropriate foot wear - non-slip socks and shoes when ambulating or mobilizing in wheelchair; Follow facility fall protocol; and Evaluate and treat as ordered or as needed. There was no revised care plan after the 6/6/19 fall. During an interview with the DON at 12:29 p.m. on 7/25/19, he confirmed that Resident # 13 fell on [DATE] and that there was no fall risk evaluation or care plan revisions following his 6/6/19 fall. 3. Record review of Resident #103's face sheet (dated 7/25/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #103's baseline care plan (dated 7/17/19) revealed that he had increased confusion and a history of falls at home. He fell at the facility on 7/16/19 and was educated on using the call light and having staff present before transferring, but it was noted that he was unable to repeat safety precautions and was unaware of his safety limitations and unsteady gait. Record review of the facility's incident/accident reports from 7/25/19 through 8/2/19 revealed that Resident #103 fell on [DATE], 7/26/19, 7/30/19, 7/31/19, and 8/1/19 - none with injury. Record review of Resident #103's incident/accident reports from 7/25/19 to 8/1/19 revealed: 7/25/19 - unwitnessed fall in resident's room - resident found behind his room door after staff heard help me - resident said that he was going to get some coffee - resident assisted into the chair at his bedside - non-slip socks and shoes were placed on him - resident returned demonstration on using the call light and educated on having staff present before transferring - bed placed in low position - door kept opened for monitoring and increased rounding Notes made on 7/26/19 and pertaining to the 7/25/19 fall were Conclusion: Therapy assisting with gait/balance issues. Door kept opened whenever possible for monitoring. Resident reminded 3 times to use walker while ambulating. Room free of environmental hazards and Interventions: Resident unaware of safety limitations, impaired memory and staff frequently reminds resident to use walker. Staff ensuring resident wears non-slip socks and shoes, call light next to resident and bed kept in low position while in bed. Nursing educating every time in room to use call light for assistance and always use walker while ambulating 7/26/19 - unwitnessed fall in resident's room - RN found him on the floor when she went in to perform evening treatment - resident was on the floor, on his back, and under his bed - resident said that he fell trying to get in bed - staff to obtain urinalysis to assess for possible UTI (which could lead to confusion/agitation) - resident assisted into bed Notes made on 7/29/19 and pertaining to the 7/26/19 fall were Interventions: Resident has memory impairment, unaware of safety limitations and with memory impairment to use walker. Nursing and staff educating resident to use walker when ambulating. Resident correctly returned demonstration using call light. Bed kept in low position while in bed with door kept opened for increased monitoring when possible and Conclusion: Nursing and staff continue educating resident to use walker when ambulating. Resident's memory impairment requires nursing and staff to educate every time in room for resident to use call light and have staff present. With increased monitoring and door kept opened whenever possible, staff prevented several falls 7/30/19 - unwitnessed fall in resident's room - resident was calling help help and was found by staff on his knees by his bed, leaning on the bed and having defecated on the floor - staff assisted him to a chair and cleaned him up Notes made on 7/31/19 and pertaining to the 7/30/19 fall were Conclusion: New intervention for toileting and increased rounding preventing multiple falls and Interventions: Resident with memory impairment, unaware of safety limitations and unsteady gait/balance without walker. Placed on toileting schedule, increased rounding, non-slip socks and shoes, bed in low position, room free of environment hazards, door kept opened whenever possible for increased rounding and staff frequently reminding resident to use walker when ambulating 7/31/19 - unwitnessed - observed lying on his right side beside his bed Notes made on 8/1/19 and pertaining to the 7/31/19 fall were Interventions: Therapy working with resident on gait/balance issues. Bed in low position, non-slip socks and shoes, room free of environmental hazards, toileting schedule, staff continues educating resident to use walker while ambulating, resident placed in view of staff when unable to sleep and door kept opened whenever possible for increased rounding. Resident has memory impairment issues, unaware of safety limitations, requires constant redirection, constant reminders to use walker while ambulating and refusing activities and Conclusion: Staff preventing multiple falls with increased rounding, door kept opened for monitoring and constant reminders to use walker. Also preventing multiple falls having resident in view of staff at night 8/1/19 - unwitnessed fall in resident's room - RN found him face down on the floor with his left arm under his head and asleep - resident assisted to living area recliner where he can be watched throughout night Notes made on 8/2/19 and pertaining to the 8/1/19 fall were Interventions: Bed in lowest position, call light next to resident, non-slip socks ans shoes, room free of environment hazards, door kept opened for increased monitoring, resident placed in WC (wheelchair) d/t (due to) weak BLE (bilateral lower extremity) strength, unsteady gait/balance, therapy working with resident and toileting schedule - resident will refuse all assistance becoming agitated and aggressive. Resident has frequent periods of refusing all ADLs. Resident has memory impairment, unaware of safety limitations and aggressive behaviors. Staff allowing resident time to process thoughts, explain every step of care before performing, honoring personal boundaries and ensuring safety and Conclusion: With increased monitoring, placing resident in WC until BLE strength and balance improves, staff have prevented multiple falls Observation of Resident #103 in his room at 1:50 p.m. on 8/2/19 revealed that the DON was picking up his lunch tray. Resident #103's walker was at the foot of his bed, there were no floor mats, and there was a wheelchair in the hallway right outside of his room. During an interview with LVN B and ADON S at 2:25 p.m. on 8/2/19, LVN B said that fall risk interventions for Resident #103 were about the same (as for Resident #48) and that Resident #103 had to be monitored frequently. LVN B said that staff had talked to Resident #103's family member and that she had informed them that Resident #103 sat on the floor when he didn't get what he wanted/needed. LVN B stated We talked about a floor mat but felt it would cause more trouble. ADON S and LVN B said that Resident #103 was on therapy services and had been on therapy services since admission. LVN B said that Resident #103 had to be redirected to his walker when he was ambulating without it. When asked about the wheelchair outside of Resident #103's room, LVN B said that staff let Resident #103 use it when he was tired. She said that Resident #103 stood up from the wheelchair and left it sitting while ambulating with no assistive device. ADON S said that, if Resident #103 got agitated at night, staff put him in a chair in the living area and that he watched television there. Record review of Resident #103's care plan (initiated on 7/16/19 and revised on 8/1/19) revealed that he had an actual fall and that interventions were Continue interventions on the at-risk plan - bed kept in low position while in bed, door kept opened whenever possible for monitoring with increased rounding; For no apparent acute injury, determine and address causative factors of the fall; PT consult for strength and mobility; Remind (Resident #103) to use walker while ambulating; When unable to sleep, place (Resident #103) in view of staff. Resident #103's care plan did not address the wheelchair. Observation of Resident #103 in his room at 9:33 a.m. on 8/3/19 revealed that he was sitting in his wheelchair. His walker was in the hallway right outside of his room. There was a scoop mattress on his bed, and a floor mat was propped against it. During an interview with CNA I at 10:08 a.m. on 8/3/19, when asked if Resident #103 used a wheelchair or walker, she said It depends. If he's unsteady, we put him in the wheelchair. Record review of Resident #103's care plan (initiated on 7/16/19 and revised on 8/2/19) revealed that he had an actual fall and that interventions were Bed kept in low position with floor mat; Ensure non-skid shoes and/or socks are on resident at all times; For no apparent acute injury, determine and address causative factors of the fall; Keep

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to be free from neglect for 3 of 15 residents (Resident #s 48, 13, and 103) whose care was reviewed in that: 1. a. The facility neglected to complete fall risk evaluations, implement new fall interventions, and ensure that staff knew what fall interventions were supposed to be in place for Resident #48. Resident #48 sustained 9 falls from 6/1/19 to 7/30/19, 3 of which involved hitting his head. Resident #48 was sent to out to the hospital for a laceration to the back of his head on 7/22/19 which required staples. He had 3 more falls after the fall on 7/22/19. b. The facility neglected to ensure that Resident #48 was wearing compression stockings as ordered by his physician, was seen by an opthamologist for his vision impairment, and was served a pureed texture diet. 2. The facility neglected to perform a fall risk evaluation and put new interventions in place for Resident #13 after he fell on [DATE] and sustained a head injury. 3. The facility neglected to implement individualized interventions for Resident #103 to prevent further falls. Resident #103 sustained 5 falls within a week. New interventions were not put in place after each fall as per facility policy. These deficient practices could affect all residents at risk for falls and with recent falls by placing them at risk for recurrent falls with/without injury and could result in furthur neglect, injury, or harm. The findings were: 1. Record review of Resident #48's face sheet (dated 7/25/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #48's significant change MDS dated [DATE] revealed that he was unable to complete the BIMS (indicating severe cognitive impairment); understood and could sometimes understand; had highly impaired vision without corrective lenses; had short and long-term memory problems; had inattention and disorganized thinking; had delusions; had physical and verbal behaviors directed toward others that had gotten worse since the prior assessment; had no wandering behaviors; rejected care daily; needed the extensive assistance of 2 staff for bed mobility and transfers; only walked once or twice with setup help and one-person physical assistance; and was unsteady. A wheelchair was checked as a mobility device. He was not on a toileting program and was always incontinent of bowel and bladder. He was on as-needed and schedules pain medication. He had 2 or more falls since the previous assessment - 2 or more with minor injury and 2 or more with no injury. He received antidepressants 7 days during the lookback period, antianxiety medications 7 days during the lookback period, and antipsychotic medications 7 days within the lookback period. Therapy services were not provided. a. Record review of Resident #48's electronic care plan (dated 7/23/19) revealed Resident #48 had an actual fall with: No injury d/t (due to) Poor balance, Poor communication/comprehension, and Unsteady gait with interventions of Continue interventions on the at-risk plan; Provide activities that promote exercise and strength building where possible; Provide 1:1 activities if bedbound; and PT (physical therapy) consult for strength and mobility. Record review of Resident #48's fall risk evaluations revealed that he scored a 16 on 6/1/19; a 25 on 6/16/19; and a 23 on 6/25/19 with scores of 10 or above indicating high fall risk. Record review of Resident #48's fall risk evaluation done on 7/23/19 (after surveyor intervention) revealed that he scored a 16 with scores of 10 or above indicating high fall risk. Record review of Resident #48's incident/accident reports from 6/1/19 to 7/23/19 revealed: 6/1/19 - unwitnessed fall in resident's room - resident found next to recliner - resident complained of pain to mid back with no acute findings note - later complained of right arm/shoulder pain - abrasion noted to right mid back measuring 8.5 x 2.5 centimeters 6/4/19 - unwitnessed fall in resident's room - family member of another resident heard him call out - no injuries 6/16/19 - unwitnessed fall (location not specified) - resident found laying on stomach with rolling walker at side - blood dripping from face - laceration to left eyebrow - able to see skull measuring 3.5 cm - resident sent to ER (emergency room ) for evaluation and treatment - rolling walker noted to be the cause of fall 6/17/19 - unwitnessed fall in dining room - resident sat down on floor - no injuries - resident noted with recent falls and increased weakness 7/5/19 - witnessed fall in resident's room - resident was standing behind wheelchair and lost balance and sat on the floor next to his bed - red blanchable area .8 x 3.5 centimeters noted to his left upper back 7/20/19 - unwitnessed fall in hallway - resident wandering into the rooms of other residents while carrying his fall mat - another resident yelled for staff - staff found Resident #48 on his fall mat - abrasion to right side of head and reddened area to right shoulder There were no post-fall interventions specified on the above incident/accident reports. Record review of Resident #48's progress notes revealed that there was also a fall on 6/29/19 for which an incident/accident report had not been completed. The 6/29/19 fall was witnessed and occurred when he was ambulating with his walker. There was no injury. Record review of Resident #48's post-fall notes from 6/1/19 to 7/23/19 (provided by the DON after the surveyor questioned the lack of post-fall interventions on the incident/accident reports) revealed: 6/1/19 fall (revision made 7/1/19) - interventions: x-rays performed with no abnormal results; resident had behavioral issues often refusing care and attempting to swing at staff while assisting; staff allow time for resident to process thoughts, will give step by step instructions of what they are going to do before performing care; resident has memory impairment; wound care monitoring and treating skin tears; resident refused therapy - conclusion: staff continues to attempt care, educate on fall precautions, and monitoring resident 6/4/19 fall (revision made 7/1/19) - interventions: resident impulsive, unaware of safety limitations, memory impairment d/t (due to) dementia with behavioral disturbance and recent changes in medications; medications reviewed with no change; room free of environmental hazards; increased rounding; choosing not to allow staff to perform toileting schedule; placed in room with high staff presence and door kept open whenever possible for monitoring in room; choosing not to participate in therapy; unable to recall teachings concerning fall precautions and refusing staff to assist with ADLs/transfers; resident curses staff while attempting to assist; nurse monitoring closely to ensure safety with staff increasing rounds - conclusion: increased rounding has prevented several falls; staff allowing resident time to process thoughts, maintaining personal boundaries while ensuring safety 6/16/19 fall (revision made 7/1/19) - interventions: resident sent to (hospital) and returned approximately 4 hours later; resident had very weak BLE (bilateral lower extremity) strength, very unsteady gait and balance, and noncompliant using call light before transferring; removed rollator due to weak BLE strength and using WC (wheelchair); 6 stitched to forehead, no abnormal results from test; resident very weak, requires increased help with ADLs; began decline in ADLs before fall; therapy to evaluate and treat 6/17/19 fall (revision made 7/23/19) - interventions: resident impulsive, unaware of safety limitations and very weak BLE (bilateral lower extremity) strength; rollator removed with resident in WC (wheelchair) d/t (due to) unsteady gait and balance; fall precautions in place with safety main goal d/t memory impairment and aggressive behaviors; resident continues refusing assistance with ADLs, transferring, and using restroom; increased rounding, bed in low position, call light next to resident, non-slip socks and shoes, staff attempted toileting schedule - resident becomes combative; door kept open whenever possible for monitoring and room free of environmental hazards - conclusion: increased rounding and WC preventing several falls 7/5/19 fall (revision made 7/23/19) - interventions: resident with memory impairment, impulsive, unaware of safety limitations, very weak BLE (bilateral lower extremity) strength and has behavioral issues becoming agitated frequently when staff attempts to assist; fall interventions - non-slip socks and shows, bed in low position with floor mat while in bed, door kept open whenever possible for monitoring, increased rounding, room free of environmental hazards, staff assisting with toileting needs whenever resident allows; staff allows resident time to process thoughts, speaks in a calm reassuring voice, and respects resident boundaries while ensuring resident's safety; while in WC (wheelchair), staff increases monitoring keeping resident close; resident will self-propel in WC; when resident attempts to stand and staff attempts to help resident, he becomes aggressive, attempting to hit staff, starts yelling and cursing; while attempting to stand from bed, has same behaviors, becoming aggressive, yelling, and cursing; staff preventing multiple falls; with all fall interventions in place and resident's behaviors, unaware of safety limitations, and memory impairment, main goal is to prevent injuries - conclusion: increased rounding with door kept open preventing several falls; staff closely monitoring while in WC to prevent resident from falling, attempting to stand; speaking to resident in calm, reassuring voice and aiding in redirection 7/20/19 fall (revision made 7/23/19) - interventions: resident high fall risk with fall precautions in place; bed kept in low position with floor mat next to bed while in bed, door kept open whenever possible for monitoring, increased rounding, room free of environmental hazards, staff assisting with toileting needs, snacks and fluids offered and constant monitoring; after pain, med (medication) are administered; very weak BLE (bilateral lower extremity) strength, very unstable gait/balance and using WC (wheelchair); staff closely monitoring - conclusion: nursing and staff preventing several falls with increased rounding There was no post-fall note for Resident #48's 6/29/19 fall. Record review of Resident #48's therapy notes revealed that he was screened on 6/17/19. On Resident #48's 6/17/19 therapy screen was written Pt (patient) resists attempt to get up and observe walking. Observation of Resident #48 lying in his bed in his room with his eyes closed at 9:21 a.m. on 7/22/19 revealed that he was yelling out Help me!. His fall mat was propped up against the other bed in his room. CNA H entered the room and said that Resident #48 sometimes yelled Help me! in his sleep and said that she had already been in the room [ROOM NUMBER] times. Observation of Resident #48 lying in his bed in his room at 3:50 p.m. on 7/22/19 revealed that he was yelling out Help me!. Resident #48 was requesting to be covered and said he was cold. The surveyor went to the hallway to get a staff member. Cook Q was mopping in the hallway and said she would get someone. The surveyor returned to Resident #48's room. Resident #48 was trying to get out of bed and was agitated. His fall mat was in place. Resident #48 pulled his call light behind his head. The surveyor asked him to use it to call for help, but he was unable to. At 3:52 p.m. on 7/22/19, the surveyor pressed Resident #48's call light for him. At 3:56 p.m. on 7/22/19, the DON entered Resident #48's room. The surveyor then left Resident #48's room and walked to the end of the hall. The surveyor returned to Resident #48's room at 3:59 p.m. on 7/22/19, and no staff were present. Resident #48 was sitting up and his legs were hanging off the side of his bed. The DON was coming down the hallway with thickened water in his hand. The DON left Resident #48 alone when he was in an agitated state. Observation of Resident #48 lying in the other bed (not his) in his room at 11:45 a.m. on 7/23/19 revealed that his call light was attached to him. The bed was not in a low position, and there was no fall mat beside it. During an interview with the DON at 11:47 a.m. on 7/23/19 (the surveyor saw him in the hallway and asked him what was going on with Resident #48 because Resident #48 wasn't in his bed), he confirmed that Resident #48 was lying in a bed that was not his, that the bed was not in a low position, and that the fall mat was not down. The DON said that Resident #48 fell the night before, had to be sent out to the hospital, and got staples to the back of his head. Record review of Resident #48's 7/22/19 6:18 p.m. progress note revealed that he was pushing his wheelchair by the doorway of his room and fell backwards. The fall was witnessed by staff, but he had regular socks and no shoes on. During an interview with CNA J at 12:03 p.m. on 7/23/19, she said that she did not put Resident #48 into the bed he was currently in. CNA J said that she put Resident #48 into bed after breakfast - around 9:20 a.m. - and saw him up in his wheelchair at the nurses' station about 30 minutes later. CNA J said that she didn't know who got Resident #48 out of bed, put him in his wheelchair, and wheeled him to the nurses' station. CNA J said that she had been off the last 4 days and stated Before I was off, he could probably get into his wheelchair himself, but I heard he had gotten unsteady. CNA J said that, when she put Resident #48 in bed, she put his wheelchair at the foot of his bed so that he wouldn't reach for it. CNA J said that she passed by Resident #48's room before her break - about 10:55 a.m. - and that he was in his wheelchair that was positioned between the 2 call light outlets on the wall. CNA J said that she went into Resident #48's room at 10:55 a.m. and asked him what he needed - the bathroom? to be put back in bed? He said no. I put the call light on him. I tried to talk him into going to the nurses' station, but he said 'I'm an old man! I know what I need!' so I left him alone. CNA J said that staff tried to keep an eye on Resident #48 at all times. During an interview with the DON at 1:38 p.m. on 7/23/19, when asked what was meant by Continue interventions on the at-risk plan for Resident #48, he stated Low beds, fall mats, taking them to the bathroom, call light in place, things like that. When asked how CNAs and other staff knew what fall prevention interventions were in place for each resident, the DON stated Word of mouth. The DON said that the at-risk plan was general and not specific to certain residents. The DON said that Resident #48 could sometimes use his call light and that, even if he couldn't, staff were still advised to keep it in his reach. When asked what was meant by increased rounding, the DON stated Ideally, at least every 30 minutes. He's on a busy hall. We tried to move him to another room, but that confused him. I'd like to do 1:1, but that's not possible. During an interview with CNA H at 9:24 a.m. on 7/24/19, she said that there was no written place where CNAs could go to see what each resident's specific care needs were. CNA H stated We know because we know the residents. She said that new employees learned by word of mouth. CNA H confirmed that Resident #48's fall mat was not down and should have been when the surveyor observed him with her at 9:21 a.m. on 7/22/19 and stated My fault - I got busy. CNA H said that she did not know where Resident #48's wheelchair should be placed when he was in bed but that she put it out of his reach and sight to prevent him from trying to get into it. When asked if she felt that Resident #48 was capable of self-transferring to a bed that was not in a low position, CNA H stated No, but he will try. During an interview with the corporate RN at 2:56 p.m. on 7/24/19, she said that all falls were evaluated and that interventions were to be care-planned. The surveyor informed the corporate RN that Resident #48's fall interventions were not care-planned, and she said that she unaware that fall interventions were not being care-planned. The surveyor showed the corporate RN Resident #48's incident/accident reports with no post-fall action taken, and she said that she informed the DON to provide the surveyor with fall conclusion notes. The surveyor showed the corporate RN the post-fall notes provided by the DON and expressed concern with increased rounding as the main, reoccurring intervention. The corporate RN confirmed that increased rounding was not working since Resident #48 continued to fall. She said that she would get with the DON to determine what had been done to prevent Resident #48's falls. The corporate RN said that staff met every morning to discuss falls and then met once a week for risk management meetings. During an interview with the corporate RN and the ADON/Treatment Nurse at 4:03 p.m. on 7/24/19, they said that fall interventions for Resident #48 included shoes and socks, a low bed, and a fall mat. When the surveyor expressed concern about Resident #48's repeated hits to his head, the corporate RN said that a helmet wouldn't work for him because he would take it off and hit someone with it. The corporate RN said that Resident #48 was on several medications for his behaviors. When asked if Resident #48's medications had been evaluated as a possible cause of his falls, the corporate RN stated They say that they have faxed the doctor for a medication review, but we're looking for it. I don't see it. During an interview with the DON and the corporate RN at 10:15 a.m. on 7/24/19, the DON said that Resident #48 was seen by a psychiatrist until his primary care physician was in the building at a time when he was having behaviors and adjusted his medications without consulting with his psychiatrist first. Resident #48's psychiatrist then backed out of his care. At 11:35 a.m. on 7/25/19, the corporate RN presented the surveyor with a handwritten timeline of Resident #48's falls to show what interventions were implemented after each one. The following information was provided: 6/1/19 - Educate on fall precautions; Monitoring 6/4/19 - Medication review with no change; Environment free of hazards; Increased rounding 6/16/19 - Removed rollator; Wheelchair in place; New shoes in place 6/17/19 - Mat at bedside; Increased rounding; Wheelchair in place 7/5/19 - Door kept open; Increased rounding; Mat in place 7/20/19 - Bed in low position; Mat in place; Increased rounding; Non-slip socks 7/23/19 - Medication review; [MEDICATION NAME] decreased to 75 milligrams from 150 milligrams During an interview with the corporate RN at 12:44 p.m. on 7/25/19, the surveyor compared the post-fall notes presented by the DON with the timeline presented by her. The corporate RN confirmed that many of the interventions on the timeline (the fall mat implemented on 6/17/19, the door kept open implemented on 7/5/19, the bed in low position implemented on 7/20/19, etc.) were not new and were already supposed to be in place. During further interview with the corporate RN at 12:44 p.m. on 7/25/19, she said that care-planned fall interventions popped up on CNA point-of-care kiosks to inform them of what interventions they needed to make sure were in place. The corporate RN confirmed that, if the fall interventions were not care-planned (as they were not care-planned for Resident #48), they would not pop of up on the CNA point-of-care kiosks. The corporate RN confirmed that staff could not determine what fall interventions had already been put in place and what new fall interventions could be tried with the facility's current system. The corporate RN confirmed that Resident #48's care plan to address falls were general and were not specific to him. Record review of the facility's incident/accident reports from 7/25/19 through 8/2/19 revealed that Resident #48 fell on [DATE], 7/29/19, and 7/30/19. The fall on 7/30/19 resulted in injury - discoloration to his skin. Record review of the facility's pharmacy reviews revealed that Resident #48 was not on the list of residents whose medications were reviewed in May, June, or (MONTH) of 2019. During an interview with LVN B and ADON S at 2:25 p.m. on 8/2/19, LVN B said that fall risk interventions for Resident #48 were a low bed, a floor mat, frequent checks, and if we start noticing him trying to get out of bed, we get him up. ADON S stated If (Resident #48) is overly agitated, we have meds - [MEDICATION NAME] and [MEDICATION NAME]. He always appears very agitated. When asked what was meant by frequent checks, LVN B and ADON S both stated constantly. They said that if Resident #48 was agitated and trying to get up, he should be moved to the nurses' station. During an interview with Resident #48's Hospice social worker at 2:47 p.m. on 8/2/19, she said that Resident #48 had physically declined in the last 2 weeks and was now being seen more often by Hospice staff. During an interview with the DON at 9:00 a.m. on 8/3/19, he said that Resident #48 passed away in his sleep at 6:05 a.m. on 8/3/19. b. Record review of Resident #48's electronic physician orders [REDACTED]. Observations of Resident #48 in his wheelchair at the nursing station and in bed at 9:12 a.m. and 11:45 a.m. on 7/23/19 revealed that he was not wearing compression stockings. At the time of the 9:12 a.m. observation, [MEDICAL CONDITION] was present. There was an indention on Resident #48's legs where his socks ended. During an interview with the DON at 11:45 a.m. on 7/23/19, he confirmed that Resident #48's compression stockings were not on. During an interview with CNA J at 12:03 p.m. on 7/23/19, she said that she did not put Resident #48's compression stockings on him that morning because she couldn't find them. During an interview with CNA H at 9:24 a.m. on 7/23/19, she said that Resident #48 did not refuse to wear his compression stockings when she worked with him. Record review of the facility's Antiembolytic Stockings (Elastic Stockings) policy (effective (MONTH) of (YEAR)) revealed It is the policy of this home to assist or apply antiembolytic stockings in a safe manner. A physician order [REDACTED]. Record review of Resident #48's care plan (last revised on 7/16/19) revealed that he had impaired visual function related to his [MEDICAL CONDITION] and was administered eye drops. Interventions included Arrange consultation with eye care practitioner as required and Monitor/document/report to MD (doctor of medicine) the following s/sx (signs/symptoms) of acute eye problems: change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o (complaints of) halos around lights, double vision, tunnel vision, blurred or hazy vision. Observations of Resident #48 at 9:21 a.m. and 3:50 p.m. on 7/22/19, 11:45 a.m. on 7/23/19, and 9:14 a.m. and 2:43 p.m. on 7/24/19 revealed that he was not wearing glasses and that there were no glasses in his room. During an interview with the DON and the corporate RN at 11:35 a.m. on 7/25/19, they said that Resident #48 was legally blind and had prescribed eye drops. The DON and the corporate RN were unsure as to whether or not Resident #48 had been seen by an eye doctor. Review of Resident #48's electronic and hard clinical records revealed no documentation to show that his eyes had been examined by an eye doctor. During an interview with the SW at 3:35 p.m. on 7/25/19, he said that Resident #48 had not been seen by an ophthalmologist since his admission to the facility. During an interview with the corporate RN at 6:13 p.m. on 7/25/19, she said that the facility did not have a policy for vision/hearing and said that they followed CMS/state regulations. Record review of Resident #48's electronic physician orders [REDACTED]. Observation of Resident #48 eating lunch in the dining room at 1:18 p.m. on 7/25/19 revealed that he was served pureed chicken enchiladas, pureed beans, pureed vegetables, and pureed orange cake. The pureed chicken enchiladas appeared to be chunky and were not of pudding consistency. During an interview with Cook Q at 1:28 p.m. on 7/25/19, she confirmed that she did not blend the chicken enchiladas for residents on pureed diets enough and said that the chunks were pieces of corn tortillas. Observation of a test portion of the pureed chicken enchiladas at 1:30 p.m. on 7/25/19 revealed that there were 1.5-inch pieces of corn tortillas in it. Record review of the facility's Pureed Texture policy (dated (YEAR)) revealed The pureed texture is a mechanical modification of the regular diet or any therapeutic diet, designed for people with moderate to severe swallowing difficulty and a poor ability to protect their airway. This texture allows pureed food (pudding like consistency) that is smooth and easily stays together. Foods should be avoided if they require chewing. 2. Record review of Resident #13's face sheet (dated 7/25/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #13's 6/6/19 incident/accident report revealed that he fell in his bathroom and hit the top of his head, sustaining a 3 x 4 centimeter gash. Due to the fall, Resident #13 was transferred to the local acute hospital emergency room and had to get sutures. Record review of Resident #13's 5/20/19 fall risk evaluation revealed that he was at high risk for falls. There were no other fall risk evaluations for Resident #13. Record review of Resident #13's care plan (initiated 5/3/19) revealed that his fall risk was addressed with interventions of Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Ensure that the resident is wearing appropriate foot wear - non-slip socks and shoes when ambulating or mobilizing in wheelchair; Follow facility fall protocol; and Evaluate and treat as ordered or as needed. There was no revised care plan after the 6/6/19 fall. During an interview with the DON at 12:29 p.m. on 7/25/19, he confirmed that Resident # 13 fell on [DATE] and that there was no fall risk evaluation or care plan revisions following his 6/6/19 fall. 3. Record review of Resident #103's face sheet (dated 7/25/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #103's baseline care plan (dated 7/17/19) revealed that he had increased confusion and a history of falls at home. He fell at the facility on 7/16/19 and was educated on using the call light and having staff present before transferring, but it was noted that he was unable to repeat safety precautions and was unaware of his safety limitations and unsteady gait. Record review of the facility's incident/accident reports from 7/25/19 through 8/2/19 revealed that Resident #103 fell on [DATE], 7/26/19, 7/30/19, 7/31/19, and 8/1/19 - none with injury. Record review of Resident #103's incident/accident reports from 7/25/19 to 8/1/19 revealed: 7/25/19 - unwitnessed fall in resident's room - resident found behind his room door after staff heard help me - resident said that he was going to get some coffee - resident assisted into the chair at his bedside - non-slip socks and shoes were placed on him - resident returned demonstration on using the call light and educated on having staff present before transferring - bed placed in low position - door kept opened for monitoring and increased rounding Notes made on 7/26/19 and pertaining to the 7/25/19 fall were Conclusion: Therapy assisting with gait/balance issues. Door kept opened whenever possible for monitoring. Resident reminded 3 times to use walker while ambulating. Room free of environmental hazards and Interventions: Resident unaware of safety limitations, impaired memory and staff frequently reminds resident to use walker. Staff ensuring resident wears non-slip socks and shoes, call light next to resident and bed kept in low position while in bed. Nursing educating every time in room to use call light for assistance and always use walker while ambulating 7/26/19 - unwitnessed fall in resident's room - RN found him on the floor when she went in to perform evening treatment - resident was on the floor, on his back, and under his bed - resident said that he fell trying to get in bed - staff to obtain urinalysis to assess for possible UTI (which could lead to confusion/agitation) - resident assisted into bed Notes made on 7/29/19 and pertaining to the 7/26/19 fall were Interventions: Resident has memory impairment, unaware of safety limitations and with memory impairment to use walker. Nursing and staff educating resident to use walker when ambulating. Resident correctly returned demonstration using call light. Bed kept in low position while in bed with door kept opened for increased monitoring when possible and Conclusion: Nursing and staff continue educating resident to use walker when ambulating. Resident's memory impairment requires nursing and staff to educate every time in room for resident to use call light and have staff present. With increased monitoring and door kept opened whenever possible, staff prevented several falls 7/30/19 - unwitnessed fall in resident's room - resident was calling help help and was found by staff on his knees by his bed, leaning on the bed and having defecated on the floor - staff assisted him to a chair and cleaned him up Notes made on 7/31/19 and pertaining to the 7/30/19 fall were Conclusion: New intervention for toileting and increased rounding preventing multiple falls and Interventions: Resident with memory impairment, unaware of safety limitations and unsteady gait/balance without walker. Placed on toileting schedule, increased rounding, non-slip socks and shoes, bed in low position, room free of environment hazards, door kept opened whenever possible for increased rounding and staff frequently reminding resident to use walker when ambulating 7/31/19 - unwitnessed - observed lying on his right side beside his bed Notes made on 8/1/19 and pertaining to the 7/31/19 fall were Interventions: Therapy working with resident on gait/balance issues. Bed in low position, non-slip socks and shoes, room free of environmental hazards, toileting schedule, staff continues educating resident to use walker while ambulating, resident placed in view of staff when unable to sleep and door kept opened whenever possible for increased rounding. Resident has memory impairment issues, unaware of safety limitations, requires constant redirection, constant reminders to use walker while ambulating and refusing activities and Conclusion: Staff preventing multiple falls with increased rounding, door kept opened for monitoring and constant reminders to use walker. Also preventing multiple falls having resident in view of staff at night 8/1/19 - unwitnessed fall in resident's room - RN found him face down on the floor with his left arm under his head and asleep - resident assisted to living area recliner where he can be watched throughout night Notes made on 8/2/19 and pertaining to the 8/1/19 fall were Interventions:

Based on observations, interviews, and record reviews, the facility failed to implement its written policies and procedures that prohibited and prevented neglect for 3 of 15 residents (Resident #s 48, 13, and 103) whose care was reviewed in that: 1. a. The facility neglected to complete fall risk evaluations, implement new fall interventions, and ensure that staff knew what fall interventions were supposed to be in place for Resident #48. Resident #48 sustained 9 falls from 6/1/19 to 7/30/19, 3 of which involved hitting his head. Resident #48 was sent to out to the hospital for a laceration to the back of his head on 7/22/19 which required staples. He had 3 more falls after the fall on 7/22/19. b. The facility neglected to ensure that Resident #48 was wearing compression stockings as ordered by his physician, was seen by an opthamologist for his vision impairment, and was served a pureed texture diet. 2. The facility neglected to perform a fall risk evaluation and put new interventions in place for Resident #13 after he fell on [DATE] and sustained a head injury. 3. The facility neglected to implement individualized interventions for Resident #103 to prevent further falls. Resident #103 sustained 5 falls within a week. New interventions were not put in place after each fall as per facility policy. These deficient practices could affect all residents at risk for falls and with recent falls by placing them at risk for recurrent falls with/without injury and could result in furthur neglect, injury, or harm. The findings were: Record review of the facility's Abuse/Reportable Events policy (effective 1/10/17) revealed All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . The facility will provide and ensure the promotion and protection of resident rights. It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of [REDACTED]. Definitions: . Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility's Falls - Evaluation and Prevention policy (dated (MONTH) of (YEAR)) revealed It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention . Resident should be evaluated for their fall risk on admission/re-admission to the home; following any change of status that may affect balance, mobility, or safety; following a fall; quarterly . Procedure: Upon admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. A restraint should be the last interventions implemented by the staff. The care plan should only specify a few interventions at a time so that the staff can determine what interventions is not successful and needs to be changed . Following a fall, the following steps should be undertaken: Evaluate the resident promptly to identify and treat injuries . Evaluate the environment where the fall occurred, noting any factors that may have contributed to the fall. Ask the resident what happened prior to the fall or what may have caused the fall. Complete the home report in the clinical software and notify the physician and responsible party. Document the physician orders [REDACTED]. If the fall was unwitnessed, initiate the investigation including witness statements from staff and residents. Try to determine who was the last person to see the resident prior to the fall and the resident's condition at the time. Review the plan of care and update the interventions as appropriate. 1. Record review of Resident #48's face sheet (dated 7/25/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #48's significant change MDS dated [DATE] revealed that he was unable to complete the BIMS (indicating severe cognitive impairment); understood and could sometimes understand; had highly impaired vision without corrective lenses; had short and long-term memory problems; had inattention and disorganized thinking; had delusions; had physical and verbal behaviors directed toward others that had gotten worse since the prior assessment; had no wandering behaviors; rejected care daily; needed the extensive assistance of 2 staff for bed mobility and transfers; only walked once or twice with setup help and one-person physical assistance; and was unsteady. A wheelchair was checked as a mobility device. He was not on a toileting program and was always incontinent of bowel and bladder. He was on as-needed and schedules pain medication. He had 2 or more falls since the previous assessment - 2 or more with minor injury and 2 or more with no injury. He received antidepressants 7 days during the lookback period, antianxiety medications 7 days during the lookback period, and antipsychotic medications 7 days within the lookback period. Therapy services were not provided. a. Record review of Resident #48's electronic care plan (dated 7/23/19) revealed Resident #48 had an actual fall with: No injury d/t (due to) Poor balance, Poor communication/comprehension, and Unsteady gait with interventions of Continue interventions on the at-risk plan; Provide activities that promote exercise and strength building where possible; Provide 1:1 activities if bedbound; and PT (physical therapy) consult for strength and mobility. Record review of Resident #48's fall risk evaluations revealed that he scored a 16 on 6/1/19; a 25 on 6/16/19; and a 23 on 6/25/19 with scores of 10 or above indicating high fall risk. Record review of Resident #48's fall risk evaluation done on 7/23/19 (after surveyor intervention) revealed that he scored a 16 with scores of 10 or above indicating high fall risk. Record review of Resident #48's incident/accident reports from 6/1/19 to 7/23/19 revealed: 6/1/19 - unwitnessed fall in resident's room - resident found next to recliner - resident complained of pain to mid back with no acute findings note - later complained of right arm/shoulder pain - abrasion noted to right mid back measuring 8.5 x 2.5 centimeters 6/4/19 - unwitnessed fall in resident's room - family member of another resident heard him call out - no injuries 6/16/19 - unwitnessed fall (location not specified) - resident found laying on stomach with rolling walker at side - blood dripping from face - laceration to left eyebrow - able to see skull measuring 3.5 cm - resident sent to ER (emergency room ) for evaluation and treatment - rolling walker noted to be the cause of fall 6/17/19 - unwitnessed fall in dining room - resident sat down on floor - no injuries - resident noted with recent falls and increased weakness 7/5/19 - witnessed fall in resident's room - resident was standing behind wheelchair and lost balance and sat on the floor next to his bed - red blanchable area .8 x 3.5 centimeters noted to his left upper back 7/20/19 - unwitnessed fall in hallway - resident wandering into the rooms of other residents while carrying his fall mat - another resident yelled for staff - staff found Resident #48 on his fall mat - abrasion to right side of head and reddened area to right shoulder There were no post-fall interventions specified on the above incident/accident reports. Record review of Resident #48's progress notes revealed that there was also a fall on 6/29/19 for which an incident/accident report had not been completed. The 6/29/19 fall was witnessed and occurred when he was ambulating with his walker. There was no injury. Record review of Resident #48's post-fall notes from 6/1/19 to 7/23/19 (provided by the DON after the surveyor questioned the lack of post-fall interventions on the incident/accident reports) revealed: 6/1/19 fall (revision made 7/1/19) - interventions: x-rays performed with no abnormal results; resident has behavioral issues often refusing care and attempting to swing at staff while assisting; staff allows time for resident to process thoughts, will give step by step instructions of what they are going to do before performing care; resident has memory impairment; wound care monitoring and treating skin tears; resident refuses therapy - conclusion: staff continues to attempt care, educate on fall precautions, and monitoring resident 6/4/19 fall (revision made 7/1/19) - interventions: resident impulsive, unaware of safety limitations, memory impairment d/t (due to) dementia with behavioral disturbance and recent changes in medications; medications reviewed with no change; room free of environmental hazards; increased rounding; choosing not to allow staff to perform toileting schedule; placed in room with high staff presence and door kept open whenever possible for monitoring in room; choosing not to participate in therapy; unable to recall teachings concerning fall precautions and refusing staff to assist with ADLs/transfers; resident curses staff while attempting to assist; nurse monitoring closely to ensure safety with staff increasing rounds - conclusion: increased rounding has prevented several falls; staff allowing resident time to process thoughts, maintaining personal boundaries while ensuring safety 6/16/19 fall (revision made 7/1/19) - interventions: resident sent to (hospital) and returned approximately 4 hours later; resident has very weak BLE (bilateral lower extremity) strength, very unsteady gait and balance, and noncompliant using call light before transferring; removed rollator due to weak BLE strength and using WC (wheelchair); 6 stitched to forehead, no abnormal results from test; resident very weak, requires increased help with ADLs; began decline in ADLs before fall; therapy to evaluate and treat 6/17/19 fall (revision made 7/23/19) - interventions: resident impulsive, unaware of safety limitations and very weak BLE (bilateral lower extremity) strength; rollator removed with resident in WC (wheelchair) d/t (due to) unsteady gait and balance; fall precautions in place with safety main goal d/t memory impairment and aggressive behaviors; resident continues refusing assistance with ADLs, transferring, and using restroom; increased rounding, bed in low position, call light next to resident, non-slip socks and shoes, staff attempted toileting schedule - resident becomes combative; door kept open whenever possible for monitoring and room free of environmental hazards - conclusion: increased rounding and WC preventing several falls 7/5/19 fall (revision made 7/23/19) - interventions: resident with memory impairment, impulsive, unaware of safety limitations, very weak BLE (bilateral lower extremity) strength and has behavioral issues becoming agitated frequently when staff attempts to assist; fall interventions - non-slip socks and shows, bed in low position with floor mat while in bed, door kept open whenever possible for monitoring, increased rounding, room free of environmental hazards, staff assisting with toileting needs whenever resident allows; staff allows resident time to process thoughts, speaks in a calm reassuring voice, and respects resident boundaries while ensuring resident's safety; while in WC (wheelchair), staff increases monitoring keeping resident close; resident will self-propel in WC; when resident attempts to stand and staff attempts to help resident, he becomes aggressive, attempting to hit staff, starts yelling and cursing; while attempting to stand from bed, has same behaviors, becoming aggressive, yelling, and cursing; staff preventing multiple falls; with all fall interventions in place and resident's behaviors, unaware of safety limitations, and memory impairment, main goal is to prevent injuries - conclusion: increased rounding with door kept open preventing several falls; staff closely monitoring while in WC to prevent resident from falling, attempting to stand; speaking to resident in calm, reassuring voice and aiding in redirection 7/20/19 fall (revision made 7/23/19) - interventions: resident high fall risk with fall precautions in place; bed kept in low position with floor mat next to bed while in bed, door kept open whenever possible for monitoring, increased rounding, room free of environmental hazards, staff assisting with toileting needs, snacks and fluids offered and constant monitoring; after pain, med (medication) are administered; very weak BLE (bilateral lower extremity) strength, very unstable gait/balance and using WC (wheelchair); staff closely monitoring - conclusion: nursing and staff preventing several falls with increased rounding There was no post-fall note for Resident #48's 6/29/19 fall. Record review of Resident #48's therapy notes revealed that he was screened on 6/17/19. On Resident #48's 6/17/19 therapy screen was written Pt (patient) resists attempt to get up and observe walking. Observation of Resident #48 lying in his bed in his room with his eyes closed at 9:21 a.m. on 7/22/19 revealed that he was yelling out Help me!. His fall mat was propped up against the other bed in his room. CNA H entered the room and said that Resident #48 sometimes yelled Help me! in his sleep and said that she had already been in the room [ROOM NUMBER] times. Observation of Resident #48 lying in his bed in his room at 3:50 p.m. on 7/22/19 revealed that he was yelling out Help me!. Resident #48 was requesting to be covered and said he was cold. The surveyor went to the hallway to get a staff member. Cook Q was mopping in the hallway and said she would get someone. The surveyor returned to Resident #48 in his room. Resident #48 was trying to get out of bed and was agitated. His fall mat was in place. Resident #48 pulled his call light behind his head. The surveyor asked him to use it to call for help, but he was unable to. At 3:52 p.m. on 7/22/19, the surveyor pressed Resident #48's call light for him. At 3:56 p.m. on 7/22/19, the DON entered Resident #48's room. The surveyor then left Resident #48's room and walked to the end of the hall. The surveyor returned to Resident #48's room at 3:59 p.m. on 7/22/19, and no staff were present. Resident #48 was sitting up and his legs were hanging off the side of his bed. The DON was coming down the hallway with thickened water in his hand. The DON left Resident #48 alone when he was in an agitated state. Observation of Resident #48 lying in the other bed (not his) in his room at 11:45 a.m. on 7/23/19 revealed that his call light was attached to him. The bed was not in a low position, and there was no fall mat beside it. During an interview with the DON at 11:47 a.m. on 7/23/19 (the surveyor saw him in the hallway and asked him what was going on with Resident #48 because Resident #48 wasn't in his bed), he confirmed that Resident #48 was lying in a bed that was not his, that the bed was not in a low position, and that the fall mat was not down. The DON said that Resident #48 fell the night before, had to be sent out to the hospital, and got staples to the back of his head. Record review of Resident #48's 7/22/19 6:18 p.m. progress note revealed that he was pushing his wheelchair by the doorway of his room and fell backwards. The fall was witnessed by staff, but he had regular socks and no shoes on. During an interview with CNA J at 12:03 p.m. on 7/23/19, she said that she did not put Resident #48 into the bed he was currently in. CNA J said that she put Resident #48 into bed after breakfast - around 9:20 a.m. - and saw him up in his wheelchair at the nurses' station about 30 minutes later. CNA J said that she didn't know who got Resident #48 out of bed, put him in his wheelchair, and wheeled him to the nurses' station. CNA J said that she had been off the last 4 days and stated Before I had off, he could probably get into his wheelchair himself, but I heard he had gotten unsteady. CNA J said that, when she put Resident #48 in bed, she put his wheelchair at the foot of his bed so that he wouldn't reach for it. CNA J said that she passed by Resident #48's room before her break - about 10:55 a.m. - and that he was in his wheelchair that was positioned between the 2 call light outlets on the wall. CNA J said that she went into Resident #48's room at 10:55 a.m. and asked him what he needed - the bathroom? to be put back in bed? He said no. I put the call light on him. I tried to talk him into going to the nurses' station, but he said 'I'm an old man! I know what I need!' so I left him alone. CNA J said that staff tried to keep an eye on Resident #48 at all times. During an interview with the DON at 1:38 p.m. on 7/23/19, when asked what was meant by Continue interventions on the at-risk plan for Resident #48, he stated Low beds, fall mats, taking them to the bathroom, call light in place, things like that. When asked how CNAs and other staff knew what fall prevention interventions were in place for each resident, the DON stated Word of mouth. The DON said that the at-risk plan was general and not specific to certain residents. The DON said that Resident #48 could sometimes use his call light and that, even if he couldn't, staff were still advised to keep it in his reach. When asked what was meant by increased rounding, the DON stated Ideally, at least every 30 minutes. He's on a busy hall. We tried to move him to another room, but that confused him. I'd like to do 1:1, but that's not possible. During an interview with CNA H at 9:24 a.m. on 7/24/19, she said that there was no written place where CNAs could go to see what each resident's specific care needs were. CNA H stated We know because we know the residents. She said that new employees learned by word of mouth. CNA H confirmed that Resident #48's fall mat was not down and should have been when the surveyor observed him with her at 9:21 a.m. on 7/22/19 and stated My fault - I got busy. CNA H said that she did not know where Resident #48's wheelchair should be placed when he was in bed but that she put it out of his reach and sight to prevent him from trying to get into it. When asked if she felt that Resident #48 was capable of self-transferring to a bed that was not in a low position, CNA H stated No, but he will try. During an interview with the corporate RN at 2:56 p.m. on 7/24/19, she said that all falls were evaluated and that interventions were to be care-planned. The surveyor informed the corporate RN that Resident #48's fall interventions were not care-planned, and she said that she unaware that fall interventions were not being care-planned. The surveyor showed the corporate RN Resident #48's incident/accident reports with no post-fall action taken, and she said that she informed the DON to provide the surveyor with fall conclusion notes. The surveyor showed the corporate RN the post-fall notes provided by the DON and expressed concern with increased rounding as the main, reoccurring intervention. The corporate RN confirmed that increased rounding was not working since Resident #48 continued to fall. She said that she would get with the DON to determine what had been done to prevent Resident #48's falls. The corporate RN said that staff met every morning to discuss falls and then met once a week for risk management meetings. During an interview with the corporate RN and the ADON/Treatment Nurse at 4:03 p.m. on 7/24/19, they said that fall interventions for Resident #48 included shoes and socks, a low bed, and a fall mat. When the surveyor expressed concern about Resident #48's repeated head hits, the corporate RN said that a helmet wouldn't work for him because he would take it off and hit someone with it. The corporate RN said that Resident #48 was on several medications for his behaviors. When asked if Resident #48's medications had been evaluated as a possible cause of his falls, the corporate RN stated They say that they have faxed the doctor for a medication review, but we're looking for that. I don't see it. During an interview with the DON and the corporate RN at 10:15 a.m. on 7/24/19, the DON said that Resident #48 was seen by a psychiatrist until his primary care physician was in the building at a time when he was having behaviors and adjusted his medications without consulting with his psychiatrist first. Resident #48's psychiatrist then backed out of his care. At 11:35 a.m. on 7/25/19, the corporate RN presented the surveyor with a handwritten timeline of Resident #48's falls to show what interventions were implemented after each one. The following information was provided: 6/1/19 - Educate on fall precautions; Monitoring 6/4/19 - Medication review with no change; Environment free of hazards; Increased rounding 6/16/19 - Removed rollator; Wheelchair in place; New shoes in place 6/17/19 - Mat at bedside; Increased rounding; Wheelchair in place 7/5/19 - Door kept open; Increased rounding; Mat in place 7/20/19 - Bed in low position; Mat in place; Increased rounding; Non-slip socks 7/23/19 - Medication review; [MEDICATION NAME] decreased to 75 milligrams from 150 milligrams During an interview with the corporate RN at 12:44 p.m. on 7/25/19, the surveyor compared the post-fall notes presented by the DON with the timeline presented by her. The corporate RN confirmed that many of the interventions on the timeline (the fall mat implemented on 6/17/19, the door kept open implemented on 7/5/19, the bed in low position implemented on 7/20/19, etc.) were not new and were already supposed to be in place. During further interview with the corporate RN at 12:44 p.m. on 7/25/19, she said that care-planned fall interventions popped up on CNA point-of-care kiosks to inform them of what interventions they needed to make sure were in place. The corporate RN confirmed that, if the fall interventions were not care-planned (as they were not care-planned for Resident #48), they would not pop of up on the CNA point-of-care kiosks. The corporate RN confirmed that staff could not determine what fall interventions had already been put in place and what new fall interventions could be tried with the facility's current system. The corporate RN confirmed that Resident #48's care plan to address falls were general and was not specific to him. Record review of the facility's incident/accident reports from 7/25/19 through 8/2/19 revealed that Resident #48 fell on [DATE], 7/29/19, and 7/30/19. The fall on 7/30/19 resulted in injury - discoloration to his skin. Record review of the facility's pharmacy reviews revealed that Resident #48 was not on the list of residents whose medications were reviewed in May, June, or (MONTH) of 2019. During an interview with LVN B and ADON S at 2:25 p.m. on 8/2/19, LVN B said that fall risk interventions for Resident #48 were a low bed, a floor mat, frequent checks, and if we start noticing him trying to get out of bed, we get him up. ADON S stated If (Resident #48) is overly agitated, we have meds - [MEDICATION NAME] and [MEDICATION NAME]. He always appears very agitated. When asked what was meant by frequent checks, LVN B and ADON S both stated constantly. They said that if Resident #48 was agitated and trying to get up, he should be moved to the nursing station. During an interview with Resident #48's Hospice social worker at 2:47 p.m. on 8/2/19, she said that Resident #48 had physically declined in the last 2 weeks and was now being seen more often by Hospice staff. During an interview with the DON at 9:00 a.m. on 8/3/19, he said that Resident #48 passed away in his sleep at 6:05 a.m. b. Record review of Resident #48's electronic physician orders [REDACTED]. Observations of Resident #48 in his wheelchair at the nursing station and in bed at 9:12 a.m. and 11:45 a.m. on 7/23/19 revealed that he was not wearing compression stockings. At the time of the 9:12 a.m. observation, [MEDICAL CONDITION] was present. There was an indention on Resident #48's legs where his socks ended. During an interview with the DON at 11:45 a.m. on 7/23/19, he confirmed that Resident #48's compression stockings were not on. During an interview with CNA J at 12:03 p.m. on 7/23/19, she said that she did not put Resident #48's compression stockings on him that morning because she couldn't find them. During an interview with CNA H at 9:24 a.m. on 7/23/19, she said that Resident #48 did not refuse to wear his compression stockings when she worked with him. Record review of the facility's Antiembolytic Stockings (Elastic Stockings) policy (effective (MONTH) of (YEAR)) revealed It is the policy of this home to assist or apply antiembolytic stockings in a safe manner. A physician order [REDACTED]. Record review of Resident #48's care plan (last revised on 7/16/19) revealed that he had impaired visual function related to his [MEDICAL CONDITION] and was administered eye drops. Interventions included Arrange consultation with eye care practitioner as required and Monitor/document/report to MD (doctor of medicine) the following s/sx (signs/symptoms) of acute eye problems: change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o (complaints of) halos around lights, double vision, tunnel vision, blurred or hazy vision. Observations of Resident #48 at 9:21 a.m. and 3:50 p.m. on 7/22/19, 11:45 a.m. on 7/23/19, and 9:14 a.m. and 2:43 p.m. on 7/24/19 revealed that he was not wearing glasses and that there were no glasses in his room. During an interview with the DON and the corporate RN at 11:35 a.m. on 7/25/19, they said that Resident #48 was legally blind and had prescribed eye drops. The DON and the corporate RN were unsure as to whether or not Resident #48 had been seen by an eye doctor. Review of Resident #48's electronic and hard clinical records revealed no documentation to show that his eyes had been examined by an eye doctor. During an interview with the SW at 3:35 p.m. on 7/25/19, he said that Resident #48 had not been seen by an ophthalmologist since his admission to the facility. During an interview with the corporate RN at 6:13 p.m. on 7/25/19, she said that the facility did not have a policy for vision/hearing and said that they followed CMS/state regulations. Record review of Resident #48's electronic physician orders [REDACTED]. Observation of Resident #48 eating lunch in the dining room at 1:18 p.m. on 7/25/19 revealed that he was served pureed chicken enchiladas, pureed beans, pureed vegetables, and pureed orange cake. The pureed chicken enchiladas appeared to be chunky and were not of pudding consistency. During an interview with Cook Q at 1:28 p.m. on 7/25/19, she confirmed that she did not blend the chicken enchiladas for residents on pureed diets enough and said that the chunks were pieces of corn tortillas. Observation of a test portion of the pureed chicken enchiladas at 1:30 p.m. on 7/25/19 revealed that there were 1.5-inch pieces of corn tortillas in it. Record review of the facility's Pureed Texture policy (dated (YEAR)) revealed The pureed texture is a mechanical modification of the regular diet or any therapeutic diet, designed for people with moderate to severe swallowing difficulty and a poor ability to protect their airway. This texture allows pureed food (pudding like consistency) that is smooth and easily stays together. Foods should be avoided if they require chewing. 2. Record review of Resident #13's face sheet (dated 7/25/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #13's 6/6/19 incident/accident report revealed that he fell in his bathroom and hit the top of his head, sustaining a 3 x 4 centimeter gash. Due to the fall, Resident #13 was transferred to the local acute hospital emergency room . Record review of Resident #13's 5/20/19 fall risk evaluation revealed that he was at high risk for falls. There were no other fall risk evaluations for Resident #13. Record review of Resident #13's care plan (initiated 5/3/19) revealed that his fall risk was addressed with interventions of Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Ensure that the resident is wearing appropriate foot wear - non-slip socks and shoes when ambulating or mobilizing in wheelchair; Follow facility fall protocol; and Evaluate and treat as ordered or as needed. There was no revised care plan after the 6/6/19 fall. During an interview with the DON at 12:29 p.m. on 7/25/19, he confirmed that Resident # 13 fell on [DATE] and that there was no fall risk evaluation or care plan revisions following his 6/6/19 fall. 3. Record review of Resident #103's face sheet (dated 7/25/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #103's baseline care plan (dated 7/17/19) revealed that he had increased confusion and a history of falls at home. He fell at the facility on 7/16/19 and was educated on using the call light and having staff present before transferring, but it was noted that he was unable to repeat safety precautions and was unaware of his safety limitations and unsteady gait. Record review of the facility's incident/accident reports from 7/25/19 through 8/2/19 revealed that Resident #103 fell on [DATE], 7/26/19, 7/30/19, 7/31/19, and 8/1/19 - none with injury. Record review of Resident #103's incident/accident reports from 7/25/19 to 8/1/19 revealed: 7/25/19 - unwitnessed fall in resident's room - resident found behind his room door after staff heard help me - resident said that he was going to get some coffee - resident assisted into the chair at his bedside - non-slip socks and shoes were placed on him - resident returned demonstration on using the call light and educated on having staff present before transferring - bed placed in low position - door kept opened for monitoring and increased rounding Notes made on 7/26/19 and pertaining to the 7/25/19 fall were Conclusion: Therapy assisting with gait/balance issues. Door kept opened whenever possible for monitoring. Resident reminded 3 times to use walker while ambulating. Room free of environmental hazards and Interventions: Resident unaware of safety limitations, impaired memory and staff frequently reminds resident to use walker. Staff ensuring resident wears non-slip socks and shoes, call light next to resident and bed kept in low position while in bed. Nursing educating every time in room to use call light for assistance and always use walker while ambulating 7/26/19 - unwitnessed fall in resident's room - RN found him on the floor when she went in to perform evening treatment - resident was on the floor, on his back, and under his bed - resident said that he fell trying to get in bed - staff to obtain urinalysis to assess for possible UTI (which would cause confusion/agitation) - resident assisted into bed Notes ma (TRUNCATED)

Based on observation, interview and record review the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care when one (1) of four (4) residents (Resident #1) reviewed for pain management. Resident #1 expressed pain by grimacing and moaning during wound care for a Stage IV pressure ulcer on 12/18/12 (full thickness tissue loss with exposed bone, tendon or muscle) on the right heel. The Resident was not assessed for pain during the treat ment and was not given pain medication or interventions to relieve his pain and the physician was not consulted to have the opportunity to intervene and order prescription pain medication. This deficient practice had the potential to contribute to unmanaged pain, increased discomfort, decreased activity level and decreased quality of life for four (4) residents identified with pressure ulcers when staff fails to appropriately assess and intervene for pain during treatment procedures. Findings Include: Review of Resident ' s #1 face sheet reflected that he was [AGE] years old and was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the consolidated physician orders [REDACTED]. In an attempt to interview Resident #1 on 12/17/12 at 1:00 PM, Resident #1 was able to respond to hearing his name, however his speech was unclear. Resident # 1 was able to use a very limited vocabulary, verbal noises and facial expressions to make his needs known. Review of Consolidated Physician order [REDACTED]. This medication was prescribed for a [DIAGNOSES REDACTED]. Review of Comprehensive Plan of Care dated 2/15/11 reflected Resident #1 was to be receiving Restorative Nursing Care through passive and active range of motion. The plan of care was last reviewed on 9/3/12. Approach #2 of the plan of care reflected "provide pressure relieving and positioning devices - as needed". Approach #6 reflected " do not force limbs / joints. Monitor for increase weakness, stiffness, pain - inform nurse. " Approach #9 reflected "assess and document pain." Approach #10 reflected "Apap 500mg Q every 4 hours PRN." Review of Comprehensive Plan of Care dated 6/21/12 reflected Resident # 1 " complains of increased pain / discomfort and is at risk for injury from decrease in activities of daily living (ADLs) " related to joint pain. This plan of care was last reviewed on 9/3/12. Approach #1 of the plan of care reflected " Monitor for signs and symptoms of increased pain / discomfort - assess resident for possible causes, give medications, treatments, physical and relaxation modalities, ect. - assess for relief. " Review of Resident ' s #1 Annual Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had upper and lower extremity impairments to both sides. The MDS reflected Resident #1 had no observed or documented signs of pain in the 5 day look back period. Review of the Quarterly Pain Evaluations dated 1/5/12, 3/29/12 and 12/5/12 reflected [DIAGNOSES REDACTED]. The evaluations dated 1/5/12 and 3/29/12 reflected " medication administration " as " what relieves the pain/hurting " . The evaluations 3/29/12 and 12/5/12 also reflected " Range Of Motion/Mobility " as pain relieving techniques. All three evaluations reflected that Resident #1 was able to express pain through " groaning " , guarded behaviors, and facial " grimacing " . Review of Nursing Weekly/Monthly Summary dated 8/14/2012 reflected that Resident #1 had experienced generalized pain on less than a daily basis. The pain was relieved by medication and position changes. Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview on 12/18/12 at 2:35 PM Restorative Aid (RA) U stated that she had been performing 15 minutes of daily passive range of motion treatments on Resident #1's upper extremities. However had not performed any Range Of Motion (ROM) on the lower extremities in past couple of months. RA U stated that she believed that PT was still active with Resident #1 and performing ROM with him. In an interview on 12/18/12 at 3:30 PM Licensed Vocational Nurse (LVN) E stated that she not been trained on wound care or done a dressing change on Resident #1 previously. LVN E stated that she would be performing the dressing change on 12/18/12. LVN E stated that she would be assisted by Certified Nurse Aid (CNA) O to hold Resident #1' s leg. An observation on 12/18/12 at 3:35 PM revealed Resident #1 was lying on his back in bed on a low air loss mattress. Resident #1's right leg was bent at the hip and the knee due to contractures. The contracted right leg was forcing the right foot into the sheet and mattress. There were no positioning devices under the right leg to keep the foot off the bed. There was a black positioning wedge on the left side of the bed that was not being used. Resident #1 was wearing foot protectors without any heel coverings. CNA O removed the foot protector of the right foot and began holding Resident #1 ' s leg up slightly at an angle so that LVN E would be able to access the wound. After setting up her workspace and placing on gloves, LVN E cut off the bandages at 3:54 PM. The pressure ulcer was measured 10 cm x 9.5 cm (no depth measurement was taken). The pressure ulcer began at the Achilles tendon, wrapped around the heel and ended roughly in the middle of the bottom and side of the foot. At the top of the wound was a white spot described to be " fatty tissue " by LVN E. At the end of the wound was a dark spot that would not wipe off. LVN E stated it appeared to be " necrotic tissue " . This observation of the pressure ulcer presented as a Stage IV (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, tendons and supporting structures) Granulated tissue could be seen throughout wound base of the pressure ulcer. During the wound care treatment when the CNA would move the Resident's his leg and when the LVN touched his wound Resident # 1 jerked his leg in a guarding behavior, The CNA was observed at 4:07 PM to ask Resident #1 if he was in pain. Resident # 1 replied " yeah " . LVN E continued to finish the treatment and bandaged the foot and heel. At 4:20 PM CNA O was observed placing the foot protector back on Resident #1's right foot and applied the black wedge under the right leg. In an interview at the same time CNA O stated that the nurse aids are "supposed to apply the wedge but it's not always done." During this observation LVN E did not assess the Resident for pain or provide any medication before, during or after the painful wound care. Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview on 12/19/12 at 11:00 AM the Director of Nursing (DON) stated that Resident #1 does not get medication for pain related to the right heel pressure ulcer. The DON stated that she did not feel that medicating Resident #1 for the pressure ulcer treatment was the correct action. The DON stated that LVN E ' s actions during the procedure were appropriate and she should not stop in the middle of the wound care to provide pain management. The DON stated that there was no pain medication that could be provided that would work fast enough to warrant the LVN to stop the wound care procedure. In an interview on 12/20/12 at 8:10 AM, Physical Therapist W stated that Resident #1 ' s contractures were so tight that she did not believe he could be moved to a regular wheel chair even if he had been receiving active PT. Physical Therapist W stated that an order for [REDACTED]. She stated that she never felt the Resident indicated that he was in pain during her treatments and that she would " adapt and modify the treatment via positioning first " if she felt that he was in pain. She stated that proper positioning for Resident #1 ' s wound care treatment should have the resident on his side, with his leg propped and then address the heel wound. Review of the Pain Management Policy dated 8/2012 reflected " the facility recognizes the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life. The facility will evaluate and identify residents experiencing pain; evaluate the existing pain and the cause(s); determine the type and severity of the pain; and develop a Care Plan for pain management. The Care Plan is implemented and continually evaluated for its effectiveness. Staff monitors and documents the resident ' s response to pain management interventions. The goal of the Pain Management Program is that pain is identified and treated effectively and consistently. " Facility provided a list dated 12/17/12 of 4 residents with pressure ulcers.

Based on observation, interview and record review the facility failed to provide necessary treatment and services to prevent infection and new sores from developing for one (1) of three (4) residents (Resident #1) reviewed for pressure ulcers when a Stage II pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both. The lesion is superficial and presents clinically as an abrasion, blister, or shallow center) on the right heel that started on 06/2012 healed, a new Stage III pressure ulcer ( full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia and presents clinically as a deep crater with or without undermining of adjacent tissue) occurred on the right heel on 08/11/2012 and progressed to Stage IV (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, tendons and supporting structures), grew larger and deeper and became with infected on 10/18/2012. During a four month period, Resident #1 ' s right heel that was fully healed from a previous Stage ll pressure ulcer, progressed to a larger, deeper Stage IV pressure ulcer with infection by 10/18/12. This deficient practice had the potential to affect 4 residents identified with pressure ulcers by contributing to deterioration of existing pressure ulcers, infection, increased pain, tissue damage, possible loss of a limb or even death. Findings include: Review of Resident ' s #1 face sheet reflected that he was [AGE] years old and was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the consolidated physician orders [REDACTED]. In an attempt to interview Resident #1 on 12/17/12 at 1:00 PM, Resident #1 was able to respond to hearing his name, however his speech was unclear. Resident # 1 was able to use a very limited vocabulary, verbal noises and facial expressions to make his needs known. Review of Comprehensive Plan of Care dated 2/15/11 reflected Resident #1 was to be receiving restorative care through passive and active range of motion. The plan of care was last reviewed on 9/3/12. Approach #6 of the plan of care reflected " do not force limbs / joints. Monitor for increase weakness, stiffness, pain - inform nurse. " Approach #10 of the plan of care reflected that " Apap ([MEDICATION NAME]) 500 milligrams (mg) Q (every) 4 hours PRN (as needed). " Review of Physician order [REDACTED]. Healed 100 % (percent). D/C (discontinue) previous orders and D/C PT (Physical Therapy). Nursing check heels Q shift and apply Z guard to ensure epithelium matures to right heel." Review of Comprehensive Plan of Care dated 6/21/12 reflected Resident # 1 " complains of increased pain / discomfort and is at risk for injury from decrease in activities of daily living (ADLs) " related to joint pain. This plan of care was last reviewed on 9/3/12. Approach #1 of the plan of care reflected " Monitor for signs and symptoms of increased pain / discomfort - assess resident for possible causes, give medications, treatments, physical and relaxation modalities, etc. - assess for relief. " Review of Physician order [REDACTED]. " Review of Resident ' s #1 Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 was at risk for developing pressure ulcers. The MDS reflected that Resident #1 had 3 current unhealed pressure ulcers, two stage II ulcers and one stage III ulcer. The MDS reflected that none of the three ulcers were present upon admission or re-entry into the facility. The MDS reflected that the Resident required extensive assistance by two or more for bed mobility and transfers. The MDS reflected that he was incontinent of both bowel and bladder. Review of Resident #1's Pressure Ulcer Care Plan for his right heel pressure ulcer dated 8/10/12 reflected goals of "Pressure ulcer will show signs of healing" and "Pressure ulcer risk will be minimized with reduction interventions." The care plan reflected the following approaches: pressure reduction mattress in bed and in the Broda chair (specialized chair for positioning), reposition every 2 hours in bed and in the chair, provide incontinence care every 2 hours and when needed, measure and stage wound weekly, complete a full body check weekly, pressure ulcer treatment as ordered, heel protectors at all times, and utilize positioning pillows while in bed. The care plan reflected weekly measurements of the pressure ulcer: from 8/10/12 to 9/26/12 the measurement of the pressure ulcer for the right heel doubled in size, from 4 centimeter (cm) x 3.2cm x 0.2cm on 8/10/12 progressing to 8cm x 7cm (no depth measurement provided) on 9/26/12. The care plan reflected no weekly measurements from 9/26/12 to 10/15/12. The care plan reflected that the right heel pressure ulcer continued to deteriorate until it reached it maximum measurement on 11/7/12 of 9.8cm x 7cm x 1cm. Review of Physician order [REDACTED]. Change to cleanse right heel with WC (wound cleaner), pat dry, and apply santyl and [MEDICATION NAME] powder BID (two times a day) and PRN (as needed) until healed. " Review of Weekly Pressure Ulcer Record dated 8/10/12 reflected Resident #1 had a 4cm length by 3.2cm width by .2 cm depth wound to the right heel which was staged as a lll and a deterioration of the wound. Pressure Ulcer Record reflected the wound had no undermining and moderate serous exudate. Pressure Ulcer Record reflected that the wound bed was red and yellow with pink surrounding skin color that was macerated. Pressure Ulcer Record reflected that there were several interventions already in place at this time, which included a loss air loss bed mattress, pillows used as positioning devices, specialized wheelchair and heel protectors. Review of the Weekly Pressure Ulcer Record dated 9/11/12 reflected that right heel ulcer was "larger" with "odor" and response to treatment had "deteriorated". Review of Physician order [REDACTED]. " Review of Nurse's Notes dated 7/4/12 through 10/25/12 reflected no notes addressing any pressure ulcer prior to 10/19/12. Nurse's Note dated 10/19/12 reflected that physical therapy collected a swab specimen from the right heel pressure ulcer to be cultured. Nurse ' s note on 10/22/12 reflected that the right heel had gotten " worse " . The note also reflected that " an X-ray be done to rule out bone infection. " Nurse ' s Note dated 10/25/12 reflected that a new order from the physician placing Resident #1 on " [MEDICATION NAME] (antibiotic) 875 milligrams (mg) BID for six (6) weeks. " Review of Physical Therapy Evaluation dated 10/19/12 reflected Resident #1 " was on rehab for wound on right heel which was cleared on 6/6/12. Discontinued with positioning program, Range of Motion (ROM) upon discharge." The Physical Therapy Evaluation reflected that he was readmitted by nursing for wound reopening from 7/21/12. Physical Therapy Evaluation reflected Resident #1 "had reoccurrence of right heel wound that has progressed to necrotic level and has not responded to nursing treatment " . Review of Physician order [REDACTED]. Offload heel with heel protection." Review of Physician order [REDACTED]. Worsening decub. " Review of Physician order [REDACTED]. [MEDICATION NAME] 875 mg PO BID " and " 2. [MEDICATION NAME] PO Q day " In an interview on 12/18/12 at 11:35 AM regarding Resident #1's stage IV right heel pressure ulcer Physical Therapist X stated that PT had placed Resident #1's active therapy on a services hold due to his meeting the Medicare part B cap. Physical Therapist X continued to state that PT was waiting on a response from Medicare to restart his treatment. She also stated that Resident #1 has been on hold for about 10 days and during that time nursing had taken over the care of the pressure ulcer. Physical Therapist X stated that the right heel pressure ulcer is "directly related to the contractures." She continued stating that the contractures are causing Resident #1 to "dig his heels in" placing added pressure on the heel. In an interview on 12/18/12 at 2:35 PM Restorative Aid (RA) U stated that she had been performing 15 minutes of daily passive range of motion with Resident #1's upper extremities, however had not performed any ROM on his lower extremities in the past couple of months. RA U stated that she believed that PT was still active with Resident #1 and they were performing ROM with him. In an interview on 12/18/12 at 3:30 PM Licensed Vocational Nurse (LVN) E stated that she not been trained on wound care or done a dressing change on Resident #1 previously. LVN E stated that she would be performing the dressing change on 12/18/12 for the surveyors observation. LVN E stated that she would be assisted by Certified Nurse Aid (CNA) O to hold Resident #1 ' s leg. An observation on 12/18/12 at 3:35 PM revealed Resident #1 was lying on his back in bed on a low air loss mattress. Resident #1's right leg was bent at the hip and the knee due to contractures. The contracted right leg was forcing the right foot into the sheet and mattress. There were no positioning devices under the right leg to keep the foot off the bed. There was a black positioning wedge on the left side of the bed that was not being used. Resident #1 was wearing foot protectors without any heel coverings. CNA O removed the foot protector of the right foot and began holding Resident #1 ' s leg up slightly at an angle so that LVN E would be able to access the wound. After setting up her workspace and placing on gloves, LVN E cut off the bandages at 3:54 PM. The pressure ulcer was measured 10 cm x 9.5 cm (no depth measurement was taken). The pressure ulcer began at the Achilles tendon, wrapped around the heel and ended roughly in the middle of the bottom and side of the foot. At the top of the wound was a white spot described to be " fatty tissue " by LVN E. At the end of the wound was a dark spot that would not wipe off. LVN E stated it appeared to be " necrotic tissue " . This observation of the pressure ulcer presented as a Stage IV (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, tendons and supporting structures) Granulated tissue could be seen throughout wound base of the pressure ulcer. During the wound care treatment when the CNA would move the Resident's his leg and when the LVN touched his wound Resident # 1 jerked his leg in a guarding behavior, The CNA was observed at 4:07 PM to ask Resident #1 if he was in pain. Resident # 1 replied " yeah " . LVN E continued to finish the treatment and bandaged the foot and heel. At 4:20 PM CNA O was observed placing the foot protector back on Resident #1's right foot and applied the black wedge under the right leg. In an interview at the same time CNA O stated that the nurse aids are "supposed to apply the wedge but it's not always done." During this observation LVN E did not assess the Resident for pain or provide any medication before, during or after the painful wound care. Review of Resident #1's Medication Administration Record from 8/2012 through 12/2012 reflected that Resident #1 had not received any prescribed pain medication. During an interview on 12/19/12 at 9:00 AM Physical Therapist W stated Resident #1 was receiving PT for wound care only. When Resident #1 was evaluated there was necrotic tissue in the right heel pressure ulcer and the physical therapist could feel bone. Even though the PT department does not stage ulcers at the facility, Physical Therapist W stated that it would have been "staged as a stage IV pressure ulcer." Resident #1 had an ulcer on the same heel earlier in the year that physical therapy "fully healed." Physical Therapist W stated Resident #1's right heel "just became bad all at once". She also stated that Resident #1's right heel pressure ulcer may not fully heal again. Physical Therapist W stated that the resident's contractures played a part in the reoccurring pressure ulcer. An observation of Resident #1 sitting in a Broda chair in the living room on 12/19/12 at 9:30 AM revealed Resident #1' s right bandaged heel was resting on a metal bar allowing the heel to press against the bar. Resident #1 was wearing foot protectors with the heel cut out, therefore there was no protection for the heel. An observation of Resident #1 sitting in a Broda chair next to the nurses' station on 12/19/12 at 10:45 AM revealed that his right foot was slightly bent resting on the foot rest. there was no pressure relieving device under the resident's foot. The right heel bandage covering the pressure ulcer had a reddish-brown coloring around the heel and bottom of the foot, which appeared to be blood. Interview on 12/19/12 at 11:00 AM the Director of Nursing (DON) stated blood on the bandage would indicate there was healthy tissue underneath the bandage. The DON stated that when a wound is noticed nursing takes primary care of that wound. It is not until 30 days of the wound not healing or "the wound cannot be handled by nursing", that orders for PT are received to evaluate and perform treatment on the wound. The wound on Resident #1's heel was caused by pressure and shearing related to the residents contractures. Resident #1's pressure ulcer had progressed to a stage IV pressure ulcer before the orders for PT were obtained on 10/19/12. In an interview on 12/20/12 at 8:10 AM, Physical Therapist W stated that PT had readmitted Resident #1 for wound care that morning. She stated that she had added a pad to the bar where Resident #1 ' s contracted foot was pushing against the Broda chair. Physical Therapist W stated that Resident #1 ' s contractures were so tight that she did not believe he could be moved to a regular wheel chair even if he had been receiving active PT. She stated that she felt that just getting Resident #1 up in the broda chair was passive therapy for him. Physical Therapist W stated that an order for [REDACTED]. She stated that Resident #1 did not need to be on any pain medication because she felt the medication would just sedate him. She stated that she never felt the resident indicated that he was in pain during her treatments and that she would " adapt and modify the treatment via positioning first " if she felt that he was in pain. Physical Therapist W stated that she was continually evaluating the resident for pain during treatments. She stated that she assesses for pain by watching for facial expressions on non-cognitively intact residents. She stated that proper positioning for Resident #1 ' s wound care treatment should have the resident on his side, with his leg propped and then address the heel wound. Physical Therapist W stated that she did not believe nurses needed to be trained to do treatments for wounds. She further stated that nurses should be able to look at a MAR and know how to perform a treatment. . Review of Skin Management Policy dated 8/2012 reflected: The Overview : "residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes." Stage III and Stage IV Pressure Ulcer Suggested Interventions 6. Assess the resident for pain related to pressure ulcer during turning, positioning, dressing changes, and debridement. Provide [MEDICATION NAME] as needed and appropriate. 7. All shearing and friction to body surfaces are minimized, ideally eliminated. Facility provided a list of 4 residents with pressure ulcers, dated 12/17/12.