Every finding on record at Avir at Stephenville

Based on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 6 (07/30/2026, 08/10/2026, 08/11/2026, 08/14/2026, 08/15/2026, and 08/16/2026) of 30 days (07/21/2026 - 08/20/2026) reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 07/30/2026, 08/10/2026, 08/11/2026, 08/14/2026, 08/15/2026, and 08/16/2026. This failure leaves residents without the nursing administrative oversight that only the DON can provide. Findings included: Record review of facility document titled, daily nurse staffing, dated 07/30/2026, reflected a daily census of 70. Record review of facility document titled, daily nurse staffing, dated 08/10/2026, reflected a daily census of 69. Record review of facility document titled, daily nurse staffing, dated 08/11/2026, reflected a daily census of 69. Record review of facility document titled, daily nurse staffing, dated 08/14/2026, reflected a daily census of 71. Record review of facility document titled, daily nurse staffing, dated 08/15/2026, reflected a daily census of 72. Record review of facility document titled, daily nurse staffing, dated 08/16/2026, reflected a daily census of 72. During an interview on 08/20/2026 at 10:54 a.m., the DON stated she did not know she was not supposed to be working on the floor if the resident census was over 60. She stated the ADON was working nights, and she had to fill in due to night nurses being sick or on vacation. She stated patient care came first in her mind, and it may have caused her to not be able to do the DON work efficiently, but she did not feel any negative outcome had occurred to the residents from her working on the floor. She stated she worked as a charge nurse the night of 07/30/2026 from 2 a.m. to 6.a.m., the night of 08/10/2026 from 6 p.m. to 6 a.m., the night of 08/11/2026 from 6 p.m. to 6 a.m., the day of 08/14/2026 from 6 a.m. to 6 p.m., the day of 08/15/2026 from 6 a.m. to 6 p.m., and the day of 08/16/2026 from 6 a.m. to 6 p.m. The DON stated she was a salary employee and did not clock-in or clock-out. During an interview on 08/20/2026 at 1:55 p.m., the ADMN stated she did not expect her DON to work on the floor and nurses had since been hired so she would not have to. She stated she and the DON share a combination of responsibility for nursing schedules. She stated she monitored the DON schedule and was involved in all nurse schedules. She stated the negative effect for the DON working on the floor would be the inability to monitor the LVNs and nursing staff. Record review of facility policy titled, Staffing, Sufficient and Competent Nursing, dated August 2022, reflected The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents.

Based on observation, interview and record review, the facility must not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 3 of 12 (NA-A, NA-B, & NA-C) non-certified nurse aides reviewed. The facility failed to ensure full-time NA-A, NA-B, and NA-C were certified within four months of the date of hire.This failure placed residents at risk of receiving inappropriate care from an individual whose skill level was not known.Findings included:Record review of the facility's employee files reflected NA-A was hired on 11/24/2025, NA-B was hired on 11/24/2025, and NA-C was hired on 2/26/2026 as non-certified nurse aides. Further review reflected NA-A filled out employment application for full-time NA position on 11/20/2025, NA-B filled out employment application for full-time laundry position on 11/24/1993, NA-C filled out employment application for NA position on 02/24/2026. Record review of the facility's job descriptions for nurse aides reflected:-NA-A signed on 03/31/2026,-NA-B signed on 08/19/2026, and -NA-C signed on 02/27/2026.Further review of the NA job descriptions reflected no evidence that NAs needed certification within a timeframe.During an observation and interview on 08/18/2026 at 2:30 p.m., NA-B was working on hall in the facility. NA-B stated she started working as a full-time NA in March of 2026. She stated she was not certified but was working on getting her certification. She stated she had been certified as a nurse aide in the past but had let the certification lapse and she was waiting on a letter to let her know when and where to go for the exam to be certified as a nurse aide again. She stated she performed incontinent care, showers, and transfers of residents.During an observation and interview on 08/18/2026 at 2:55 p.m., NA-C was working on a hall in the facility. NA-C was seen leaving a resident room with a plastic bag of soiled trash and she disposed of the trash and washed her hands in room with lined trash bins and sink. She stated she had been working in the facility as a full-time nurse aide since February of 2026. She stated she performed incontinent care alone but would need assistance of a certified nurse aide to perform showers, and transfers. She stated she was waiting for the exam to be certified and there was an issue with the documents submitted not being notarized which delayed her exam. She stated she went through the nurse aide course at the facility and had taken the written test. She stated she may have been told she needed to be certified within a certain time frame but could not remember how long she had to be certified to continue to work as a nurse aide.During an observation and interview on 08/19/2026 at 2:55 p.m. NA-A was observed working on a hall in the facility. She stated she originally started in the facility as a NA in November of 2025. She stated she then left and came back to work in the facility in May of 2026. She stated she went to another facility as a nurse aide in between working at this facility. She stated had gone through the clinical course at this facility and had taken the written test. She stated she was going for her certification exam on Friday 08/21/2026. She stated she performed feeding assistance and she could change linens on beds alone. She stated she performed showers, incontinent care and transfers with another certified nurse aide. During an interview on 08/19/2026 at 3:35 p.m., the ADMN stated she had noticed there were uncertified staff members including the nurse aides hired before she became the Administrator in May of 2026. She stated she initiated the nurse aides to start the NATCEP course in the facility with an instructor from another town at that time. She stated the nurse aides that had been hired since she had started were given 30 days to get their certification. She stated her expectation would be for the regulation to be followed and the facility did not have a policy for NA certification. She stated the issue started before she was hired and did not have an explanation for why they were not certified. She stated there was a potential for residents to not receive competent care because the NAs did not get their certification within 120 days from hire. During an interview on 08/19/2026 at 4:47 p.m., the DON stated her expectation was for NAs to be certified within 90 days of hire. She stated she did not know why the NAs were not certified within that time frame for NA-A, NA-B, and NA-C because they were hired before she became the DON. She stated the facility had several DONs since she was hired in December of 2025 as a charge nurse. She stated she then became the ADON and recently became the DON. She stated NAs should be certified and there was a potential for residents to have negative outcomes from receiving care performed by nurse aides that were not certified. During an interview on 08/20/2026 at 10:45 a.m., the HR stated she had worked in the facility as HR since 2023. She stated the job descriptions should be signed during onboarding of new hires and did not know why NA-B's job description was not signed prior to yesterday. She stated she had sent NA-B the job description to be signed in July of 2026 but it was not signed until yesterday after she reminded NA-B to sign it. She stated NA-B started originally in the laundry department and was moved to full time NA on 03/15/2026. She stated NA-A was originally hired on 11/24/2025 and termed on 01/05/2026. She stated NA-A was rehired on 03/12/2026 as a full time NA. She stated NA-C was also hired as a full time NA. She stated she would collect the job applications and the ADON, DON, and ADMN would have her ask the applicants to come in for an interview to decide if the applicant was qualified for the position. She stated the ADON, DON, and ADMN would let her know who they approved so that she could send out the employment offer and get the applicant set up for orientation. She stated she performed the new hire orientation, and she would tell the NAs at that time that they needed to become certified within 120 days. She stated she also would set up the NAs for the NATCEP 60-hour course for them to complete within 30 days of hire. She stated the previous ADON, who no longer worked for the company, was responsible for making sure the NAs were certified within 120 days. She stated after she had gotten the NAs oriented, she would provide documents when asked to the ADON but did not monitor that the NAs became certified. She stated now, the ADMN was monitoring. The HR stated NA-A, NA-B, and NA-C were hired prior to the ADMN starting her position but now the ADMN was working on getting all the NAs certified.Record review of facility policy titled, Staffing, Sufficient and Competent Nursing, dated August 2022, reflected 4. Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities. 5. Competency requirements and training for nursing staff are established and monitor by nursing leadership with input from the medical director. Further review reflected no evidence about time frame a full-time NA needed to be certified. At the time of exit on 08/20/2026 at 2:15 p.m., the requested policy for NA certification was not provided by the ADMN or the DON. NA certification policy was requested on 08/19/2026 at 3:21 p.m.

Based on observation, interview, and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity director for 1 of 1 (activities staff) reviewed for staff qualifications. The facility failed on 08/18/2026 to ensure the activities director (AD) hired 04/09/2026 had completed State approved training to direct facility activities. This failure could place residents who participated in facility activities at risk of physiological, psychological, social, and spiritual harm by receiving services from unlicensed personnel.Findings included: Record review of the AD's employee file on 08/19/2026 at 4:40 p.m. revealed hire date of 04/09/2026. Review of Employment Application for Activity Director, was signed on 04/09/2026 by AD. No evidence of the AD had taken an Activity Director course prior to applying for the position. Review of Activities Director Job Description, was signed by AD on 04/16/2026. Further review reflected no evidence of a certification requirement needed for AD in job description. Record review of facility's grievance log, dated 07/09/2026, reflected multiple residents were unhappy they were not getting to do many activities, they were not receiving the daily news, and they did not have a July 4th parade this year. During an interview on 08/18/2026 at 12:17 p.m., Resident #7 stated he was upset the new activities director had changed the out of facility store runs to once a month and before they were twice a week. He stated he did not go to any of the activities. He stated he wanted a mobile library because he liked to read books and the activities director stated she would get the residents a mobile library. He stated that had not occurred yet. During an observation conducted on 08/18/2026 at 2:10 p.m. there were multiple residents in the dining room playing Bingo. The AD was in the dining room initiating the game. During an interview on 08/19/2026 at 2:32 p.m., the AD stated her experience was from an ALF and she did not need to be certified for that position. She stated her current position had been a little new regarding certifications. She stated she was finishing up her certification at that exact moment, and it would be completed on 08/29/2026. She stated she had a variety of activities that the residents could do themselves or she would provide. She stated the bible study was not provided by her, but a church came in to provide or the residents would provide for themselves. During an interview on 08/19/2026 at 3:35 p.m., the ADMN stated she initiated the training for the AD. She stated she was passionate about residents getting correct activities and she was working with the AD by going over the activity calendar with her. She stated they were implementing new activities so that residents could leave the facility. She stated not having a certified AD could lead to the residents not receiving appropriate activities. She stated the facility did not have a policy about Activity Director certification and she expected for the regulation to be followed. During an interview on 08/20/2026 at 10:45 a.m., HR stated the ADMN was who did interviews and hired the department heads including the AD. She stated she was unsure if the AD had to be certified and that she had given the AD the information about the course the previous AD had taken to become certified. She stated she kept asking the AD for her certification, but the AD had not provided it. The HR stated the AD was in a course and she had until 08/29/2026 to complete it. She stated the ADMN knew the AD was not certified but the AD was hired by the previous ADMN. The HR stated the ADMN monitored employees that were hired for appropriate certifications. She stated the AD not having certification could lead to the AD not doing the job at the upmost potential. At the time of exit on 08/20/2026 at 2:15 p.m., the requested policy for Activity Director Training was not provided by the ADMN. AD policy for Activity Director Training was requested on 08/19/2026 at 3:21 p.m.

Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for one (Resident # 9) of two residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting For resident #9. This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #9's face sheet dated 6/4/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: autistic disorder (a condition related to brain development that affects how people see others and socialize with them), unsteadiness on feet, bipolar disorder severe and depressed with psychotic symptoms ( a mental condition that affects a person's mood, energy, activity, and thought, and is characterized by hallucinations and delusions), skin picking disorder (a mental health condition characterized by compulsive skin picking that can lead to significant physical and emotional distress), other lack of coordination (trouble controlling body movements), scoliosis (an abnormal curve of the spine), profound intellectual disabilities (significant limitations in mental functioning and daily living skills), and epilepsy, unspecified (a seizure disorder). Record review of Resident #9's quarterly MDS assessment dated [DATE] revealed no BIMS score was noted but was marked as severely impaired under the cognitive skills for daily decision making. Record review of Resident # 9's PASRR Level 1 Screening Summary dated 10/16/24 revealed a positive response for a known or suspected diagnosis of intellectual disability, mental illness and developmental disability. Record review of Resident # 9's PASRR Evaluation dated 10/17/24 revealed he was identified as having an intellectual disability and requires specialized services. Record review of Resident # 9's quarterly MDS assessment dated [DATE] revealed no BIMS score was noted but was marked as moderately impaired under the cognitive skills for daily decision making. Record review of Resident # 9's PASRR Evaluation dated 11/20/25 revealed he was identified as having an intellectual disability and requires specialized services. Record review of Resident #4's PCSP dated 2/25/26 revealed IDT meeting held on 2/25/2026. Attendees included the resident, the PASRR habilitation coordinator, a social worker, PTA, DOR/COTA, MDS Nurse, PTA and nursing facility representatives. The following NFSS were identified and confirmed: Specialized Occupational Therapy Assessment, Specialized Occupational Therapy, Specialized Speech Therapy Assessment and Specialized Speech Therapy, Specialized Physical Therapy Assessment and Specialized Physical Therapy. During an interview on 6/5/26 at 1:00 pm, the DOR stated the NFSS for Resident #4 was not submitted. The DOR stated she was previously unaware of her responsibility to submit the NFSS and the assessments into the long -term care portal for approval. She stated she was not familiar with the PASARR Specialized Services Process and she did not submit the paperwork in simple because she thought the LIDDA took care of things from her end. She stated Resident #4 could have a decrease in his quality of Life or functional status from not having his services initiated in a timely manner. She stated that Resident # 4 had Speech Therapy, Occupational Therapy and Physical Therapy Services ordered at the facility during the time since his meeting with the IDT, so he had not suffered a negative outcome. During an interview on 6/5/26 at 1:10 pm, the SW stated she had never worked in long term care before. She stated she is not sure what her responsibility is as far as arranging services that the IDT decided upon through NFSS. She stated she needed more training on the process and her role in obtaining and coordinating services and failure to complete the NFSS in a timely manner could prevent the resident from receiving PASSR Services in a timely manner and lead to a decline in his quality of life. During an interview on 6/5/26 at 1:27 pm, the Administrator stated she was familiar with the PASRR process and that the NFSS is completed by the DOR and should be submitted within 20 days. The Administrator stated the facility had had a transition to a new company and she had only been employed at this facility for a short time. She stated it would be her expectation that the Social Worker and the DOR would attend and schedule the IDT meeting and submit the necessary paperwork for the NFSS services decided upon within the appropriate times. Review of the policy titled PASRR, dated 1/20/26 stated in part: Purpose -The aim of the PASRR program is to identify residents with Mental Illness (MI),Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) andto ensure they are properly placed, whether in community or in a Nursing Facility (NF)and to ensure they receive the services they require for their MI, or ID/DD. The IDT Meeting Process The Social Worker or designee must contact the LIDDA/LMHA to schedule anIDT meeting within two calendar days of resident admission. The facility must convene the IDT meeting within fourteen calendar days of admission. The IDT must be composed of a team that includes the resident, the residentslegally authorized representative if any, an RN a representative of LIDDA/LMHA,if the resident is on hospice, the hospice nurse, and other persons as needed. The IDT will review and discuss the recommended Specialized Services on thePE and come to an agreement on which specialized services the resident needs. The IDT will identify the most appropriate entity to provide those services and willfollow-up to ensure they are provided to the resident. Post IDT Meeting Responsibilities Once the IDT makes its determinations about specialized care, the facility will;1. Include all specialized services and support activities in the residentscomprehensive plan of care and provide a copy to the LA.2. The facility will initiate the request for specialized services within twentybusiness days of the IDT meeting, implement Specialized Servicestherapy within three business days after receiving approval from HHSC inthe online portal and order CMWC and/or DME within five business daysof receiving approval from HHSC in the online portal.3. The MDS Coordinator or designee will document the IDT minutes and allspecialized services into the online portal on the PCSP within three business days after the IDT meeting and annually thereafter. Record review of state agency website https://www.hhs.texas.gov/regulations/forms/2000-2999/form-2362-receipt-certification-a-qualified-rehabilitation-professional revealed the following in part: Requesting Habilitative Services: A speech, occupational or physical therapist may request habilitative therapies (physical, occupational or speech therapy) for a PASRR-positive person for up to 6 months at a time. Requests for Authorization of Specialized Services for Residents of Nursing Facilities Requesting Authorization of Habilitative Physical, Occupational or Speech Therapy. To request Habilitative therapies, nursing facility providers must submit a Nursing Facility Specialized Service (NFSS) form on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. Additionally, each request must be accompanied by corresponding signature sheets or other attachments. A licensed therapist must complete and submit the following for each type of habilitative therapy service requested. New Request: New (Submit initial assessment). An initial therapy assessment completed by a licensed therapist is required. The service request must include a treatment plan. PASRR NF Specialized Services (NFSS) - Therapy Signature Page (for Therapist, Referring Physician and Nursing Facility Administrator signatures).

Based on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 1 of 5 residents (Resident #4) reviewed for pharmaceutical services, in that: The facility failed to reorder medication for Resident #4 before his supply was depleted. These failures could place residents who receive medications at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications. The findings included: Record review of Resident #4's face sheet dated 6/5/26, revealed a [AGE] year-old male initially admitted on [DATE] with the following diagnoses: bladder disorder (a condition of the bladder that affects how the bladder stores or releases urine), UTI (an infection involving the bladder and kidneys) Record review of Resident #4's Quarterly MDS dated [DATE] revealed Section-C Cognitive Patterns Resident #4 had a BIMS score of 15, which meant he was cognitively intact. Section H revealed he was always continent of bladder and occasionally incontinent of bowel. Record review of Resident #4's physician orders revealed Gemtesa Oral Tablet 75 MG (Vibegron) Give 1 tablet.by mouth at bedtime related to bladder disorder dated 05/18/26. Record review of the medication administration record on 06/05/2025 at 3:30 PM for revealed Resident # 4 did not receive his Gemtesa on 6/2/26, or on 6/3/26 . Review of the Care Plan revised 4/12/26 for Resident #4 revealed, focus: has an overactive bladder and has a history of UTI's (urinary tract infections).Goal: Resident #4 will be continent during waking hours through the review date. Interventions: Administer medications as ordered. (Gemtesa and D-Mannose) Ensure Resident #4 has an unobstructed path to the bathroom. Record review of the Nursing progress notes written by LVN #1 dated 6/3/26 at 5:07 PM revealed: This nurse was made aware of the medication Gemtesa being unavailable from the Pharmacy. This nurse contacted the pharmacy to request a refill of the above-mentioned medication. This nurse was informed that the insurance would no longer cover the Gemtesa and to have it filled the facility would have to sign a facility authorization to bill form. This nurse spoke with the administrator and the form to bill the facility was filled out and faxed to the pharmacy. This nurse then followed up with the pharmacist to attempt to have the medication STAT delivered but the pharmacist stated, The delivery manager said he would be unable to schedule a STAT delivery for today or any day this week due to an influx of 20 facilities on their route. This nurse communicated all this to the physician, the administrator, and to [Resident #4] No new orders at this time. [Resident #4] verbalized gratitude for getting the medication filled. During an Interview on 6/3/26 at 1:00 PM Resident #4 stated that he had not received his medication for his overactive bladder for several days. He stated he was not aware of how long he had gone without the medication, but he thought the medication was not working because he had to urinate so much. He stated the ADON told him that they were out of the Medication on 6/3/26 and he had not received it. He stated he just wanted his medication because he needs it. During an Interview with the ADON at 4:00 PM on 6/3/26, she stated she had not given the Resident his Gemtesa because there was no medication in the cart. She stated the medication should have been reordered before the supply was exhausted. She stated she notified LVN #1 that the medication was not available so he could contact the pharmacy and reorder it. She stated that failing to administer the medication when the medication was ordered and not notifying the physician that it was not available could have caused an adverse effect for the residents. The resident could have had an increase in his overactive bladder symptoms and not received the appropriate treatment that he needed. During an interview with LVN #1 at 4:30 PM on 6/3/26 he stated he was not aware until today that Resident #4 had missed doses of his Gemtesa. He stated he would address the matter, contact the pharmacy, and make any necessary treatment changes if indicated. He stated he would notify the pharmacy and the physician. In an interview with the Administrator on 6/3/2026 at 5:00 PM, the DON reported she expected Gemtessa to be ordered when the last dose is used, and her expectation was that residents should not run out of their medications. She stated that there were medications in the emergency kit that could be administered, but due to the price of the Gemtesa, it was not a medication that was available in the emergency kit. She stated failure to receive medication as ordered could be detrimental to a resident's health. She confirmed the medication could not be found and stated it had been re-ordered today. She stated she believed the failure occurred because there was a lack of communication between the Day shift and the night shift. Record Review of the Policy titled medication Administration, dated revised April 2019 stated in part: Medications are administered in accordance with prescriber orders, including any required time frame.Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:enhancing optimal therapeutic effect of the medication.preventing potential medication or food interactions; andhonoring resident choices and preferences, consistent with his or her care plan.Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and the need for additional staff training.Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 1 of 4 residents (Resident #406) reviewed for medication consents. The facility failed to ensure Resident #406 or their representative signed consent for hormone medication medroxyprogesterone acetate (Provera) (a female hormone prescribed to women to prevent pregnancy, hormone replacement therapy and management of abnormal uterine bleeding. When prescribed to men, the medication reduced testosterone levels, lowering sexual drive) prior to administering the medication. This failure could affect residents by placing them at risk of not being informed of their health status, which would allow them to make informed decisions regarding their care.Findings include: Record review of Resident #406's electronic face sheet, dated 03/25/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #406 had a medical diagnosis of bipolar disorder (a chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels). Record review of Resident #406's Quarterly MDS, dated [DATE], revealed in Section C - Cognitive Patters, subsection C0500. BIMS Summary Score, of 15 out of 15 indicating intact cognition. Record review of Resident #406's comprehensive care plan, dated 03/25/2026, revealed no sexual behaviors were identified and/or addressed. Record review of Resident #406's electronic physician orders revealed Resident #406 was prescribed Provera 5 mg daily by mouth for sexual behaviors on 03/23/2026. The order was entered by the NP. Record review of Resident #406's MAR, dated March 2026, reflected Resident #406 received Provera 5 mg daily on 03/23/2026 and 03/24/2026 at 9:00 p.m. Record review of Resident #406's electronic medical chart, accessed on 03/25/2026, reflected no evidence he consented to Provera prior to receiving the medication starting on March 23, 2026, using HHSC Form 3713. Record review of Resident #406 Progress Notes, Psychiatric Periodic Evaluation dated 03/23/2026: This is a [AGE] year-old male resident was evaluated at staff request for a periodic psychiatric assessment due to reports of worsening depression and anxiety. Staff report intermittent episodes of hypersexual and inappropriate sexual behavior; however, these behaviors are not persistent and remain manageable with redirection. A comprehensive review of the medical record was completed. In response to ongoing depressive and anxiety symptoms, escitalopram (Lexapro) 10 mg orally daily was discontinued, and paroxetine [Paxil, an antidepressant] 20 mg orally daily was initiated. Record review Resident #406's progress notes dated 3/24/2026 at 06:10 a.m., Note Text: Resident started on Provera and Paroxetine. Educated resident on medications and provided printed information at resident request. Will monitor for adverse/allergic reactions x 3 days. Progress note entered by LVN-A. During an interview on 03/25/2026 at 8:55 a.m., the NP stated Resident #406 had a history of watching pornographic videos all day on his television and masturbating. She stated Resident #406 would not stop the activity or turn off the television when staff entered the room. She stated staff that was aware of these behaviors always knocked and waited for residents' permission before entering. She explained when she recently ordered a urinalysis for a suspected urinary tract infection, the first sample provided by the resident was nothing but semen. Observation and interview on 03/25/2026 at 12:31 p.m., Resident #406 was in the hall outside of the conference room discussing the new medication orders with RN-A. RN-A stated she was not aware of the Provera order. Resident #406 then came into the conference room with the generic name of Provera written down. Resident #406 stated the case manager from MHMR told him during a visit earlier in the day that he had been prescribed the medication without his knowledge. He stated he did not sign consent for Provera. Resident #406 stated he was not going to take the Provera I don't need anything for my sex drive. I don't even have a girlfriend in this place. During an interview on 03/252026 at 12:41 p.m., the DON stated the prescriber was responsible for obtaining the signed consent. Requested signed consents from DON for Resident #406 Paxil and Provera. During an interview and record review on 03/25/2026 at 12:43 p.m., the DON provided signed consent for Paxil but stated she did not have a signed consent for Provera. She stated Resident #406 informed her he was not going to take Provera, so she was going to discontinue it. During an interview on 03/27/2026 at 8:40 a.m., the DON stated she talked with Resident #406 yesterday about his concerns with signed consent. She stated Resident #406 threatened to take my nursing license. During an interview on 03/27/2026 at 8:55 a.m., Resident #406 stated he wanted to talk about this hormone thing. He stated he asked the NP 2 days ago and she told him she did not order the hormone, the psychiatric (psych) physician ordered it. He stated the psych physician talked to the nurses and NP about his behaviors. Resident #406 explained that the psych physician showed him the changes he was making to his medications and a hormone was not mentioned. He stated he had a night nurse look up the order to see who ordered the hormone and was told the NP ordered it. Resident #406 denied any adverse reactions to taking 2 doses of the hormone. During a phone interview on 03/27/2026 at 10:57 a.m., the psych physician stated he visited Resident #406 on 03/23/2026 at the facility. He stated he did not prescribe Provera. The physician stated he talked to the resident, educated him on the antidepressant prescribed, and briefly talked about the Provera prescribed by the NP. He stated the resident's response was whatever you think is appropriate, you are the professional and know what is best. The physician stated he did not obtain signed consents, the facility was responsible for obtaining a signed consent form. During an interview on 03/27/2026 at 11:21 a.m., the ADON stated the nurse that took the order was responsible for obtaining signed consent. She explained if the nurse was unable to get the resident to sign a consent, the nurse should ask one of us to get the resident to sign the form. The facility was unable to provide a policy on obtaining written consent to administer medication.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #5, Resident #20 and Resident #53) reviewed for care plans in that: The facility failed to ensure Resident #5 had a care plan in place for use of a mechanical lift.The facility failed to ensure Resident #20 had a care plan in place for use of a mechanical lift.The facility failed to ensure Resident #53 had a care plan in place for hospice services. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs safely.The findings included the following:Resident #5Review of Resident #5's Resident Face Sheet dated 07/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of heart failure, type 2 diabetes mellitus, stage 4 (an ulcer that extends through the muscle) pressure ulcer, peripheral vascular disease (insufficient blood circulation to the arms and legs), dementia, difficulty sleeping, anxiety, gout (a type of arthritis), major depressive disorder, amputation of left foot, weakness, iron deficiency, high blood pressure, alcohol abuse, nicotine dependence, and nausea. Review of Resident #5's Quarterly MDS assessment dated [DATE], Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #5 scored 15 out of 15 indicating intact cognition. Section GG - Functional Abilities, subsection GG0110 Prior Device Use C. Mechanical Lift was not selected. Record review of Resident #5's Comprehensive Care Plan reviewed/revised 07/22/2025 did not include use of a mechanical lift for transfers as a focus of care or intervention. During an interview and observation on 07/23/2025 at 10:10 AM, Resident #5 was sitting in his wheelchair in the dining room. Noted mechanical lift sling under the resident. Resident stated the staff got him out of bed using the mechanical lift due to his inability to bear weight related to the amputation of his left foot and his size. Resident #20Review of Resident #20's Resident Face Sheet dated 07/24/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of heart failure, high blood pressure, obesity, anxiety, major depressive disorder, atrial fibrillation, enlarged heart, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), gastrointestinal (stomach and intestine) bleeding, chronic pulmonary embolism (blood clot in the lung), nerve pain, difficulty with coordination, and respiratory failure. Review of Resident #20's admission MDS Assessment, dated 05/05/2025, Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #20 scored 15 out of 15 indicating intact cognition. Section GG - Functional Abilities, subsection GG0110 Prior Device Use C. Mechanical Lift was not selected. Record review of Resident #20's Comprehensive Care Plan reviewed/revised 06/09/2025 did not include use of a mechanical lift for transfers as a focus of care or intervention. During an interview on 07/23/2025 at 6:34 AM, Resident #20 stated the staffed used a mechanical lift to transfer her from the bed to a chair and back again. Resident #53Review of Resident #53's electronic face sheet dated 07/24/2025, revealed an [AGE] year-old female admitted to the facility on [DATE] and to hospice services on 07/01/2025 with diagnoses to include: Alzheimer's, kidney disease, and urinary tract infection. Review of Resident #53's Quarterly MDS dated [DATE], revealed a BIMS score of 03 out of 15 which indicated severe cognitive impairment. Review of Section O - Special Treatments, Procedures, and Programs, subsection O0110, item K1 Hospice Care, column b. While a Resident was selected. Review of Resident #53's electronic Physicians Orders dated 07/01/2025 revealed: Resident has hospice services for diagnoses of Alzheimer's Disease. Review of Resident #53's Comprehensive Care Plan last review completed 03/07/2025, revealed no evidence of resident being on hospice services. During an interview on 07/24/2025 at 12:50 PM, the DON stated use of a mechanical lift to transfer residents should be on the comprehensive resident centered care plan. She stated the facility did not have a policy that she was aware of that specifically addressed requiring a physician's order for a mechanical lift or for inclusion of the mechanical lift on the care plan. The DON stated one possible reason for the failure to include use of a mechanical lift on care plan was due to all the changes the facility had been going through. She stated creation of the care plans was a joint effort that included the medical director, MDS Coordinator and DON. She stated her expectations were for an order to be obtained and the residents care plans updated. The DON stated training was a work in progress with the newly hired leadership team. She stated possible consequences of failing to include use of a mechanical lift on a care plan was that she felt care planning provided residents with a list of expectations, gave residents a voice to convey their concerns, needs and wants. Failing to include the use of a mechanical lift did not give residents a complete list of the care they should expect to receive from the facility or an opportunity to state their preferences. During an interview on 07/24/2025 at 1:00 PM, the RNC stated the reason for the failure to include the use of mechanical lifts on resident care plans was due to the recent turnover in the facility. She stated she did not consider the lack of a physician's order of any consequence to the residents. She stated the care plan was a communication tool but was rarely utilized by the staff. The RNC stated she felt there would be no repercussions related to the failure to care plan the use of a mechanical lift. The facility provided policies titled Activities of Daily Living (ADL), Supporting and Lifting Machine, Using a Mechanical. These policies did not address obtaining a physician's order to use a mechanical lift or including the use of a mechanical lift on the care plan.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 (Resident #53) of 4 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included:*the certificate of terminal illness and the hospice election form; *how the communication will be documented between the facility and the hospice provider; and *the physician certification and recertification of the terminal illness. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Review of Resident #53's electronic face sheet dated 07/24/2025, revealed an [AGE] year-old female admitted to the facility on [DATE] and to hospice services on 07/01/2025 with diagnoses to include: Alzheimer's, kidney disease, and urinary tract infection. Review of Resident #53's Quarterly MDS dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. Review of Section O: revealed Resident #53 was on hospice care. Review of Resident #53's Comprehensive Care Plan last review completed 03/07/2025, revealed no evidence of resident being on hospice services. Review of Resident #53's electronic Physicians Orders revealed: Resident has hospice services for diagnoses of Alzheimer's Disease, dated 07/01/2025. Review of Resident #53's clinical records from 02/24/2025 to 07/24/2025, revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness, hospice election form, or any form of communication between the facility and the hospice provider for Resident #53. During an interview on 07/24/2025 at 12:21 PM, the DON stated communication between hospice staff and facility staff was done verbally. She stated communication forms should be filled out daily to ensure that everyone was aware and the residents' status and care concerns. She stated the communication sheet should be filled out and she did not know why this was not being done. She stated the facility should have a copy of the election form and the certification of terminal illness. She stated it was her responsibility to ensure that the required documents were in the facility. Review of facility policy titled, Hospice Program, revised July 2017, revealed in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation . 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual residents' needs. These responsibilities include the following .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .12. Our facility is responsible for a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process. B. Communicating with hospice representatives and other healthcare providers participating on the provision of care .d. Obtaining the following information from the hospice . 3.) Physician certification of the terminal illness specific to each resident.

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 (CNA-A, CNA-B, and CNA-C) staff observed during incontinent care. The facility failed to ensure that staff (CNA-A, CNA-B and CNA-C) performed proper peri-care (incontinent care) for Resident #1 and Resident #2. These failures placed residents of the facility at risk of infections from incontinent care. Findings included: Resident #1 Record Review of resident #1's Face Sheet dated 01/10/2025 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on 06/15/2022. Review of Resident #28's diagnoses revealed: Hypertension (high blood pressure), and Lack of coordination. Record review of Resident # 1's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 06 (severe cognitively impairment). Section H-Bladder and Bowel, resident always incontinent. During an observation on 04/08/2025 at 2:35 PM, CNA-A and CNA-C performed peri-care for Resident #2. CNA-A folded each wipe and reused the folded wipe on the resident. CNA-A also did not pull back and clean the resident's foreskin while performing pericare. During an interview on 04/08/2025 at 2:55 PM, CNA-A stated she had not performed pericare correctly because she folded the wipes and reused. She stated she also had not pulled back the resident foreskin and cleaned it incorrectly. CNA-A stated in not doing so could have caused buildup and lead to an infection. During an interview on 04/08/2025 at 3:00 PM, the DON stated, pericare should have been performed using one wipe, one swipe technique. She stated the wipes were not to be folded. The DON stated pericare should have begun with pulling back the foreskin of the resident and in not doing so, could have resulted with a resident infection. Resident #2 Record Review of resident #2's Face Sheet dated 06/14/2024 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on 12/21/2020. Review of Resident #2's diagnoses revealed: Diabetes Mellitus, Generalized edema (swelling), Peripheral vascular disease, and noncompliance. Record review of Resident # 2's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact). Section H-Bladder and Bowel, resident always incontinent. During an observation on 04/08/2025 at 4:19 PM, CNA-A and CNA-B performed pericare for Resident #2 and began from back to front of resident. During an interview on 04/08/2025 at 4:45 PM, the DON stated, for male residents that were uncircumcised, staff should have pulled the foreskin back and clean and returning the foreskin afterward. She stated she had trained her staff to use the one wipe, one swipe method for all residents. She stated all pericare should have begun from front to back. The DON state it was the DON who monitored with random checkoffs and quarterly. She stated the negative impact of not having pulled back the foreskin and not having performed the one wipe one swipe on residents was possibly infection and a possible uti (urinary tract infection). She stated biggest concern for her was the foreskin not being retracted and could have caused a significant infection. The DON stated she in serviced the staff on pericare just a couple of weeks ago. She stated her expectations was for staff to perform pericare correctly every time whether they was being watched or not. The DON stated the failure occurred the with the staff not having followed the policy on how pericare was to be provided. Record review of the CNA-A, CNA-B, and CNA'C's Pericare competencies revealed: CNA-A dated 03/17/2025 with all pericare skills having been met. CNA-B dated 03/25/2025 with all pericare skills having been met. CNA-C dated 03/25/2025 with all pericare skills having been met. Record review of the facility policy titled Perineal Care with a revised date of February 2018 revealed: Male 1. Follow steps below: Take the wipe in one hand and gently grasp the penis shaft. If, the resident is uncircumcised gently pull back the foreskin and wipe the head of the penus beginning at the urethral opening working outward and away from the penis head (circular motion). Use new wipe with each stroke. After cleaning is complete gently move the foreskin back into it's natural position if uncircumcised. Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum. Using a new wipe with each stroke clean from the upper part of the leg to the hip. Repeat on the other side and then once from hip bone to hip bone. Turn the resident over and repeat on the back side

Based on observation, interviews, and record reviews the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 2 ( Resident #8 and Resident #10) of 6 residents reviewed for rights in that: 1. Resident #8's bathroom was observed to be unsafe and unsanitary. 2. Resident #8 and Resident #10 complained of roaches in their rooms and bathrooms. This deficient practice could place residents at risk of living in an unsanitary environment, and psychosocial harm due to diminished quality of life. Findings included: Record review of Resident #8's Face Sheet, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Acute (sudden) upper respiratory infection (a viral infection that affects the nose, sinuses, or throat), Complete lesion of L2 level of lumbar spinal cord (a spinal cord injury (SCI) that can cause permanent disability, significant morbidity, or even mortality), sequela (a condition which was the consequence of a previous disease or injury), Hypoglycemia (condition in which your blood sugar level is lower than the standard range), Acute (sudden) diastolic (congestive) heart failure (the left ventricle has become stiffer than normal), and Spinal stenosis (occurs when the space inside the backbone is too small), lumbar region (the part of the spine that's located between the ribs and pelvic) without neurogenic claudication (without the spinal nerves in the lower spine compressed). Record review of Resident #8's Quarterly MDS Assessment, dated [DATE], Section C- Cognitive Response Patterns revealed a BIMS score of 13, which indicated intact cognitive response. Record review of Resident #10's Face Sheet, dated, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Essential (primary) hypertension, Dysphagia (difficulty swallowing), unspecified; Chronic kidney disease, stage 4 (severe), Chronic obstructive pulmonary disease, and Cerebral infarction (stroke caused by a blockage or interruption of blood flow to the brain), unspecified. Record Review of Resident #10's Quarterly MDS Assessment, dated [DATE], Section C- Cognitive Response Patterns revealed a BIMS score of 08, which indicated a moderate impairment response. During an interview on [DATE] at 10:22 a.m., Resident #10 said the night prior she had seen a large roach crawl under her chest of drawers that was across the room from her bed. Resident #10 said the bug was not a water roach but a large regular cock roach. Resident #10 said she saw large roaches in her bathroom often. Resident #10 said this bothered her because she did not like roaches. Resident #10 said she always kept her house and bathroom clean when she lived at home. Resident #10 said her mom told her when she was growing up that if you had roaches in your house, you were unclean. During an interview on [DATE] at 10:34 a.m., Resident #8 said he was upset about the water roaches in the facility. Resident #8 said he had cock roaches in bathroom and the roaches came out at night. Resident #8 said he would turn on the light and the roaches would run everywhere. Resident #8 said his sink in his bathroom was about to fall off the wall and the toilet was unsteady. Resident #8 said someone needed to replace the base of his toilet. As investigator opened the bathroom door, Resident #8 said he was glad someone looked at his bathroom because he had reported the need for repairs to the housekeeper and no one had fixed the sink or toilet. Resident #8 said he was a large man and he had to lean on something to go to the bathroom and he felt unsafe that the sink would fall off and he would hit his face on the floor and bust his chin. Resident #8 said he was also afraid his toilet would fall over, and he would fall and would not be able to get off the floor. During on observation on [DATE] beginning at 10:40 a.m., of Resident #8's bathroom, observed the sink was a wall mounted porcelain type attached only at the back of the sink. Observed the sink tilted slightly downward in front. Observed the sink was unsteady and moved when pressure was applied to the front. Observed the sink was attached to the wall behind the faucet with a board, approximately 12 inches long by 2 inches in width. Observed the board was screwed into the drywall on each end of the board. Observed the area across the top of sink between the board and faucet and along the sides where the sink met with the drywall, a thick layer of caulk had been applied to attach the sink to the wall. Observed on the right side of the sink, at the top the sink, a ,d+[DATE] inch gap where the sink had pulled away from the wall. Observed the toilet and observed a black substance and old off-white caulking material around the entire base of the toilet. When toilet was touched, the unit moved and was unsteady at the base of the toilet. Observed the toilet lid was lose and unsteady. Observed the right side of the toilet, between the unit and the wall and saw a piece of caulking material that was covered in a black substance, pulled away from the toilet approximately 6 inches in length. Observed the floor was covered in a yellow substance with dirt and fuzz. The area where the tile and drywall met was covered in a yellow, dark stain. Observed a died roach under the sink. During an interview on [DATE] at 2:52 p.m., the Administrator said he was not aware Resident #8's sink and toilet were in need of repair. The Administrator said the facility had remounted Resident #8's sink in the past and Resident #8 put pressure on the sink when he went to bathroom because he was a large man. The Administrator said the facility would need to find a different way to mount Resident #8's sink to be more secure. Record review of the facility pest control service log revealed an entry of log check and initials on [DATE] and the facility was serviced for roaches, spiders, and beetles based on a log check and documentation and initials on [DATE] Record review of the facility's policy, Resident Rights, dated ,d+[DATE], revealed employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed about rights and responsibilities.

Based on observation, interviews and record reviews, the facility failed to ensure the resident environment remains free of accident hazards as possible 2 (Resident #7 and Resident #8) of 6 reviewed for accidents The DON brought a dog to work at the facility that bit Resident #7 on the ankle and was aggressive toward Resident #8. This was determined at no actual harm with the potential for more than minimal harm at past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation dated on 07/08/2024 when staff were in-serviced no dogs were allowed at the facility. This deficient practice could place residents at risk of an unsafe environment that could lead to a diminished quality of life. Findings included: Record review of Resident #7's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Major depressive disorder (a mental illness that can cause a persistent low mood and loss of interest in activities that are usually enjoyable), recurrent severe without psychotic features, Chronic (persisting) obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), and Dysphagia (difficulty swallowing), oropharyngeal phase (the first phase of swallowing and involves the mouth and throat). Record review of Resident #7's Quarterly MDS Assessment, dated 05/17/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #8's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Acute (sudden) upper respiratory infection (a viral infection that affects the nose, sinuses, or throat), Complete lesion of L2 level of lumbar spinal cord (a spinal cord injury (SCI) that can cause permanent disability, significant morbidity, or even mortality), sequela (a condition which was the consequence of a previous disease or injury), Hypoglycemia (condition in which your blood sugar level is lower than the standard range), Acute (sudden) diastolic (congestive) heart failure (the left ventricle has become stiffer than normal), and Spinal stenosis (occurs when the space inside the backbone is too small), lumbar region (the part of the spine that's located between the ribs and pelvic) without neurogenic claudication (without the spinal nerves in the lower spine compressed). Record review of Resident #8's Quarterly MDS Assessment, dated 06/21/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 13, which indicated intact cognitive response. During an observation on 07/17/2024 at 5:48 a.m., observed a small, silver bowl in the floor of the DON's office and a small dog crate under the desk with a blanket. Observed there was no dog present. During an interview on 07/17/2024 at 5:50 a.m., the DON said she previously brought her dog to work but did not at the present time. The DON said the last time she brought her dog to the facility was approximately 11 or 12 days prior. During an interview on 07/17/2024 at 10:25 a.m., NA A said the DON brought her dog to the facility in the past. NA A said the dog snapped at her in an aggressive way on one occasion because she walked up and startled the dog. NA A said the dog did not make contact with her. NA A said she did not report the incident to the DON or Administrator because she did not think the incident was relevant. NA A said the incident had occurred within the last two months, but she could not remember the date. During an interview on 07/17/2024 at 2:25 p.m., RN C said the DON's dog had snapped at her in an aggressive manner on Hall 5 one day and she put her foot out to block the dog. RN C said she was not in-serviced on whether or not it was allowed for staff to bring a pet to work. RN C said she did not think it was appropriate for a staff member to bring a pet to the facility because the staff needed to concentrate on their assigned tasks. RN C said the incident had occurred within the last month, but she could not remember the date. During an interview on 07/18/2024 at 10:34 a.m., Resident #8 said approximately a month prior, as he sat on his scooter by the nurses' station, he was approached by the DON's dog. Resident #8 said he was sitting by the birdcage and the dog ran up to him like it wanted to be petted and Resident #8 reached down, and the dog snapped at him in a defensive manner. Resident #8 said he was not afraid of dogs, but the incident made him mad because he did not want other residents to be bitten. During an interview on 07/18/2024 at 11:40 a.m., the DON said she was not aware that her dog had nipped or snapped residents or was aggressive toward residents or other people. During an interview on 07/18/2024 at 12:23 p.m., the Business Office Manager said she was aware the DON brought her dog to work, and she kept the dog in her office 99% of the time. The Business Office Manager said the dog would approach residents, visit resident in their rooms, and laid on their beds. The Business Office Manager said the dog's favorite place to run up to was to the bird cage in the rotunda area or the side door where the dog went out to go the restroom. The Business Office Manager said the dog at one time ran up to a resident's family member and pressed his nose to back of her leg, but the dog never nipped. The Business Office Manager said the dog approached others. During an interview 07/18/2024 at 3:58 p.m., Resident #7 said she was bit on the ankle by the DON's dog a couple of months prior. She said she was walking by the nurses' station and the dog reached out and bit her on the right ankle on the outside of the ankle. Resident #7 said the bite broke the skin. Resident #7 said she did not tell anyone because she did not want to cause trouble. When asked to explain, Resident #7 she said she had to go to the nurses to get her meds and she wanted to keep the peace. Resident #7 said she was afraid of the dog after the incident. Observation no scar on Resident #7's right ankle, on outer side where Resident #7 pointed when she showed where the dog had bitten her. Record review of Resident #7's Progress Notes, dated 03/12/2024 to 07/17/2024, revealed no injury or open area to Resident #7's ankle. Record review of a facility in-service sign-in sheet, dated 07/08/2024, revealed staff were informed, No dogs allowed by staff. Do not bring your pets to work day or night by the Administrator. Record review of the facility's dog policy, [Facility Name] and [Facility Name] Doggie Contract, not dated, revealed if the dog is a disturbance to the resident population, the dog must leave. This could include but it's not limited to barking, biting, pooping, smelling, growling, chasing, aggravating, spitting, howling, peeing, humping, rolling, hunting, etc. 4. revealed the dog must be: friendly to all residents, staff, and family members. 5. revealed the dog must be: not allowed to wander the facility alone without the resident with the dog. There was no policy that outlined and directed situations when employees brought dogs to the facility provided to this investigator when requested multiple times while on-site 07/17/2024 - 07/23/2024. Record review revealed the DON did not have a contract or facility documentation signed that indicated she would agree to the [Facility Name] Doggie Contract and facility policy. Record review revealed the DON's dog was up to date on vaccinations. This was identified as PNC, correction date of in-service (07/08/24)

Based on interview and record reviews the facility failed to ensure resident had the right to be free from abuse for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect. The facility failed to prevent CNA D from verbally abusing Resident #4 and Resident #5 on 07/04/2024 witnessed by RN C when she yelled, screamed, and slammed the door. These failures could place residents at risk of fear, emotional distress, and decreased quality of life, and further abuse. Findings included: Record review of Resident #4's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with of diagnoses of Ataxic (lack of voluntary muscle control) cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture) , Other speech and language deficits following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and spinal cord) and cerebral infarction (condition that occurs when blood flow to the brain is disrupted, causing tissue death in the brain), Anxiety disorder (mental health condition that can cause significant and uncontrollable feelings of fear and anxiety), unspecified (do not meet the exact criteria for any other anxiety disorder), and Dysphagia (difficulty swallowing), unspecified Record review of Resident #4's Quarterly MDS Assessment, dated 06/13/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 09, which indicated a moderate impairment response. Record review of Resident #5's Face Sheet, dated 07/23/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture), unspecified-Infantile (occurred before, during, or shortly after birth), Parkinsonism (brain condition that cause slowed movements, stiffness, and tremors), unspecified, Unspecified voice and resonance disorder (can involve issues with the quality, pitch, or volume of the voice). Record review of Resident #5's Annual MDS Assessment, dated 06/27/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 05, which indicated a moderate impairment response. During an interview on 07/17/2024 at 4:47 a.m., LVN E said she had worked with CNA D and said CNA D's voice was loud and at times she talked to residents harshly. LVN E said she was not sure at times if CNA D was upset or stern. During an interview on 07/17/2024 at 9:34 a.m., CNA D said she did not yell at Resident #4 or Resident #5 and denied she slammed the door. CNA D said RN C had threatened her that RN C was going to call the state and the police if she ever abused the residents. CNA D said the incident occurred on 07/04/2024. CNA D said she felt RN C was harassing her and she called the DON to report RN C. CNA D denied she ever yelled at any resident and said she had a loud voice naturally. CNA D said she had been trained and in-serviced on abuse and neglect. During an interview on 07/17/2024 at 9:46 a.m., the DON said RN C had brought the concern that CNA D had yelled at Resident #4 and Resident #5 to her on 07/04/2024. The DON said CNA D had also called her that day as well to report she felt harassed by RN C because RN C had threatened to report her to the state. The DON said the allegation of verbal abuse was not reported to HHSC Regulatory because Resident #4 and Resident #5 denied the allegation that CNA D yelled at them and said CNA D was just loud. The DON said CNA D could be loud and abrasive and once the staff got to know her, differences could be worked out and staff were able to work with CNA D. The DON said she did not document her interview with Resident #4 and Resident #5. During a confidential phone interview on 07/17/2024 at 1:01 p.m., the confidential person said RN C had reported she had witnessed CNA D yell and scream at Resident #4 and Resident #5 on 07/04/2024. The confidential person said she reported the incident to the DON and the Administrator per procedure. The confidential person said she had witnessed CNA D be loud, rude, and verbally aggressive toward residents in the past. The confidential person said she had filled out grievance forms about CNA D, but nothing became of them. During a group interview on 07/17/2024 at 1:37 p.m., with Resident #4 and Resident #5, Resident #5 said she knew CNA D and called her by her first name. Resident #5 said CNA D talked loudly when she came in the room on 07/04/2024, but she also yelled at her and Resident #4. Resident #5 said CNA D did not like it when she or Resident #4 pulled their call light. Resident #5 said she did not want to get anyone in trouble. Resident #5 looked around the room and refused to make eye contact at this point. Resident #5 said it made her nervous to think she would be yelled at and said CNA D yelled at her and Resident #4 sometimes. Resident #5 said she did not tell anyone because she did not want to get anyone in trouble. Resident #4 was observed during the conversation to sit in her wheelchair, hunched down, and quiet. When engaged, Resident #4 said she remembered CNA D yelled at her, but the questions made her nervous. Resident #4 called CNA D by her first name. Resident #4 said CNA D yelled sometimes in a mean way, but she was nervous to talk about it. During an interview on 07/17/2024 at 2:25 p.m., RN C said she witnessed CNA D as she walked by the nurses' station and enter the room of Resident #4 and Resident #5 and yell at the residents in loud, irritated tone of voice on the evening of 07/04/2024. RN C said she witnessed CNA D as she slammed the door and continued to yell and scream so loud she could hear CNA D's voice through the wall. RN C said CNA D told Resident #4 and Resident #5, to calm down, stop repeating questions, you already had your medication. RN C said when CNA D came out, RN C told CNA D that the screaming was unacceptable and if she did it again, RN C would report her to the state and the police. RN C said CNA D tone of voice was loud at times, but during the specific incident on 07/04/2024, CNA D sounded harsh, rude, and hateful. RN C said she reported the incident to the ADON, DON and Administrator immediately or less than hour after she witnessed the incident. During an interview 07/18/2024 at 2:42 p.m., the Administrator said the allegation that CNA D was verbally aggressive to Resident #4 and Resident #5 was not reported to him but was reported to the DON. The Administrator said the DON had informed him she had interviewed Resident #4 and Resident #5 and they denied the allegation. During an interview on 07/18/2024 at 2:52 p.m., the DON said RN C reported to her that RN C had witnessed, in RN C's opinion, CNA D open Resident #4 and Resident #5's door and yell and scream at the residents and slam the door. The DON said she first checked on the residents and interviewed Resident #4 and Resident #5 and asked specific questions in regard to CNA D. The DON said Resident #4 and Resident #5 denied all the allegations. The DON said she reported the incident to the Administrator. The DON said she spoke with CNA D about the allegation and details. The DON said CNA D denied all allegations and said she had witnesses. The DON said she did not interview RN C because Resident #4 and Resident #5 denied the allegation. The DON said CNA D was not removed from the floor because there was not an investigation. The DON said she did not document the incident or interview the witnesses CNA D said saw her during the alleged incident. During a group interview on 07/18/2024 at 2:52 p.m., the Administrator said that he had not had any complaints or grievances forms from staff or residents concerning CNA D. The Administrator said he had never had any grievances forms that were filed to disappear. The DON said the facility did not have grievance forms disappear and all grievance forms were addressed promptly. Record review of CNA D's employee record revealed CNA D had no relevant disciplinary actions. Record review of the facility's policy, Preventing Resident Abuse, dated 12/2013, revealed the facility would condone any form of resident abuse and continually monitor the facility's policies and procedures. The abuse prevention/intervention program includes: encouraging all personnel to report any signs or suspected incidents of abuse to facility management immediately; training all staff and practitioners how to resolve conflict appropriately; training staff to understand and manage a resident's verbal and physical aggression. Record review of the facility policy, Abuse Investigations, dated 11/2010, revealed all reports of resident abuse and neglect shall be promptly and thoroughly investigated by facility management. 1. Should an incident or suspect incident of resident abuse or neglect be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the of the investigation. 3. The individual conducting the investigation will, as a minimum: c. Interview the person reporting the incident; d. Interview the witnesses; e. Interview staff members (on all shifts) who have had contact with the resident; f. Interview other residents to who the accused employee provides care or services to; g. Review all events leading up to the event k. Focusing the investigation on determining if abuse or neglect has occurred, the extent, the cause; l. Provide complete and thorough documentation of the investigation. 7. Employee(s) who had been accused of resident abuse would be suspended from duty until the results of the investigation had been reviewed by the administrator. Record review of the facility's policy, Reporting Abuse to Facility Management, dated 04/2012, revealed: It is the responsibility of our employees, facility, consultants, Attending Physicians, family, visitors, etc., to promptly report any incident or suspected incident of neglect or residence abut to facility management without fear of retaliation. 4. Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing or in absence of the Director of Nursing, to the Nurse Supervisor on duty. Failure to report such an incident may result in legal/criminal action being filed against individual(s) withholding such information. 8. The Administrator or Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator or Director of Nursing must be called at home or paged and informed of such incident. The facility will take all necessary actions as a result of the investigation. 12. A completed copy of documentation forms and written statements from witnesses must be provided to the administrator within two hours of the occurrence of an incident or suspected abuse. An immediate investigation will be made in a copy of the findings of such investigation will be provided to the administrator within three to five days. Record review of the facility's policy, Reporting Abuse to State Agencies and Other Entities/Individuals, dated 11/2010, revealed all suspected violations of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Policy Interpretation: 1. Should a suspected violation of abuse and neglect be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility

Based on observation, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect. The facility failed to report to the Health and Human Services Commission State Survey Agency and other officials when an alleged allegation of verbal abuse was reported by RN C when she witnessed CNA D verbally abuse Resident # on 07/04/2024. This deficient practice could place residents at risk of ongoing neglect. Findings included: Record review of Resident #4's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with of diagnoses of Ataxic (lack of voluntary muscle control) cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture) , Other speech and language deficits following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and spinal cord) and cerebral infarction (condition that occurs when blood flow to the brain is disrupted, causing tissue death in the brain), Anxiety disorder (mental health condition that can cause significant and uncontrollable feelings of fear and anxiety), unspecified (do not meet the exact criteria for any other anxiety disorder), and Dysphagia (difficulty swallowing), unspecified Record review of Resident #4's Quarterly MDS Assessment, dated 06/13/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 09, which indicated a moderate impairment response. Record review of Resident #5's Face Sheet, dated 07/23/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture), unspecified-Infantile (occurred before, during, or shortly after birth), Parkinsonism (brain condition that cause slowed movements, stiffness, and tremors), unspecified, Unspecified voice and resonance disorder (can involve issues with the quality, pitch, or volume of the voice). Record review of Resident #5's Annual MDS Assessment, dated 06/27/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 05, which indicated a moderate impairment response. During an interview on 07/17/2024 at 2:25 p.m., RN C said on the evening of 07/04/2024, she witnessed CNA D as she walked by the nurses' station and enter the room of Resident #4 and Resident #5 and yell at the residents in loud, irritated tone of voice. RN C said she witnessed CNA D as she slammed the door and continued to yell and scream so loud she could hear through the wall. RN C said CNA D told Resident #4 and Resident #5, to calm down, stop repeating questions, you already had your medication. RN C said when CNA D came out, she told CNA D that the screaming was unacceptable. RN C said CNA D tone of voice was loud at times, but during the specific incident on 07/04/2024, that time, CNA D sounded harsh, rude, and hateful. RN C said she notified the Administrator, DON and ADON and reported what she witnessed immediately or less than hour after she witnessed the incident. RN C said she was never questioned about the incident and continued to observe CNA D work the floor. During an interview 07/18/2024 at 2:42 p.m., the Administrator identified himself as the facility's Abuse Coordinator. The Administrator said the allegation that CNA D was verbally aggressive to Resident #4 and Resident #5 was not reported to him but was reported to the DON. The Administrator said the DON had informed him she had interviewed Resident #4 and Resident #5 and they denied the allegation. During a group interview on 07/18/2024 at 2:52 p.m., the DON said RN C reported to her that RN C had witnessed, in RN C's opinion, CNA D open Resident #4 and Resident #5's door and yell and scream at the residents and slam the door. The DON said she first checked on the residents and interviewed Resident #4 and Resident #5 and asked specific questions in regard to CNA D. The DON said Resident #4 and Resident #5 denied all the allegations. The DON said she reported to the incident to the Administrator. The DON said she spoke with CNA D about the allegation and details. The DON said CNA D denied and said she had witnesses. The DON said she did not interview RN C because Resident #4 and Resident #5 denied the allegation. The DON said CNA D was not removed from the floor because there was not an investigation. The DON said she did not document the incident or investigate the any further, including the witnesses CNA D had reported. The DON said she did not report the incident to the state. Record review of the facility's policy, Preventing Resident Abuse, dated 12/2013, revealed the facility would condone any form of resident abuse and continually monitor the facility's policies and procedures. The abuse prevention/intervention program includes: encouraging all personnel to report any signs or suspected incidents of abuse to facility management immediately; training all staff and practitioners how to resolve conflict appropriately; training staff to understand and manage a resident's verbal and physical aggression. Record review of the facility policy, Abuse Investigations, dated 11/2010, revealed all reports of resident abuse and neglect shall be promptly and thoroughly investigated by facility management. 1. Should an incident or suspect incident of resident abuse or neglect be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the of the investigation. 3. The individual conducting the investigation will, as a minimum: c. Interview the person reporting the incident; d. Interview the witnesses; e. Interview staff members (on all shifts) who have had contact with the resident; f. Interview other residents to who the accused employee provides care or services to; g. Review all events leading up to the event k. Focusing the investigation on determining if abuse or neglect has occurred, the extent, the cause; l. Provide complete and thorough documentation of the investigation. 7. Employee(s) who had been accused of resident abuse would be suspended from duty until the results of the investigation had been reviewed by the administrator. Record review of the facility's policy, Reporting Abuse to Facility Management, dated 04/2012, revealed: It is the responsibility of our employees, facility, consultants, Attending Physicians, family, visitors, etc., to promptly report any incident or suspected incident of neglect or residence abut to facility management without fear of retaliation. 4. Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing or in absence of the Director of Nursing, to the Nurse Supervisor on duty. Failure to report such an incident may result in legal/criminal action being filed against individual(s) withholding such information. 8. The Administrator or Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator or Director of Nursing must be called at home or paged and informed of such incident. The facility will take all necessary actions as a result of the investigation. Record review of the facility's policy, Reporting Abuse to State Agencies and Other Entities/Individuals, dated 11/2010, revealed all suspected violations of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Policy Interpretation: 1. Should a suspected violation of abuse and neglect be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility

Based on interviews and record reviews, the facility failed to have evidence that all violations in response to abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect. The facility failed to investigate the allegation of verbal abuse by CNA D on 07/04/2024 towards Resident #4 and Resident #5 witnessed by RN C. The failure could place residents at risk of allegation of abuse not being thoroughly investigated and at risk of ongoing abuse. Findings included: Record review of Resident #4's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with of diagnoses of Ataxic (lack of voluntary muscle control) cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture) , Other speech and language deficits following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and spinal cord) and cerebral infarction (condition that occurs when blood flow to the brain is disrupted, causing tissue death in the brain), Anxiety disorder (mental health condition that can cause significant and uncontrollable feelings of fear and anxiety), unspecified (do not meet the exact criteria for any other anxiety disorder), and Dysphagia (difficulty swallowing), unspecified Record review of Resident #4's Quarterly MDS Assessment, dated 06/13/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 09, which indicated a moderate impairment response. Record review of Resident #5's Face Sheet, dated 07/23/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture), unspecified-Infantile (occurred before, during, or shortly after birth), Parkinsonism (brain condition that cause slowed movements, stiffness, and tremors), unspecified, Unspecified voice and resonance disorder (can involve issues with the quality, pitch, or volume of the voice). Record review of Resident #5's Annual MDS Assessment, dated 06/27/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 05, which indicated a moderate impairment response. During an interview on 07/17/2024 at 2:25 p.m., RN C said she witnessed CNA D as she walked by the nurses' station and enter the room of Resident #4 and Resident #5 and yell at the residents in loud, irritated tone of voice. RN C said she witnessed CNA D as she slammed the door and continued to yell and scream so loud she could hear through the wall. RN C said CNA D told Resident #4 and Resident #5, to calm down, stop repeating questions, you already had your medication. RN C said when CNA D came out, she told CNA D that the screaming was unacceptable. RN C said CNA D voice tone was loud at times, but at during the specific incident on 07/04/2024, that time, CNA D sounded harsh, rude, and hateful. RN C said she notified Administrator, DON and ADON and reported what she witnessed immediately or less than hour after she witnessed the incident. RN C said she was never questioned about the incident and continued to observe CNA D work the floor. During an interview 07/18/2024 at 2:42 p.m., the Administrator identified himself as the facility's Abuse Coordinator. The Administrator said the allegation that CNA D was verbally aggressive to Resident #4 and Resident #5 was not reported to him but was reported to the DON. The Administrator said the DON had informed him she had interviewed Resident #4 and Resident #5 and they denied the allegation. The Administrator said he did not investigate the incident further based on the statement of the DON and no documentation was obtained. During a group interview on 07/18/2024 at 2:52 p.m., the DON said RN C reported to her that RN C had witnessed, in RN C's opinion, CNA D open Resident #4 and Resident #5's door and yell and scream at the resident and slam the door. The DON said she first checked on the residents and interviewed Resident #4 and Resident #5 and asked specific questions in regard to CNA D. The DON said Resident #4 and Resident #5 denied all the allegations. The DON said she reported to the incident to the Administrator. The DON said she spoke with CNA D about the allegation and details. The DON said CNA D denied and said she had witnesses. The DON said she did not interview RN C because Resident #4 and Resident #5 denied the allegation. The DON said CNA D was not removed from the floor because there was not an investigation. The DON said she did not document the incident or investigate the incident any further, including the witnesses CNA D had reported. Record review of the facility's policy, Preventing Resident Abuse, dated 12/2013, revealed the facility would condone any form of resident abuse and continually monitor the facility's policies and procedures. The abuse prevention/intervention program includes: encouraging all personnel to report any signs or suspected incidents of abuse to facility management immediately; training all staff and practitioners how to resolve conflict appropriately; training staff to understand and manage a resident's verbal and physical aggression. Record review of the facility policy, Abuse Investigations, dated 11/2010, revealed all reports of resident abuse and neglect shall be promptly and thoroughly investigated by facility management. 1. Should an incident or suspect incident of resident abuse or neglect be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the of the investigation. 3. The individual conducting the investigation will, as a minimum: c. Interview the person reporting the incident; d. Interview the witnesses; e. Interview staff members (on all shifts) who have had contact with the resident; f. Interview other residents to who the accused employee provides care or services to; g. Review all events leading up to the event k. Focusing the investigation on determining if abuse or neglect has occurred, the extent, the cause; l. Provide complete and thorough documentation of the investigation. 7. Employee(s) who had been accused of resident abuse would be suspended from duty until the results of the investigation had been reviewed by the administrator. Record review of the facility's policy, Reporting Abuse to Facility Management, dated 04/2012, revealed: 4. Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing or in absence of the Director of Nursing, to the Nurse Supervisor on duty. Failure to report such an incident may result in legal/criminal action being filed against individual(s) withholding such information. 12. A completed copy of documentation forms and written statements from witnesses must be provided to the administrator within two hours of the occurrence of an incident or suspected abuse. An immediate investigation will be made in a copy of the findings of such investigation will be provided to the administrator within three to five days.

Based on observation, interview, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident (Resident #7) reviewed for peripheral intravenous care. 1. The facility failed to ensure LVN A administered Resident #7's IV (intravenous) antibiotics consistent with professional standards of practice and in accordance with physician orders. 2. The facility did not ensure Residents #7's central line dressings were changed per the physician's order. 3. The facility failed to draw labs weekly per physician orders while Resident #7 was on IV antibiotics. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:23 p.m. While the IJ was lowered on [DATE] at 11:22 p.m., the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures placed residents at risk of relapse of an ongoing infection and developing a secondary infection. Findings include: Resident #7 Record review of Resident #7's face sheet dated [DATE] revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on date [DATE]. Resident #7's diagnoses included: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (surgery involving skin and below skin tissue), presence of left artificial knee joint (previous left knee surgery), encounter for removal of internal fixation device (surgery revision), methicillin resistant staphylococcus aureus infection (antibiotic resistant infection), and pain. Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed: BIMS score of 13 which indicated cognition was intact. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed resident received IV medication. Record review of Resident #7's care plan dated [DATE] revealed resident had right chest central line and was at risk for infection, pain, infiltration, cardiac, and respiratory issues. The goal was for Resident #7 to be free from infections, infiltration, and adverse effects. The facility staff approach included for staff to assess IV site q shift and prn. Further review of care plan revealed Resident #7 had post-surgical history of infection. The goal was for Resident #7's infection to be cleared by the target date and for complications related to the infection. The facility staff approach included staff will administer medications as ordered, monitor lab work as ordered and report results to physician. Record review of Resident #7's electronic physician orders dated [DATE] revealed: Midline catheter: change catheter site dressing / securement device every week on Monday and as needed with transparent dressing with start date of [DATE]. Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed midline catheter dressing had been changed: 1. [DATE] by LVN B 2. [DATE] by LVN C 3. [DATE] by LVN B Resident #7's electronic physician orders dated [DATE] revealed: meropenem 1 gram to be administered IV every 8 hours for diagnosis of infection and inflammatory reaction due to internal left knee prosthesis (left artificial knee infection). Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed meropenem had been administered: 1. [DATE] at 4:00 p.m. by LVN A 2. [DATE] at 8:00 a.m. by LVN A 3. [DATE] at 4:00 p.m. by LVN A 4. [DATE] at 12:00 a.m. by LVN A 5. [DATE] at 8:00 p.m. by LVN A Review of Resident # 7's electronic physician orders dated [DATE] revealed: lab CBC w/Diff (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) lab to be drawn once a day on Thursday with start date of [DATE]. Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed lab CBC w/Diff, CMP, ESR, and CRP lab was performed: 1. [DATE] by DON 2. [DATE] by LVN C 3. [DATE] by LVN A 4. [DATE] by LVN C Record review of Resident #7's lab results dated [DATE] revealed WBC was 7.97 (acceptable range between 4.0 - 11.0), ESR was 37 (acceptable range between 0 - 30), and CRP was 0.4 (acceptable range between 0.0 - 0.6). Record review of Resident #7's lab results dated [DATE] revealed WBC was 11.42 (acceptable range between 4.0 - 11.0) indicated infection, ESR was 30 (acceptable range between 4.0 - 11.0), and CRP was 0.6 (acceptable range between 0.0 - 0.6). Record review of Resident #7's hospital discharge paperwork dated [DATE] revealed a progress note from the IDP revealed she had original left total knee arthroplasty (surgical procedure in which parts of a damaged joint are removed and replaced) (in 2007, followed by revision in February 2020, then followed by two subsequent incision and drainage procedures in 2020. In [DATE], she underwent explant (removal of surgical hardware) of left knee arthroplasty and spacer placement. On [DATE] she underwent revision of left total knee arthroplasty. The plan was to continue meropenem (antibiotic medication), follow up on cultures, six weeks of antibiotic with end of treatment [DATE], monitor labs, supportive care, and placement of tunneled catheter ordered. Discharge planning included meropenem 1 gram every 8 hours with end date [DATE]. Patient to follow up in the ID (Infectious Disease) clinic in 3 weeks. Check lab CBC (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) while on IV antibiotics. Provide central line dressing weekly and prn. During an observation and interview on [DATE] at 10:49 a.m., Resident #7 had IV bag of 100 mL of NS infusing into right chest double lumen central line. On the medication bag there were instructions to *ACTIVATE VIAL PRIOR TO USE*. In the vial white powder (meropenem 1 gram) was observed and was dry. No date and time were written on IV tubing or on IV bag and it was being infused at 100 mL/hr using IV pump. There was approximately 25 mL left of NS in bag. The central line dressing loose, pulled away from skin toward bottom of the dressing, was not sealed to maintain sterile environment and moved when Resident #7 lifted shirt. Resident #7 stated she did not know when the dressing had been changed last. She stated she did not remember if facility staff had ever changed out the dressing. Date observed on central line dressing to be [DATE]. During an interview on [DATE] at 11:14 a.m., the DON stated she expected for central line dressings to be changed every 7 days or prn when dressing was compromised. She stated central line dressing should be assessed by every nurse that is performing IV medication administration and she did not know why the central line dressing had not been changed since [DATE]. She stated central line dressings should be intact and it should not be loose at the bottom. The DON stated not performing dressing changes when needed or every 7 days could cause resident to have infection at the insertion site. She stated that she expected IV tubing to be timed and dated when it was hung. She did not know why tubing was not timed and dated. She stated the powdered medication in vial should have been activated by popping the seal from IV bag to powdered vial, then mixing into the solution in IV bag prior to medication being administered. She stated she had personally checked off LVN A on IV medication administration and did not know why she failed to mix medication into the bag. She stated that sometimes the pharmacy would send already mixed medication in solution and LVN A may have thought it was already mixed. She stated not mixing medication meant that resident did not get antibiotic as ordered and she had instructed LVN A to call physician to notify of missed dose. The DON stated she monitored IV medication was given correctly. During an interview on [DATE] at 11:21 a.m., LVN A stated she had administered IV medication that morning. She stated she hung medication with new tubing but did not label tubing with date or time. She stated the central line dressing should be intact and tight to skin. She stated she would change the central line dressing. LVN A stated loose central line dressing could cause resident to have infection and should be sealed. She stated she did not mix up the medication from vial into IV bag because it was coming premixed, and she thought medication was in the bag without her having to mix it. She stated not mixing the medication meant that resident did not get antibiotic dose. During an interview on [DATE] at 12:28 p.m., the Pharmacy Director with contracted pharmacy the facility used stated the pharmacy record showed as long as the pharmacy had been filling meropenem (antibiotic) medication to Resident #7, the facility had received medication in a snap together vial. He stated typically it was an insurance issue on how the medication was filled. He stated the pharmacy had written instructions on the bag label to activate vial prior to use but no separate instructions were sent to the facility. He stated the effect of facility staff not activating vial would interfere with mixing the medication and no antibiotic would have been infused if it was not activated prior to infusion. He stated the effect on the resident would be she would have gotten hydration with a little bit of sodium, and it would not have harmed her. He stated whatever the medication in the vial was prescribed to treat, would not have been treated and could have interfered with wound healing if Resident #7 missed doses. During a follow up interview on [DATE] at 02:49 p.m., the DON stated IV Certificate education should include management of the IV access site including central lines, and administration of IV medication including how to prepare medication. The DON stated IV Certification education was provided outside of the facility, but the curriculum matched what the contracted pharmacy had in their training. She stated no other residents in the facility had IV medication ordered currently that had to be activated prior to administration currently. The DON stated she talked to the nurse that was responsible for changing the central line dressing on [DATE]. She stated LVN B told her the central line dressing was not changed by LVN B due to there was a treatment nurse that day and LVN B assumed the treatment nurse would change the dressing. The DON stated she expected the nurses signing the MAR to verify that all treatments had been performed prior to leaving for the day and LVN B had been in-serviced on that. She stated Resident #7's wound had been healing and the surgeon had been pleased with the progress. She stated Resident #7 continued to have a wound vac in place and no impaired healing had been observed. The DON stated the facility reached out to Resident #7's attending physician that prescribed medication to notify her of the delayed meropenem dose and the facility was awaiting response. She stated the Medical Director of facility had been informed of delayed meropenem dose and new order obtained for medication dose to be rescheduled for 1300, 2100, and 0500 because of the medication error earlier. During a follow up interview at [DATE] at 03:30 p.m., LVN A stated it had been over a year ago when she was certified on IV medication and that she would assume that the IV Certification went over mixing IV medication. LVN A stated in the last month and a half she had been floating and working in different areas and times. She stated she usually did not work on the hall Resident #7 resided on and she had filled in 2 nights shifts on that hall. She stated she did notice the central line dressing was loose prior to administering IV meropenem medication that morning but had not noticed the date on the dressing. She stated the central line dressing was not secured to the skin and she had planned to change the dressing after medication had been administered. She stated central line dressing being loose could cause site infection. She stated she had administered meropenem to Resident #7 previously and medication had been delivered premixed with no need to activate the vial. She stated she did not feel that any negative outcome occurred to the resident from central line dressing not being changed or medication error. She stated she had called the Medical Director when she could not get ahold of the ordering physician, and a new order was received to administer another dose at 1:00 pm so that Resident #7 did not miss a dose, and then retime medication every 8 hours after the 1:00 p.m. dose. During a phone interview on [DATE] at 04:32 p.m., the Medical Director stated he expected staff to follow pharmacy instructions when administering medications. He stated that he was not familiar with the specifics of IV medication that had snap together vials but that he expected nurses to be trained on how to prepare medications that were being administered. The MD stated the effect of not getting meropenem as ordered for sepsis or infection may aggravate the infection and could have caused a flare up from the infection or relapse of an ongoing infection. He stated he assumed the nurses and the ADON, and the DON were who monitored medication was given as directed. He stated he was notified that medication was delayed and he did give directions to give medication and readjust every 8 hours with new time so that medication would not be missed. He expected IV tubing to be changed per protocol and not changing tubing could lead to secondary infection. He stated he expected tubing and medication bag to be labeled with a date because staff will get busy and may forget when bag / tubing was hung. He stated he expected central line dressings to be changed every 7 days per protocol and that it would be changed if dressing was compromised. He expected that dressing be secured to the skin and not changing could lead to secondary infection and insertion site infection risk. During an attempted telephone interview on [DATE] at 10:25 a.m., the Attending Physician did not answer the phone. Left message with office staff to please have her return phone call. The Attending Physician did not return call. During an attempted phone interview on [DATE] at 10:48 a.m., LVN D did not answer the phone and a message to return the call was left. The LVN D did not return call. During an attempted phone interview on [DATE] at 10:51 a.m., LVN B did not answer the phone and there was no option to leave a voice message. During a phone interview on [DATE] at 10:54 a.m., LVN C stated he had worked for the facility on and off for the last 3 years. He stated that if medication came with instructions to activate vial prior to use, there was a blue stem that needed to be snapped to break the seal. LVN C stated after seal broken then he would get NS into vial and mix with powdered medication. He stated the mixed liquid and medication in the vial would be drained back into IV bag prior to being administer. He stated he did not remember any of Resident #7's IV medication being delivered to facility pre-mixed, but the pharmacy had done that in the past for other residents. He stated when medication is pre-mixed, it is time sensitive so medication would only be delivered in lesser amounts. He stated he had not noticed medication not being prepared per instructions. He stated if medications were not mixed prior to administration, the effect on the resident would be that they only received hydration. He stated central line dressings should be changed once a week and as needed. He stated central line dressing would need to be changed if it was loose and could become looser with clothing changes. He stated the effect of not changing central line dressings every 7 days or as needed is hard to determine because if the dressings were still sealed, he believed the port of entry would not be exposed in some cases, but it could lead to skin breakdown from skin not being allowed to breath. He stated he had not changed the central line dressing and that if he had signed that he had performed it was signed in error. He stated he would sign off on task in MAR prior to performing task and would have made his best effort to perform the task. He stated the error may have been due to there are a lot of distractions in the facility and may have forgotten to perform. He felt that the facility had enough staff and was not shorthanded. He stated that distractions resulted from him trying to make himself available to all residents and would be approached routinely by residents even if they were not assigned to him and he would attempt to help them. During an interview on [DATE] at 11:15 a.m., LVN F stated she had worked at the facility for a little over a year. LVN F stated she had IV medication training prior to working at the facility and had a refresher on [DATE]. She stated if the medication label stated activate vial prior to use that meant the nurse must break seal then mix with the saline prior to IV administration. She stated Resident #7's IV medication had never come from pharmacy pre-mixed. LVN F stated she had not had any concerns about other nursing staff related to administering IV medication administration. She stated that not activating vial prior to medication administration could cause Resident #7 to not get medication, her wound may not have healed quickly, or the infection to become worse. She stated the central line dressing should be replaced every 72 hours. She stated nurses should change the central line dressing if dressing was loose, and not changing as ordered or as needed could cause infection. She stated nurses should document treatment performed in MAR after the nurse had completed the treatment. During a phone interview on [DATE] at 11:18 a.m., RN E stated that she was the nurse at the IDP's office. She stated her expectation would be for central line dressing changes to occur every 7 days or prn for any soiled, loose, wet dressings. She stated loose meant that insertion cite was exposed by clear part of dressing becoming compromised. She stated the central line dressing site should be monitored every shift. RN E stated the effect of not changing the central line dressing routinely and as needed would cause highly increased risk for central line infection in the blood stream. She stated IDP was using meropenem to treat an active infection and she expected IV antibiotics to be administered per physician's orders. She stated IDP should be notified when IV antibiotics were missed, or medication was delayed, and she had not received any notification from the facility of the medication error. She stated the effect of missing or delaying doses of meropenem could cause Resident #7's active diagnosis to be not treated properly, delayed healing, cause the infection to worsen, and risk hurting the resident. Could also cause prolonged antibiotic treatment, rehospitalization , and incision site failure. RN E stated she was unsure if missing antibiotic doses would cause any risk for surgery hardware failure. She stated the failure of not administering antibiotics as ordered could expose residents to extended treatments. RN E stated she had made two attempts to contact facility requesting lab results as IDP ordered lab CBC w/Diff (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) labs to be drawn weekly on Monday while on IV therapy. At that time, she stated she had not received any lab results from the facility and as a result IDP planned on drawing labs in their office during post hospitalization visit. During a follow up interview on [DATE] at 2:49 p.m., the DON stated the only labs that the facility had drawn from Resident #7 were done on [DATE]. She stated the facility had gotten a call from IDP office requesting labs on [DATE] and she did not know that labs had not been performed. She stated the facility should have drawn labs as ordered and the order would have been found on hospital discharge paperwork. She was unsure how often the order was for at that time. She stated the facility would be drawing labs when resident returned from physicians' visits in another town and would send results to IDP office. She stated it was her expectation that documentation in EMR be done after treatment had been performed. She stated she did not know why nurses had documented without performing the treatment. She stated nurses should not document something another nurse had stated they had performed. She stated the effect on the resident could be missed treatments. She stated that she monitors treatments are done by running EMR reports that would show when treatment had been missed and observing staff perform treatments. During an interview on [DATE] at 2:51 p.m., LVN B stated she had worked for the facility for 3 years in [DATE]. She stated she had received IV antibiotic medication administration training. LVN B stated when an IV was labeled activate prior to use and it was the antibiotic that Resident #7 used, the nurse should have snapped the connection from IV bag to vial, squeezed solution from IV bag into vial and mixed with powder, then with bag upside down squeezed bag to allow mixed solution into IV bag to prepare medication prior to it being infused. She stated she had not remembered seeing any premixed medication in the facility for Resident #7 after her most recent hospitalization . LVN B stated she had not had any concerns about other nursing staff not activating IV medication, but she would usually be the nurse who started medication dose in the morning with fresh tubing, so night nurse would not leave empty medication bag for her to observe. She stated tubing should be changed every 24 hours. She stated when new IV tubing was used then it should have a date, time, and nurses initial on it so that other staff know when it was first used. She stated missing IV antibiotic dose could cause Resident #7 to have longer healing time and would be considered a medication error. She was unsure what policy stated about central line dressing frequency but stated that it should be changed as ordered and prn when dressing was loose. LVN B stated not changing central line dressing when ordered or needed could cause another type of infection and significant problems by leaving area open for bacteria to get into insertion site. She stated she worked on [DATE] and she did sign that central line dressing had been changed since the facility had a RN performing treatments that day and she thought the RN changed the dressing. She stated usually the RN treatment nurse would let her know treatment had been performed and she would sign that it had been completed. She stated that she should have verified by observing central line dressing had been changed and did not remember why she did not verify it prior to signing that it was completed in MAR. She stated she had been in-serviced about central line dressings yesterday on changing dressing per orders and verifying treatment done prior to checking off it had been performed. She stated she should not check off treatments she had not performed. During a follow up interview on [DATE] at 3:00 PM, the DON stated there were no labs drawn for Resident #7 since being discharged from the hospital and admitted into facility. She stated she expected the nurse to look at the EMAR to know when the lab was ordered and that if a nurse signed off the EMAR that lab was collected after procedure had been performed. She stated the nurse should send lab to the hospital if they signed off that lab was collected. She stated the order revealed labs were to be drawn by an RN as it was to be drawn from central line and should have been done weekly. The DON stated it was her as DON that did the lab trackers and with the nurses being flagged in the EMAR to alert them to draw the labs. She stated there would be potential harm to the resident based off of her labs not being drawn, which could have caused the resident to have become septic. During a telephone interview on [DATE] at 3:26 p.m., LVN D stated she had worked for the facility for four or five years. She stated she had completed IV class but did not remember the date of original training, but the DON had a copy of certification. She stated she had received more training in IV administration on [DATE]. LVN D stated when an IV was labeled activate prior to use the seal needed to be broken and medication in vial mixed with solution from IV bag prior to administration. She stated the pharmacy had only delivered IV antibiotic medication that needed to be activated for Resident #7 since her most recent surgery. She stated she had no concerns about other nursing staff not mixing antibiotic medication prior to administering. She stated the effect of not mixing IV antibiotic could cause resident to not to get medication that she needed, and medication would not help whatever Resident #7 receiving medication for. She stated she believed the central line dressing needed to be changed every 7 days but would have to look at facility policy to verify that information. She stated the central line dressing would need to be changed if it had become loose, soiled, or damaged to prevent infection by bacteria getting under the dressing. She stated she assessed the dressing every time she administered IV medication and at least once a shift. LVN D stated she only documents completion of treatment in MAR when she completed the treatment that was ordered. During an attempted telephone interview on [DATE] at 3:52 p.m., Resident #7's emergency family member could not be reached with directions. The phone number dialed was not a working number. During a follow-up interview on [DATE] at 4:04 p.m., the DON stated Resident #7 was back from the ID physician's appointment and orthopedic surgeon's appointment. She provided paperwork the facility had received from ID physician's appointment but stated orthopedic surgeon did not send any additional paperwork from office visit. She stated that she was not sure why a new order from ID physician for PO antibiotic after IV antibiotic was completed. She stated Resident #7 was alert and more than likely would be able to answer basic questions about office visits. The DON stated she had started the afternoon dose of IV meropenem when the resident returned to facility after she had drawn blood from central line for lab work. During a follow up observation and interview on [DATE] at 4:09 p.m., Resident #7 sat in wheelchair in her room with an immobilizing brace on her left leg. IV pump on and alarm beeped with IV tubing connected to her central line. A staff member entered the room and informed the resident that she had notified the nurse of the pump alarm, and she was not allowed to touch the pump. IV meropenem had been pre-mixed prior to infusion and tubing labeled with paper tape. Resident #7 stated that she had a plastic surgeon appointment scheduled for [DATE] and that appointment was made prior to her ID physician and orthopedic surgeon's appointments. She stated she did not know why ID had ordered oral antibiotic in addition to IV antibiotic. Resident #7 stated that the orthopedic surgeon did not think that the wound vac had been healing her left knee surgical wound and that was why she was scheduled to see plastic surgeon tomorrow to discuss surgical options. She stated she was nervous about having another surgery since she almost died during the last surgery. The call light was in reach. Record review of summary of infectious disease physicians visit dated [DATE] revealed: Complete IV antibiotic on ,d+[DATE] as scheduled and we will send orders to remove PICC line. Start Levaquin 500mg PO daily on ,d+[DATE]. Follow up with orthopedic surgeon in 6 weeks .next appointment [DATE]. During a follow up interview on [DATE] at 11:12 a.m., the DON stated she did not think that increased WBC lab value on [DATE] had anything due to IV antibiotic administration and stated there was no way of proving Resident #7 had any missed doses just the delayed dose on ,d+[DATE]. She stated she thought the WBC lab could have been related to Resident #7's emotional distress on [DATE] or how the DON drew the lab. The DON stated that she may have drawn lab too quickly and she believed that may have affected lab value. She stated the facility faxed over lab results to IDP office and she would call and speak with RN E at the clinic to see how IDP interpreted the lab results. She stated at that time she had no information on how IDP had interpreted the lab value. She stated that she had spoken to the orthopedic surgeon's office who stated oral antibiotic daily after IV antibiotic would need to be administered for the remainder of resident's life. She stated she was told that the antibiotic may change to different antibiotic medication, but the resident would need treatment for the rest of her life. During a follow up interview on [DATE] at 03:12 p.m., Resident #7 stated she was seen by plastic surgeon for her left knee wound. She stated during the plastic surgeon's appointment, she was told the surgeon recommended a skin graft and if the graft did not work then they wanted to amputate. She said that she did not want an amputation. During an attempted telephone interview on [DATE] 11:23 a.m. with the MD, the MD did not answer and a message to return call was left. During an attempted telephone interview on [DATE] 11:23 a.m. with the IDP nurse, RN E, RN E did not answer and a message to return call was left. During an interview on [DATE] at 08:13 p.m., the ADMN stated he expected staff to not sign off on treatments unless they verified the treatment was done. He stated staff should not sign off on treatments prior to performing them. The ADMN stated that he expected dressings to be looked at to verify the date on the dressing and assess the site. He stated he felt the failure occurred due to staff becoming busy and had intention of performing but then forgot. The ADMN stated ADON monitors that treatments are performed, and DON was who monitored also. He stated the effect of not performing treatments could lead to infection. Record review of LVN A's certificate titled Texas IV Therapy Certification dated [DATE] revealed LVN A completed 14 contact hours of the course. Record review of LVN A's skills check off titled Medication Administration dated [DATE] revealed no evidence of activating vial on snap vial system had been performed. Record review of LVN A's skills check off titled Medication Administration dated [DATE] revealed no evidence of activating vial on snap vial system had been performed. Record review of facility policy titled Lab and Diagnostic Results - Clinical Protocol revised on [DATE] revealed: The physician will identify and order diagnostic and lab testing based on diagnostic

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 2 residents (Resident #7 and #51) reviewed for medication errors. The facility failed to administer Resident #7's IV (intravenous) antibiotics as ordered by the physician on [DATE], [DATE] (two doses), [DATE], and [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:23 p.m. While the IJ was lowered on [DATE] at 11:22 p.m., the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. The facility failed to ensure nursing staff administered Resident #51's Insulin Glargine as ordered by the physician. LVN N failed to administer Resident #51's Insulin Glargine 7 times during a 2-month review period, per physician order. RN F failed to administer Resident #51's Insulin Glargine 4 times during a 2-month review period, per physician order. LVN D failed to administer Resident #51's Insulin Glargine 1 time during a 2-month review period, per physician order. LVN M failed to administer Resident #51's Insulin Glargine 1 time during a 2-month review period, per physician order. These failures placed residents at risk of relapse of an ongoing infection and developing a secondary infection, and at risk of diabetic complications. Findings include: Resident #7 Record review of Resident #7's face sheet dated [DATE] revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on date [DATE]. Resident #7's diagnoses included: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (surgery involving skin and below skin tissue), presence of left artificial knee joint (previous left knee surgery), encounter for removal of internal fixation device (surgery revision), methicillin resistant staphylococcus aureus infection (antibiotic resistant infection), and pain. Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed: BIMS score of 13 which indicated cognition was intact. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed resident received IV medication. Record review of Resident #7's care plan dated [DATE] revealed resident had right chest central line and was at risk for infection, pain, infiltration, cardiac, and respiratory issues. The goal was for Resident #7 to be free from infections, infiltration, and adverse effects. The facility staff approach included for staff to assess IV site q shift and prn. Further review of care plan revealed Resident #7 had post-surgical history of infection. The goal was for Resident #7's infection to be cleared by the target date and for complications related to the infection. The facility staff approach included staff will administer medications as ordered, monitor lab work as ordered and report results to physician. Resident #7's electronic physician orders dated [DATE] revealed: meropenem 1 gram to be administered IV every 8 hours for diagnosis of infection and inflammatory reaction due to internal left knee prosthesis (left artificial knee infection). Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed meropenem had been administered: 1. [DATE] at 4:00 p.m. by LVN A 2. [DATE] at 8:00 a.m. by LVN A 3. [DATE] at 4:00 p.m. by LVN A 4. [DATE] at 12:00 a.m. by LVN A 5. [DATE] at 8:00 p.m. by LVN A Record review of Resident #7's lab results dated [DATE] revealed WBC was 7.97 (acceptable range between 4.0 - 11.0), ESR was 37 (acceptable range between 0 - 30), and CRP was 0.4 (acceptable range between 0.0 - 0.6). Record review of Resident #7's lab results dated [DATE] revealed WBC was 11.42 (acceptable range between 4.0 - 11.0) indicated infection, ESR was 30 (acceptable range between 4.0 - 11.0), and CRP was 0.6 (acceptable range between 0.0 - 0.6). Record review of Resident #7's hospital discharge paperwork dated [DATE] revealed a progress note from the IDP revealed she had original left total knee arthroplasty (surgical procedure in which parts of a damaged joint are removed and replaced) (in 2007, followed by revision in February 2020, then followed by two subsequent incision and drainage procedures in 2020. In [DATE], she underwent explant (removal of surgical hardware) of left knee arthroplasty and spacer placement. On [DATE] she underwent revision of left total knee arthroplasty. The plan was to continue meropenem (antibiotic medication), follow up on cultures, six weeks of antibiotic with end of treatment [DATE], monitor labs, supportive care, and placement of tunneled catheter ordered. Discharge planning included meropenem 1 gram every 8 hours with end date [DATE]. Patient to follow up in the ID (Infectious Disease) clinic in 3 weeks. Check lab CBC (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) while on IV antibiotics. Provide central line dressing weekly and prn. During an observation and interview on [DATE] at 10:49 a.m., Resident #7 had IV bag of 100 mL of NS infusing into right chest double lumen central line. On the medication bag there were instructions to *ACTIVATE VIAL PRIOR TO USE*. In the vial white powder (meropenem 1 gram) was observed and was dry. No date and time were written on IV tubing or on IV bag and it was being infused at 100 mL/hr using IV pump. There was approximately 25 mL left of NS in bag. The central line dressing loose, pulled away from skin toward bottom of the dressing, was not sealed to maintain sterile environment and moved when Resident #7 lifted shirt. Resident #7 stated she did not know when the dressing had been changed last. She stated she did not remember if facility staff had ever changed out the dressing. Date observed on central line dressing to be [DATE]. During an interview on [DATE] at 11:14 a.m., the DON stated the powdered medication in vial should have been activated by popping the seal from IV bag to powdered vial, then mixing into the solution in IV bag prior to medication being administered. She stated she had personally checked off LVN A on IV medication administration and did not know why she failed to mix medication into the bag. She stated that sometimes the pharmacy would send already mixed medication in solution and LVN A may have thought it was already mixed. She stated not mixing medication meant that resident did not get antibiotic as ordered and she had instructed LVN A to call physician to notify of missed dose. The DON stated she monitored IV medication was given correctly. During an interview on [DATE] at 11:21 a.m., LVN A stated she had administered IV medication that morning. She stated she hung medication with new tubing but did not label tubing with date or time. She stated the central line dressing should be intact and tight to skin. She stated she would change the central line dressing. LVN A stated loose central line dressing could cause resident to have infection and should be sealed. She stated she did not mix up the medication from vial into IV bag because it was coming premixed, and she thought medication was in the bag without her having to mix it. She stated not mixing the medication meant that resident did not get antibiotic dose. During an interview on [DATE] at 12:28 p.m., the Pharmacy Director with contracted pharmacy the facility used stated the pharmacy record showed as long as the pharmacy had been filling meropenem (antibiotic) medication to Resident #7, the facility had received medication in a snap together vial. He stated typically it was an insurance issue on how the medication was filled. He stated the pharmacy had written instructions on the bag label to activate vial prior to use but no separate instructions were sent to the facility. He stated the effect of facility staff not activating vial would interfere with mixing the medication and no antibiotic would have been infused if it was not activated prior to infusion. He stated the effect on the resident would be she would have gotten hydration with a little bit of sodium, and it would not have harmed her. He stated whatever the medication in the vial was prescribed to treat, would not have been treated and could have interfered with wound healing if Resident #7 missed doses. During a follow up interview on [DATE] at 02:49 p.m., the DON stated IV Certificate education should include management of the IV access site including central lines, and administration of IV medication including how to prepare medication. The DON stated IV Certification education was provided outside of the facility, but the curriculum matched what the contracted pharmacy had in their training. She stated no other residents in the facility had IV medication ordered currently that had to be activated prior to administration currently. The DON stated she talked to the nurse that was responsible for changing the central line dressing on [DATE]. She stated LVN B told her the central line dressing was not changed by LVN B due to there was a treatment nurse that day and LVN B assumed the treatment nurse would change the dressing. The DON stated she expected the nurses signing the MAR to verify that all treatments had been performed prior to leaving for the day and LVN B had been in-serviced on that. She stated Resident #7's wound had been healing and the surgeon had been pleased with the progress. She stated Resident #7 continued to have a wound vac in place and no impaired healing had been observed. The DON stated the facility reached out to Resident #7's attending physician that prescribed medication to notify her of the delayed meropenem dose and the facility was awaiting response. She stated the Medical Director of facility had been informed of delayed meropenem dose and new order obtained for medication dose to be rescheduled for 1300, 2100, and 0500 because of the medication error earlier. During a follow up interview at [DATE] at 03:30 p.m., LVN A stated it had been over a year ago when she was certified on IV medication and that she would assume that the IV Certification went over mixing IV medication. LVN A stated in the last month and a half she had been floating and working in different areas and times. She stated she usually did not work on the hall Resident #7 resided on and she had filled in 2 nights shifts on that hall. She stated she did notice the central line dressing was loose prior to administering IV meropenem medication that morning but had not noticed the date on the dressing. She stated the central line dressing was not secured to the skin and she had planned to change the dressing after medication had been administered. She stated central line dressing being loose could cause site infection. She stated she had administered meropenem to Resident #7 previously and medication had been delivered premixed with no need to activate the vial. She stated she did not feel that any negative outcome occurred to the resident from central line dressing not being changed or medication error. She stated she had called the Medical Director when she could not get ahold of the ordering physician, and a new order was received to administer another dose at 1:00 pm so that Resident #7 did not miss a dose, and then retime medication every 8 hours after the 1:00 p.m. dose. During a phone interview on [DATE] at 04:32 p.m., the Medical Director stated he expected staff to follow pharmacy instructions when administering medications. He stated that he was not familiar with the specifics of IV medication that had snap together vials but that he expected nurses to be trained on how to prepare medications that were being administered. The MD stated the effect of not getting meropenem as ordered for sepsis or infection may aggravate the infection and could have caused a flare up from the infection or relapse of an ongoing infection. He stated he assumed the nurses and the ADON, and the DON were who monitored medication was given as directed. He stated he was notified that medication was delayed and he did give directions to give medication and readjust every 8 hours with new time so that medication would not be missed. He expected IV tubing to be changed per protocol and not changing tubing could lead to secondary infection. He stated he expected tubing and medication bag to be labeled with a date because staff will get busy and may forget when bag / tubing was hung. He stated he expected central line dressings to be changed every 7 days per protocol and that it would be changed if dressing was compromised. He expected that dressing be secured to the skin and not changing could lead to secondary infection and insertion site infection risk. During an attempted telephone interview on [DATE] at 10:25 a.m., the Attending Physician did not answer the phone. Left message with office staff to please have her return phone call. The Attending Physician did not return call. During an attempted phone interview on [DATE] at 10:48 a.m., LVN D did not answer the phone and a message to return the call was left. The LVN D did not return call. During an attempted phone interview on [DATE] at 10:51 a.m., LVN B did not answer the phone and there was no option to leave a voice message. During a phone interview on [DATE] at 10:54 a.m., LVN C stated he had worked for the facility on and off for the last 3 years. He stated that if medication came with instructions to activate vial prior to use, there was a blue stem that needed to be snapped to break the seal. LVN C stated after seal broken then he would get NS into vial and mix with powdered medication. He stated the mixed liquid and medication in the vial would be drained back into IV bag prior to being administer. He stated he did not remember any of Resident #7's IV medication being delivered to facility pre-mixed, but the pharmacy had done that in the past for other residents. He stated when medication is pre-mixed, it is time sensitive so medication would only be delivered in lesser amounts. He stated he had not noticed medication not being prepared per instructions. He stated if medications were not mixed prior to administration, the effect on the resident would be that they only received hydration. He stated central line dressings should be changed once a week and as needed. He stated central line dressing would need to be changed if it was loose and could become looser with clothing changes. He stated the effect of not changing central line dressings every 7 days or as needed is hard to determine because if the dressings were still sealed, he believed the port of entry would not be exposed in some cases, but it could lead to skin breakdown from skin not being allowed to breath. He stated he had not changed the central line dressing and that if he had signed that he had performed it was signed in error. He stated he would sign off on task in MAR prior to performing task and would have made his best effort to perform the task. He stated the error may have been due to there are a lot of distractions in the facility and may have forgotten to perform. He felt that the facility had enough staff and was not shorthanded. He stated that distractions resulted from him trying to make himself available to all residents and would be approached routinely by residents even if they were not assigned to him and he would attempt to help them. During an interview on [DATE] at 11:15 a.m., LVN F stated she had worked at the facility for a little over a year. LVN F stated she had IV medication training prior to working at the facility and had a refresher on [DATE]. She stated if the medication label stated activate vial prior to use that meant the nurse must break seal then mix with the saline prior to IV administration. She stated Resident #7's IV medication had never come from pharmacy pre-mixed. LVN F stated she had not had any concerns about other nursing staff related to administering IV medication administration. She stated that not activating vial prior to medication administration could cause Resident #7 to not get medication, her wound may not have healed quickly, or the infection to become worse. She stated the central line dressing should be replaced every 72 hours. She stated nurses should change the central line dressing if dressing was loose, and not changing as ordered or as needed could cause infection. She stated nurses should document treatment performed in MAR after the nurse had completed the treatment. During a phone interview on [DATE] at 11:18 a.m., RN E stated that she was the nurse at the IDP's office. She stated her expectation would be for central line dressing changes to occur every 7 days or prn for any soiled, loose, wet dressings. She stated loose meant that insertion cite was exposed by clear part of dressing becoming compromised. She stated the central line dressing site should be monitored every shift. RN E stated the effect of not changing the central line dressing routinely and as needed would cause highly increased risk for central line infection in the blood stream. She stated IDP was using meropenem to treat an active infection and she expected IV antibiotics to be administered per physician's orders. She stated IDP should be notified when IV antibiotics were missed, or medication was delayed, and she had not received any notification from the facility of the medication error. She stated the effect of missing or delaying doses of meropenem could cause Resident #7's active diagnosis to be not treated properly, delayed healing, cause the infection to worsen, and risk hurting the resident. Could also cause prolonged antibiotic treatment, rehospitalization , and incision site failure. RN E stated she was unsure if missing antibiotic doses would cause any risk for surgery hardware failure. She stated the failure of not administering antibiotics as ordered could expose residents to extended treatments. RN E stated she had made two attempts to contact facility requesting lab results as IDP ordered lab CBC w/Diff (a blood test that measures red blood cell count, white blood cell count and platelet count), CMP (a blood test that measures the body's fluid balance, electrolytes like sodium and potassium, and how well the kidneys and liver are working), ESR (a blood test that measures the level of inflammation in the body), CRP (a blood test that can measure a protein produced by the liver in response to inflammation or infection in the body) labs to be drawn weekly on Monday while on IV therapy. At that time, she stated she had not received any lab results from the facility and as a result IDP planned on drawing labs in their office during post hospitalization visit. During a follow up interview on [DATE] at 2:49 p.m., the DON stated the only labs that the facility had drawn from Resident #7 were done on [DATE]. She stated the facility had gotten a call from IDP office requesting labs on [DATE] and she did not know that labs had not been performed. She stated the facility should have drawn labs as ordered and the order would have been found on hospital discharge paperwork. She was unsure how often the order was for at that time. She stated the facility would be drawing labs when resident returned from physicians' visits in another town and would send results to IDP office. She stated it was her expectation that documentation in EMR be done after treatment had been performed. She stated she did not know why nurses had documented without performing the treatment. She stated nurses should not document something another nurse had stated they had performed. She stated the effect on the resident could be missed treatments. She stated that she monitors treatments are done by running EMR reports that would show when treatment had been missed and observing staff perform treatments. During an interview on [DATE] at 2:51 p.m., LVN B stated she had worked for the facility for 3 years in [DATE]. She stated she had received IV antibiotic medication administration training. LVN B stated when an IV was labeled activate prior to use and it was the antibiotic that Resident #7 used, the nurse should have snapped the connection from IV bag to vial, squeezed solution from IV bag into vial and mixed with powder, then with bag upside down squeezed bag to allow mixed solution into IV bag to prepare medication prior to it being infused. She stated she had not remembered seeing any premixed medication in the facility for Resident #7 after her most recent hospitalization . LVN B stated she had not had any concerns about other nursing staff not activating IV medication, but she would usually be the nurse who started medication dose in the morning with fresh tubing, so night nurse would not leave empty medication bag for her to observe. She stated tubing should be changed every 24 hours. She stated when new IV tubing was used then it should have a date, time, and nurses initial on it so that other staff know when it was first used. She stated missing IV antibiotic dose could cause Resident #7 to have longer healing time and would be considered a medication error. She was unsure what policy stated about central line dressing frequency but stated that it should be changed as ordered and prn when dressing was loose. LVN B stated not changing central line dressing when ordered or needed could cause another type of infection and significant problems by leaving area open for bacteria to get into insertion site. She stated she worked on [DATE] and she did sign that central line dressing had been changed since the facility had a RN performing treatments that day and she thought the RN changed the dressing. She stated usually the RN treatment nurse would let her know treatment had been performed and she would sign that it had been completed. She stated that she should have verified by observing central line dressing had been changed and did not remember why she did not verify it prior to signing that it was completed in MAR. She stated she had been in-serviced about central line dressings yesterday on changing dressing per orders and verifying treatment done prior to checking off it had been performed. She stated she should not check off treatments she had not performed. During a follow up interview on [DATE] at 3:00 PM, the DON stated there were no labs drawn for Resident #7 since being discharged from the hospital and admitted into facility. She stated she expected the nurse to look at the EMAR to know when the lab was ordered and that if a nurse signed off the EMAR that lab was collected after procedure had been performed. She stated the nurse should send lab to the hospital if they signed off that lab was collected. She stated the order revealed labs were to be drawn by an RN as it was to be drawn from central line and should have been done weekly. The DON stated it was her as DON that did the lab trackers and with the nurses being flagged in the EMAR to alert them to draw the labs. She stated there would be potential harm to the resident based off of her labs not being drawn, which could have caused the resident to have become septic. During a telephone interview on [DATE] at 3:26 p.m., LVN D stated she had worked for the facility for four or five years. She stated she had completed IV class but did not remember the date of original training, but the DON had a copy of certification. She stated she had received more training in IV administration on [DATE]. LVN D stated when an IV was labeled activate prior to use the seal needed to be broken and medication in vial mixed with solution from IV bag prior to administration. She stated the pharmacy had only delivered IV antibiotic medication that needed to be activated for Resident #7 since her most recent surgery. She stated she had no concerns about other nursing staff not mixing antibiotic medication prior to administering. She stated the effect of not mixing IV antibiotic could cause resident to not to get medication that she needed, and medication would not help whatever Resident #7 receiving medication for. She stated she believed the central line dressing needed to be changed every 7 days but would have to look at facility policy to verify that information. She stated the central line dressing would need to be changed if it had become loose, soiled, or damaged to prevent infection by bacteria getting under the dressing. She stated she assessed the dressing every time she administered IV medication and at least once a shift. LVN D stated she only documents completion of treatment in MAR when she completed the treatment that was ordered. During an attempted telephone interview on [DATE] at 3:52 p.m., Resident #7's emergency family member could not be reached with directions. The phone number dialed was not a working number. During a follow-up interview on [DATE] at 4:04 p.m., the DON stated Resident #7 was back from the ID physician's appointment and orthopedic surgeon's appointment. She provided paperwork the facility had received from ID physician's appointment but stated orthopedic surgeon did not send any additional paperwork from office visit. She stated that she was not sure why a new order from ID physician for PO antibiotic after IV antibiotic was completed. She stated Resident #7 was alert and more than likely would be able to answer basic questions about office visits. The DON stated she had started the afternoon dose of IV meropenem when the resident returned to facility after she had drawn blood from central line for lab work. During a follow up observation and interview on [DATE] at 4:09 p.m., Resident #7 sat in wheelchair in her room with an immobilizing brace on her left leg. IV pump on and alarm beeped with IV tubing connected to her central line. A staff member entered the room and informed the resident that she had notified the nurse of the pump alarm, and she was not allowed to touch the pump. IV meropenem had been pre-mixed prior to infusion and tubing labeled with paper tape. Resident #7 stated that she had a plastic surgeon appointment scheduled for [DATE] and that appointment was made prior to her ID physician and orthopedic surgeon's appointments. She stated she did not know why ID had ordered oral antibiotic in addition to IV antibiotic. Resident #7 stated that the orthopedic surgeon did not think that the wound vac had been healing her left knee surgical wound and that was why she was scheduled to see plastic surgeon tomorrow to discuss surgical options. She stated she was nervous about having another surgery since she almost died during the last surgery. The call light was in reach. Record review of summary of infectious disease physicians visit dated [DATE] revealed: Complete IV antibiotic on ,d+[DATE] as scheduled and we will send orders to remove PICC line. Start Levaquin 500mg PO daily on ,d+[DATE]. Follow up with orthopedic surgeon in 6 weeks .next appointment [DATE]. During a follow up interview on [DATE] at 11:12 a.m., the DON stated she did not think that increased WBC lab value on [DATE] had anything due to IV antibiotic administration and stated there was no way of proving Resident #7 had any missed doses just the delayed dose on ,d+[DATE]. She stated she thought the WBC lab could have been related to Resident #7's emotional distress on [DATE] or how the DON drew the lab. The DON stated that she may have drawn lab too quickly and she believed that may have affected lab value. She stated the facility faxed over lab results to IDP office and she would call and speak with RN E at the clinic to see how IDP interpreted the lab results. She stated at that time she had no information on how IDP had interpreted the lab value. She stated that she had spoken to the orthopedic surgeon's office who stated oral antibiotic daily after IV antibiotic would need to be administered for the remainder of resident's life. She stated she was told that the antibiotic may change to different antibiotic medication, but the resident would need treatment for the rest of her life. During a follow up interview on [DATE] at 03:12 p.m., Resident #7 stated she was seen by plastic surgeon for her left knee wound. She stated during the plastic surgeon's appointment, she was told the surgeon recommended a skin graft and if the graft did not work then they wanted to amputate. She said that she did not want an amputation. During an attempted telephone interview on [DATE] 11:23 a.m. with the MD, the MD did not answer and a message to return call was left. During an attempted telephone interview on [DATE] 11:23 a.m. with the IDP nurse, RN E, RN E did not answer and a message to return call was left. During an interview on [DATE] at 08:13 p.m., the ADMN stated he expected staff to not sign off on treatments unless they verified the treatment was done. He stated staff should not sign off on treatments prior to performing them. The ADMN stated that he expected dressings to be looked at to verify the date on the dressing and assess the site. He stated he felt the failure occurred due to staff becoming busy and had intention of performing but then forgot. The ADMN stated ADON monitors that treatments are performed, and DON was who monitored also. He stated the effect of not performing treatments could lead to infection. Record review of LVN A's certificate titled Texas IV Therapy Certification dated [DATE] revealed LVN A completed 14 contact hours of the course. Record review of LVN A's skills check off titled Medication Administration dated [DATE] revealed no evidence of activating vial on snap vial system had been performed. Record review of LVN A's skills check off titled Medication Administration dated [DATE] revealed no evidence of activating vial on snap vial system had been performed. Record review of facility policy titled Lab and Diagnostic Results - Clinical Protocol revised on [DATE] revealed: The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Record review of facility policy titled Administration of IV Fluids and Medications Reconstituting and Adding Medications to an IV Bag dated 2011 revealed: Reconstituting and adding medications to an IV bag will be done by the professional nurse with documented IV education, as designated by the facility, and as allowed by state regulations. IV medication that is supplied in powdered form must be reconstituted prior to adding it to the IV bag. The nurse who administers the medication will be the same nurse who reconstituted the medication. The nurse reconstituting a medication must be aware of drug stability issues and administer the dose within the appropriate time frame. Consult with the IV pharmacist as needed. After reconstituting and adding medication to an IV bag the infusion must be started within one hour .Label IV bag with resident's name, medication added, dose, rate of infusion, date, time, and initials. Administer and document. Record review of facility policy titled Dressing Change for Vascular Access Devices dated 2011 revealed: Central venous access device and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present, or for further assessment if infection is suspected. Transparent semi-permeable membrane dressings are changed every 7 days and PRN. Transparent semi-permeable membrane dressings are changed every 7 days and PRN. If a chlorh [TRUNCATED]

44728 Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Resident #2, Resident #7, Resident #28, Resident #51) of 18 residents reviewed for comprehensive care plans. The facility failed to develop a PASRR care plan Resident #2. The facility failed to develop care plan goals for Resident #28 related to his ADL Functions. The facility failed to ensure LVN N administered Resident #51's Insulin Glargine 7 times during a 2-month review period, per physician order. The facility failed to ensure RN F administered Resident #51's Insulin Glargine 4 times during a 2-month review period, per physician order. The facility failed to ensure LVN D administered Resident #51's Insulin Glargine 1 time during a 2-month review period, per physician order. The facility failed to ensure LVN M administered Resident #51's Insulin Glargine 1 time during a 2-month review period, per physician order. The facility failed to ensure LVN B changed Resident #7's central line dressing, when LVN B documented she had changed the central line dressing. The Facility failed to ensure LVN C changed Resident #7's central line dressing, when LVN C documented he had changed the central line dressing. These failures could affect residents by placing them at risk for not having their individual needs met. Findings included: Resident #2 Record review of Resident #2's face sheet dated [DATE] revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses hypertension (high blood pressure), type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), pressure ulcer of right buttock, stage 3, muscle wasting, paranoid schizophrenia, and major depressive disorder. Record review of Resident #2's Admission MDS dated [DATE] revealed Section C- Cognitive Patterns, Resident #2 had a BIMS score of 0 meaning an interview was not conducted with resident because Resident #2 was rarely/never understood. Record review of Resident #2's PASRR Level 1 Screening dated [DATE] revealed Resident #2 was PASRR positive and required PASRR services. Record review of Resident #2's Comprehensive Care Plan dated [DATE] revealed no evidence of Resident #2's PASRR services identified in the Comprehensive Care Plan. Resident #28 Review of Resident # 28's face sheet dated [DATE] revealed a [AGE] year-old male admitted on [DATE] and her latest admission on [DATE]. Resident #28's diagnosis was, Hypertension (high blood pressure), Lack of coordination, and Diarrhea. Review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact). Section H-Bladder and Bowel, resident always incontinent. Section GG-Functional Abilities and Goals, Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). Record review of Resident #28's Care Plan dated [DATE] revealed no evidence of goals for the target date for his ADL Functions. Resident #51 Record review of Resident #51's face sheet dated [DATE] revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses heart failure, hypertension (high blood pressure), type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), peripheral vascular disease, coronary artery disease and wound infection. Record review of Resident #51's Annual MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #51 had a BIMS score of 14 meaning cognitive intact. Record review of Resident #51's care plan dated [DATE] revealed; Diabetic status will remain stable AEB by resident blood sugar staying within the resident's normal limits through next quarter. Edited on [DATE]. Interventions for Resident #51 revealed: Administer medications as ordered and monitor for side effects, effectiveness. Date Initiated: [DATE], Revision on: [DATE]. Record review of Resident #51's physician order dated [DATE] revealed: Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/ml (3ml) 25 units subcutaneous twice per day, with a start date of [DATE], no evidence of specific parameters. Record review of Resident #51's electronic MAR for the months of [DATE] and [DATE] revealed insulins being held: 1. [DATE] Lantus 25 units held at 7:00AM recorded by LVN N. 2. [DATE] Lantus 25 units held at 7:00AM recorded by LVN N. 3. [DATE] Lantus 13 units given at 8:00PM recorded by RN F. 4. [DATE] Lantus 25 units held at 7:00AM recorded by LVN N. 5. [DATE] Lantus 25 units held at 7:00AM recorded by LVN N. 6. [DATE] Lantus 25 units held at 7:00AM recorded by LVN N. 7. [DATE] Lantus 25 units held at 8:00PM recorded by LVN D. 8. [DATE] Lantus 13 units given at 8:00PM recorded by RN F. 9. [DATE] Lantus 12 units given at 8:00PM recorded by RN F. 10. [DATE] Lantus 25 units held at 7:00AM recorded by LVN N. 11. [DATE] Lantus 25 units held at 8:00PM recorded by LVN M. 12. [DATE] Lantus 25 units held at 7:00AM recorded by LVN N. 13. [DATE] Lantus 10 units given at 8:00PM recorded by RN F. Review of Resident #51's electronic progress notes for [DATE] and [DATE] revealed no evidence of notification of physician for holding ordered insulin or adjusting units of insulin given. Observation on [DATE] at 2:30 PM revealed Resident #41 sitting in wheelchair at nurses station. Resident #41 appeared to be clean and alert but would only respond with head nod to questions. Resident #7 Record review of Resident #7's face sheet dated [DATE] revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on date [DATE]. Resident #7's diagnoses included: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (surgery involving skin and below skin tissue), presence of left artificial knee joint (previous left knee surgery), encounter for removal of internal fixation device (surgery revision), methicillin resistant staphylococcus aureus infection (antibiotic resistant infection), and pain. Record review of Resident #7's quarterly MDS dated [DATE] revealed: BIMS score of 13 which indicated cognitively intact. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed resident received IV medication. Record review of Resident #7's care plan dated [DATE] revealed resident had right chest central line and was at risk for infection, pain, infiltration, cardiac and respiratory issues. The goal was for Resident #7 to be free from infections, infiltration, and adverse effects. The facility staff approach included for staff to assess IV site q shift and prn. Further review of care plan revealed Resident #7 had post-surgical history of infection. The goal was for Resident #7's infection to be cleared by the target date and for complications related to the infection. The facility staff approach included staff will administer medications as ordered, monitor lab work as ordered and report results to physician. Record review of Resident #7's electronic physician orders dated [DATE] revealed: Midline catheter: change catheter site dressing / securement device every week on Monday and as needed with transparent dressing with start date of [DATE]. Further investigation revealed midline catheter was really a central line. Record review of Resident #7's electronic MAR for the months of [DATE] and [DATE] revealed midline catheter dressing had been changed: 1. [DATE] by LVN B 2. [DATE] by LVN C 3. [DATE] by LVN B During an interview on [DATE] at 10:54 AM LVN C stated he had not changed the central line dressing and that if he had signed that he had performed it was signed in error. He stated he would sign off on task in MAR prior to performing task and would have made his best effort to perform the task. He stated the error may have been due to there were a lot of distractions in the facility and may have forgotten to perform. He stated that distractions resulted from him trying to make himself available to all residents and would be approached routinely by residents even if they were not assigned to him and he would attempt to help them. During an interview on [DATE] at 2:51 PM LVN B stated she worked on [DATE] and she did sign that central line dressing had been changed since the facility had a RN performing treatments that day and she thought the RN changed the dressing. She stated usually the RN treatment nurse would let her know treatment had been performed and she would sign that it had been completed. She stated that she should have verified by observing central line dressing had been changed and did not remember why she did not verify it prior to signing that it was completed in MAR. She stated she had been in-serviced about central line dressings yesterday on changing dressing per orders and verifying treatment done prior to checking off it had been performed. She stated she should not check off treatments she had not performed. During an attempted telephone interview on [DATE] at 3:10 PM with LVN B, LVN B did not answer and message to return call was left, LVN B did not return call. During an attempted telephone interview on [DATE] at 3:12 PM with LVN C, LVN C did not answer and message to return call was left, LVN C did not return call. During an interview on [DATE] at 9:56 AM LVN N stated she was an LVN N and had worked at the facility since [DATE]. LVN N stated she had received training on how to administer insulin. LVN N stated Lantus was a long-acting insulin that lasts for 8 to 10 hours and will be peak at 6 hours. LVN N stated there should have been parameters to follow in the physician's orders. LVN N stated Resident #51's Lantus order did not have parameters but would hold if his blood glucose was low. LVN N stated she had not contacted Resident #51's physician about holding his Lantus. LVN N stated she had used her nursing judgment from the history she had with Resident #51. LVN N stated her nursing judgement was based on the Texas Board of Nursing. LVN N stated she had never adjusted the units ordered for Lantus and the physician should have been contacted if the units were changed. LVN N stated the negative impact to residents for not following physician orders could have been residents could have been running high blood sugars, high blood sugars decrease wound healing, blood pressures be altered, could be eating and drinking more because sugars running high, and could have gone into diabetic coma. During an interview on [DATE] at 10: 30 AM the DON stated her expectation was that nursing staff follow physician orders, if they make any changes to medication dosage, they should have contacted the physician and document conversation with Dr and his recommendations. The DON stated she had been the DON at the facility for the past 2 years. The DON stated she had received training (when she started at facility and from her nursing education) and her staff had received training on how to administer insulin. The DON stated nursing staff were trained as part of their checked off at hire and during the yearly competencies. The DON stated Lantus was a long-acting insulin. The DON stated the units of Lantus was based on each resident's needs. The DON stated nurses should have followed the physician's order. The DON stated if nurse felt they needed to hold Lantus they should have contacted the physician and the conversation with the physician should have been documented in Resident's progress notes or on the MAR. The DON stated the standard of practice the facility followed was the Board of Nursing standards of Practice. The DON stated the negative impact to residents for not following physician orders could have been not having good control of blood glucose, which could have been hard on the body, that could have led to detrimental effects if blood glucose was too high or too low for too long. The DON stated what led to failure of LVN N not contacting physician was LVN N had worked at facility for several months and knew the physicians orders and parameter and got complacent of what his normal parameters are and it did not trigger to contact the physician. The DON stated she did not know of any of her nurses who would have changed medication dosage without speaking to physician first, the failure happened because staff did not document those conversations. The DON stated changing medications dosage without speaking with physician would be nurses practicing out of their scope, this could have caused detrimental effects to residents. During an interview on [DATE] at 11:27 am the MD stated his expectation was that nursing staff follow orders and contact him with any changes. The MD stated he did not have an issue with holding Lantus with a blood glucose below 100. The MD stated the Lantus dosage should not have been altered unless he was contacted. The MD stated Resident #51 missing the doses of Lantus did not have an adverse effect on resident. During an interview on [DATE] at 03:38 PM RN F stated she had adjusted Resident #51's Lantus before based on his blood glucose and if he was going to eat a snack or not. RN F stated another nurse had told her it was ok to give him lower dose. RN F stated she did not know if she had messaged the physician or she failed to document conversation with physician. RN F stated at another facility a resident died because their blood glucose bottomed out, she stated she guessed that incident skewed her judgement. During an interview on [DATE] at 8:13 PM the ADMN stated his expectation was nurses should have contacted physician before holding and/or changing dosage of medication. The ADMN stated residents could have been affected by infections not getting better, worsen, insulin being held could have caused them to have extremely low or extremely high blood glucose. The ADMN stated what led to failure was nurse staff used their judgement because they felt they knew the resident's routine and their blood sugar ranges. The ADMN stated his expectation was staff's documentation be done accurately, correctly and thorough. The ADMN stated staff should never assume someone else was going to complete a treatment and documents for them or you should not click prior to completing a treatment. The ADMN stated what led to failure was she had gotten busy and forgot to perform the task/treatment. The ADMN stated the effect on residents could have been treatments missed, infections or wounds could have gotten worse. The DON and the ADON were responsible for monitoring to ensure staff were performing tasks/treatment. During an interview on [DATE] at 2:18 PM the MDS Coordinator stated that if a resident was PASSAR positive it should have been incorporated in the Comprehensive care plan. The MDS Coordinator stated she was responsible for ensuring the comprehensive care plans were complete. The MDS Coordinator stated she did not have an excuse to why the documents had not been uploaded into the care plan. During an interview on [DATE] at 2:36 PM the DON stated the goal boxes should have been checked in the blanks and was an oversight the template had not been completed. She stated there were templates that the MDS applied, with it not being finished. The DON stated the potential for harm possibly could have been not giving the proper care to residents. The DON stated the facility protocol was for staff to go look at the Care Plans and should have been caught by now. She stated the negative impact for residents was staff not knowing exactly what they were supposed to be working on for them. During an interview on [DATE] at 2:30 PM the ADON stated the DON should have monitored as well as upper management that helped with resident Care plan. She stated staff should have followed up if they had seen there were no comment in the blanks. The ADON stated the failure occurred with staff not rechecking their work and with using a template, she stated it's a fill in the blank. She stated she felt the negative impact to residents could have been improper care with her expectations was for all goals and interventions to be completed. Record review of Policy and Procedure for Comprehensive Person-Centered Care Plan dated 2010 revealed: Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; e. Reflect treatment goals, timetables and objectives in measurable outcomes; Record review of Texas Board of Nursing website, https://www.bon.texas.gov accessed on [DATE] revealed A nurse has a duty to the patient which cannot be superseded by hospital policy or physician's order. Record review of the Texas Board of Nursing website, https://www.bon.texas.gov/pdfs/practice_dept_, accessed on [DATE] revealed Scope of Practice Decision-Making Model dated [DATE]: 2. Is the activity or intervention authorized by a valid order If there is any question about the accuracy or appropriateness of an order, clarification must be sought [Board Rule 217.11(1)(N)] Record review of Texas Board of Nursing website, https://www.bon.texas.gov/rr_current/,d+[DATE].asp.html, accessed on [DATE] revealed Board Rule 217.11(1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; Record review of facility job description titled Registered Nurse dated February 2024 revealed: Monitor medication passes and treatment schedules to assure that medications are being administered as ordered and that treatments are provided as scheduled. Consult with the resident's physician and planning resident care, treatment, rehabilitation, etc. Notify the resident's physician and responsible party when there is a change in their resident's condition or unusual incident Document in the nurses notes appropriate information to indicate that the plan of care is being followed Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long term care. Record review of facility job description titled Licensed Vocational Nurse dated February 2024 revealed: Monitor medication passes and treatment schedules to assure that medications are being administered as ordered and that treatments are provided as scheduled. Consult with the resident's physician and planning resident care, treatment, rehabilitation, etc. Notify the resident's physician and responsible party when there is a change in their resident's condition or unusual incident Document in the nurses notes appropriate information to indicate that the plan of care is being followed Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long term care. 48883

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 1 of 18 residents (Residents #70) reviewed for respiratory care. The facility failed to ensure that Residents #70's oxygen tubing had been changed and dated once weekly. This failure placed residents that used oxygen/treatments at risk of respiratory complications and/or possible respiratory infections. Findings included: Review of Resident # 70's face sheet dated 06/14/2024 revealed an [AGE] year-old female admitted on [DATE]. Resident #70's diagnoses was, Chronic respiratory failure, heart disease, upper respiratory infection, cough, pain, anxiety, and shortness of breath. Review of Resident #70's Review of Resident #70's open ended (no end date) orders, dated 07/12/2023, revealed: Change nebulizer tubing every week on Sunday, once a day on Sunday 6:00 PM-6:00AM shift. Review of Resident # 70's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 09 (moderately impaired). Section O-Special Treatments-Respiratory Treatments-Oxygen Therapy. Review of Resident # 70's care plan dated 04/26/2024 revealed: Category-Oxygen Therapy. Problem-Potential for complications, s/sx (signs and symptoms) related to diagnosis of COPD. Goal-Will have respiratory rate within normal limits, be free of s/sx of respiratory distress, and maintain optimal functioning within limitations imposed by disease process through review date. Approach- Nebulizer treatments and/ or inhalers as ordered. Monitor for effectiveness, and side effects. During an observation on 06/14/2024 at 2:55 PM with the DON of Resident#70's Nebulizer tubing revealed it had 05/06/2024 written on it. During an interview on 06/14/2024 at 2:55 PM the DON stated the Nebulizer tubing should have been changed since 05/06/2024. She stated the tubing should have been removed from the nebulizer, and staff should never have dated the tubing per policy. The DON stated she did not know how to respond to who should have been monitored. She stated Oxygen tubing, should be changed every Sunday at night whether the resident used it, or not. The DON stated there were some controversies dating the tubing when changed or not because it pops up on the computer Sunday night for the staff to change out. She stated she felt there was not a need to place the date on the tubing. She stated the Interdisciplinary Team should have monitored making rounds. and they can tell with by looking and the way they look. The DON stated the negative effects could have placed residents at potential higher risk of respiratory infection as well as hovering bacteria. She stated the failure occurred with not following the EMAR and changing the tubing on the nebulizer when time. The facility provided no evidence of a policy in which the respiratory tubing should be dated when changed.

Based on interviews and record reviews the facility failed to ensure physician visits were conducted once every 30 days for 2 of 18 residents (Resident #2, Resident #73) and every 60 days for 4 of 18 residents (Resident #25, Resident #46, Resident #51, Resident #56) who were reviewed for physician visits. The facility failed to have Resident #2 seen by physician at least once every 30 days for the first 90 days after admission on 3/13/2024. The facility failed to provide documentation that Resident #2 was seen in April 2024. The facility failed to have Resident #73 seen by physician at least once every 30 days for the first 90 days after admission on 2/7/2024. The facility failed to provide documentation that Resident #73 was seen in March 2024, April 2024 and May 2024. The facility failed to have Resident #25 seen by physician at least every 60 days after the first 90 days for the past year from March 2023. The facility failed to provide documentation that Resident #25 was seen April 2023 and August 2023. The facility failed to have Resident #46 seen by physician at least every 60 days after the first 90 days for the past year from March 2023. The facility failed to provide documentation that Resident #46 was seen December 2023. The facility failed to have Resident #51 seen by physician at least every 60 days after the first 90 days for the past year from March 2023. The facility failed to provide documentation that Resident #51 was seen April 2023. The facility failed to have Resident #56 seen by physician at least every 60 days after the first 90 days for the past year from March 2023. The facility failed to provide documentation that Resident #56 was seen April 2023. These failures could lead to a decline in health status or untreated conditions. Findings included: Resident #2 Record review of Resident #2's face sheet dated 06/14/2024 revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses hypertension (high blood pressure), type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), pressure ulcer of right buttock, stage 3, muscle wasting, paranoid schizophrenia, and major depressive disorder. Record review of Resident #2's Admission MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #2 had a BIMS score of 0 meaning an interview was not conducted with resident because Resident #2 was rarely/never understood. Record review of Resident #2's electronic charting and paper review revealed no physician visit for April 2024. Resident #73 Record review of Resident #73's face sheet dated 06/14/2024 revealed [AGE] year-old male originally admitted on [DATE] with the following diagnoses Alzheimer's disease, acute kidney failure, and hypertension (high blood pressure). Record review of Resident #73's Quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #73 had a BIMS score of 0 meaning an interview was not conducted with resident because Resident #2 was rarely/never understood. Record review of Resident #73's electronic charting and paper review revealed no physician visits for March 2024, April 2024 and May 2024. Resident # 25 Record review of Resident #25's face sheet dated 06/14/2024 revealed [AGE] year-old female originally admitted on [DATE] with the following diagnoses respiratory failure, anxiety disorder, pain, kidney failure and type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well). Record review of Resident #25's Quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #25 had a BIMS score of 15 meaning cognitively intact. Record review of Resident #25's electronic charting and paper review revealed no physician visits for April 2023. Resident #51 Record review of Resident #51's face sheet dated 06/14/2024 revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses heart failure, hypertension (high blood pressure), type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), peripheral vascular disease, coronary artery disease and wound infection. Record review of Resident #51's Annual MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #51 had a BIMS score of 14 meaning cognitive intact. Record review of Resident #51's electronic charting and paper review revealed no physician visit for April 2023. Resident #56 Record review of Resident #56's face sheet dated 06/14/2024 revealed a [AGE] year-old male originally admitted on [DATE], with the following diagnoses hypertension (high blood pressure), major depressive disorder, anxiety, age related cognitive decline, pain and nicotine dependence. Record review of Resident #56's Quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns Resident #56 had a BIMS score of 8 meaning moderate cognitive impairment. Record review of Resident #56's electronic charting and paper review revealed no physician visit for April 2023. During an interview on 06/14/2024 at 7:35 PM the DON stated her expectation was that residents should have been seen within 30 days of their admission, then every 30 days within the first 90 days, and then every 60 days after. The DON stated she was responsible for monitoring and ensuring residents received their physician visits timely. The DON stated residents could have been affected by not receiving their physician visits by orders not being reviewed by physician, and residents may not have been assessed accurately. The DON stated what led to failure was physicians not coming in to see their residents. The DON stated she had realized physicians were not seeing residents per the required guidelines and had been working with their MD on how to better track visits. The DON stated she was not sure what happened in April 2023 because there were several missed visits missed by the MD. During an interview on 06/14/2024 at 8:13 PM the ADMN stated his expectation was that residents be seen by physician per guidelines. The ADMN stated that residents should have been seen by their primary physician every 30 days for the first 90 days and then every 60 days thereafter. The ADMN stated he knew they had issues with physician visits not occurring in timely manner, but that the DON had been working on a better system to track physician visits. The ADMN stated the DON was responsible for monitoring physician visits. The ADMN stated residents could have been affected by having missed physician visits, residents like to see their physician, missed medication changes, or wounds not being assessed. The ADMN stated what led to failure was not being able to get physicians to come in timely manner. Record review of facility policy titled Physician Visits with the date of April 2013 revealed, The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter.

Based on interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance for 3 of 10 days reviewed for sufficient staffing. The facility failed to maintain nurse staffing at the level indicated by the PPD budget on 05/04/2024, 05/12/2024 and 06/01/2024. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met. Findings included: Record review of timesheets dated 05/04/2024 revealed 168.65 hours worked by direct care staff. Per facility PPD and census, 222.30 direct care staff hours were needed. Record review of timesheets dated 05/12/2024 revealed 199.39 hours worked by direct care staff. Per facility PPD and census, 228 direct care staff hours were needed. Record review of timesheets dated 06/01/2024 revealed 170.84 hours worked by direct care staff. Per facility PPD and census, 228 direct care staff hours were needed. During an interview on 06/10/2024 at 10:49 AM Resident # 7 stated there was not enough staff. Resident #7 stated at night she might have to wait an hour to be changed and she had issues with skin breakdown. Resident #7 stated she did not feel she was getting enough showers and normally got one shower a week but sometimes twice. During an interview on 06/10/2024 at 4:38 PM Resident # 29 stated the facility was short staffed on the weekends and at night. Resident #29 stated she had a fall recently, during the day. Resident #29 stated it took several staff to take care of her, she was fearful that if she were to fall on the weekend or at night and another resident were to fall also there would not be enough staff to take care of them both. During an interview on 06/10/24 at 8:50 PM RN K refused to answer any questions concerning the facility being short staffed or fear of retaliation. RN K stated, I value my job too much, and did not provide any other response. During a confidential interview on 06/12/2024 at 10:38 AM stated they were happy the state surveyors where in the building because it meant they would have the help they needed to take care of residents. Confidential interview was tearful as they explained there have been several times that there were only 2 aides to take care of the residents on five of the 6 halls. During an interview on 06/12/2024 at 2:52 PM Resident #4 stated it took staff a while to answer her call light. Resident #4 stated she felt they did not have enough people working at the facility. Resident #4 stated she had issues with her wound dressing falling off in the middle of the night and staff not putting another bandage on until the next afternoon. Resident #4 stated she was scared that loose stool would get into her wound. During an interview on 06/14/24 at 7:35 PM the DON stated the ADON was responsible for completing the daily staffing schedule. The DON stated she was responsible to monitor staffing. The DON stated her expectation was to have one CNA per 5 of 6 halls and 2 CNA's on the secure unit for the day shift. 2-3 nurses' day shift. The DON stated her expectation for the night shift was 4 aides and 2 nurses and with partial nurse. The DON stated their cooperate has a rate that provides the goal for direct care staff, the PPD rate was 2.85. The DON stated you multiply the PPD by the census and that gives the total direct care staff hours needed. The DON stated being short staffed could have affected residents by higher risk of falls, call lights not being answered timely, or potential for residents missing showers. The DON stated what led to failure was not having enough staff and they have tried to hire more staff. During an interview on 06/14/2024 at 8:13 PM the ADMN stated the ADON was responsible for scheduling and the DON will makes adjustments to the schedule. The ADMN stated his expectation was to reach the PPD goal daily or as close to it as they can. The ADMN stated not reaching the daily PPD goal could have caused skin break down from having to wait too long for peri care, people who fall could have had to lay in floor waiting to be evaluated. The ADMN stated he, the DON and the ADON monitored by using the staffing sheet. The ADMN stated what led to failure of being under the PPD goal was staff quit without giving notice, will call in, or will no show/no call. The ADMN stated he has a budget sheet, from corporate, that provided him with the PPD. The ADMN stated the PPD for direct care staff was 2.85. Record review of facility policy titled, Staffing dated April 2007 revealed Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our residents needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available ton each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. Record review of facility provided form revealed the direct care total (PPD) was 2.85.

Based on observation, interview, and record review, the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #47) of 24 residents reviewed for accidents. The facility failed to provide a transportation van in which the residents were not required to lean backwards or to the side while being pushed into the van to avoid striking their heads on a latch on the top of the van, and failed to ensure residents who were unable to grasp the arms of the wheelchair were secured into the wheelchair while the van lift was being elevated. These failures resulted in Resident #47, a quadriplegic, being leaned to the right, by staff, to avoid the latch and falling out of his wheelchair. The facility failed to ensure three of three van drivers placed wheelchairs in the lift according to the Lift Owner's Manual. The Van Transportation Aide failed to place Resident #47 in the wheelchair lift according to the Lift Owner's Manual, Resident #47 was placed into the van facing inward instead of outward, and the Aide rode up with the resident on the lift, which resulted in the Aide being behind the resident instead of in front of him when the wheelchair was pushed into the van. He was unable to prevent Resident #47's fall from the wheelchair. This failure could affect the 33 residents who were wheelchair bound and relied on the facility van for transportation, by placing them at risk for injuries. Findings included: Review of Resident #47's MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was totally dependent on two staff for ADL's and transfer to his wheelchair. He was severely cognitively impaired. He was 68 inches tall and weighed 145lbs. In a telephone interview on 02/22/18 at 09:05 a.m. a family member of Resident #47's stated the resident was currently hospitalized for [REDACTED]. He stated a nurse at the facility notified him on 02/01/18 of the fall, he was told the resident had fallen forward in the van and struck his collar bone on the door jam. Review of the Provider Investigation Report, signed by the Administrator and dated 02/06/18, revealed on 02/01/18 at 12:55 p.m., Resident #47 slid to the van floor from the wheelchair after the Transportation Aide had wheeled him from the lift. The Aide reported that he was still behind the wheelchair about to move to the front to fasten Resident #47 in. Upon full assessment of the resident, pain was noted to his left shoulder and x-rays revealed a left shoulder fracture. A re-admission skin assessment performed by the DON on 02/01/18 at 1:25 p.m. revealed 18cm x 6cm dark purple hematoma to left posterior upper arm. This area is where resident and transport aide reported that occurred when he slid from his WC to the floor of the van and his left posterior arm drug on the left WC arm on his way down. Resident reported he thought this was when I broke my arm. Superficial abrasion noted to left hip that measures 3cm x 4cm. 18cm x 12cm purplish dark red blanchable area to entire side of left buttocks . 18cm x 12cm purplish dark red area that is blanchable to entire right buttocks . 8cm x 7cm red blanchable area to right lateral hip. Resident complained of pain with ROM (range of motion) of all extremities with most acute pain being in his left shoulder area . The Provider Action Taken Post-Investigation reflected the following: Re-education to anyone that transports resident's on loading in van, when to call 911, not moving residents after a fall, what the definition is of a fall and reporting any incidents that happen in the van immediately and not waiting until you get back to the facility. Staff that are transportation staff demonstrated competency of how to load, secure chair, and secure the resident and verbalized understanding of emergency procedures during transports. Disciplinary action given to driver w/(with) the re-education with follow up competencies. In a telephone interview conducted on 02/22/18 at 09:10 a.m. the Van Transportation Aide revealed his main duty was driving the facility van, he also helped in the facility as needed. He stated he did receive training, in the steps on loading and unloading and securing the passengers when he first started in the position. He stated the van at the time of the incident, was the same van that was driven now. There was a lift on the rear of the van. On 02/01/18 he picked Resident #47 up from the hospital to return him to the nursing facility. He loaded Resident #47's wheelchair onto the lift, with the resident facing toward the inside of the van, he stood on the lift behind the resident as the lift rose to the level of the van floor. He had placed the resident's arms inside of the arms of the wheelchair as the resident was unable to hang on to the side rails and there was no safety belt for the resident while on the lift. He explained that the resident was unable to bend his neck or his waist so while he pushed the wheelchair into the van, he placed his right hand on top of the resident's head and leaned him to the right, to avoid a door latch that protruded from the top of the van. The resident kept sliding to the right and slid out of the chair landing on his right side on the van floor, he slid like a sack of potatoes. He stated he was unable to assist the resident during the fall because he was behind the wheelchair. He stated he checked the resident and found no injuries and the resident had not complained of pain. He further stated the resident was usually able to speak clearly but he was not as alert as usual due to medication. I'm sure it wasn't comfortable for him, It's possible he said 'Ow!', I guess he could have said 'Ow' but it wasn't so distinct that I could remember it. Two people he had worked with previously happened to be in the hospital parking lot and assisted him in getting the resident back into his wheelchair, he cradled the resident in his arms and the two other people picked up the resident's feet. He did not contact the facility I made a terrible blunder, I should have (contacted the facility) but I did not. When he returned to the facility, he put the resident back to bed. He stated the two people who had assisted him in the hospital parking lot had evidently notified the facility of the fall because the ADON asked him if there had been an incident and he said yes. She took him to the DON's office and when asked if the resident had fallen he said no. He stated I have seen a lot of severe falls, and this was an incident, yes, he fell out of the chair but it seemed very minor, it was not threatening in any way. He stated he did not think of the incident as a fall so when asked if the resident had fallen he had said no. Now I realize it was definitely a fall. The transport Aide stated wheelchairs were always put into the van facing forward. Review of Investigation Statements given by Resident #47 on 02/01/18 at 12:45 p.m. and 1:25 p.m. revealed the resident complained his shoulder hurt My damn shoulder hurts, it's broke. When the resident was asked when he broke his shoulder he stated he fell out of the wheelchair in the van. He stammered and non-verbally indicated he hurt his shoulder on the arm of the wheelchair. In a telephone Interview 02/22/18 at 12:11 p.m. the Maintenance supervisor stated he drove the facility transport van at times. When he put residents who were in wheelchairs, into the van, the resident was facing forward, toward the inside of the van with the back of the WC facing the parking lot. He stated he would have the residents lower their heads to protect them from hitting their head on the door latch. He stated the van lift is Braun L955 and was the same lift in use in (MONTH) (YEAR). In a telephone Interview 02/22/18 at 12:16 p.m. the Activity Director stated she would sometimes drive resident's in the facility transport van. She stated when loading residents in wheelchairs onto the van she would ensure the resident was facing into the van with the back of the WC facing the parking lot. She stated she needed to put the heads down of everyone in wheelchairs so their heads did not strike the latch on the roof of the van. She stated she would not know what she would do if Resident #47 could not lean his head forward. In a telephone interview 02/22/18 at 1:12 p.m. A customer Service Representative of the Braun Lift stated wheelchairs needed to face outwards, toward the parking lot due to weight distribution. If the resident were to fall, the resident's weight would cause the chair to fall backwards, into the van, rather than onto the parking lot. She stated it was not safe for anyone, other than the resident in the wheelchair, to ride on the lift when the lift was in service. She stated the person would not be strapped in and the movement of the lift could make the person fall. She stated it would also cause the weight to be distributed differently and decrease the safety of the resident in the wheelchair. Interview 02/23/18 at 08:40 a.m. the Administrator stated she and the Maintenance Supervisor performed the re-training of the staff that drive the facility van on 02/02/18. She stated staff were taught to place the wheelchair residents in the van facing forward, into the van. She stated staff protected the resident's heads from the door latch as they are pushed into the van. When questioned, she stated she was unaware the safety manual for the van lift indicated the wheelchair needed to be facing outward, toward the parking lot while being raised into the van. She stated Resident #47 had travelled in the van on 01/04/18 and on 02/01/18. She stated she had not realized that Resident #47 was unable to bow his head and going forward, anyone who was unable to bend at the neck or waist would not be able to be transported in the facility's van. She stated there were no safety restraints for the resident's during lift service, there were handles the resident could grasp. She stated the Van Transportation Aide was hired on 10/19/17. Observation 03/23/18 at 3:32 p.m. The Activity Director demonstrated how residents in wheelchairs were placed in the van. She stated she had received updated training today and knew to place the resident in the van facing outwards. The ADON who stated she was 5ft 5, was placed in a wheelchair and placed on the van lift. The wheelchair was locked in place and the ADON held onto the arms of the wheelchair as the wheelchair was raised to the van floor. The Activity Director then went around to the side of the van and entered the van through the side doors to pull the wheelchair into the van. The door latch on the back door of the van protruded down approximately one inch and was on a level with the top third of the ADON's head. The Activity Director placed her hand on the ADON's head as the ADON lowered her head to protect it from striking the latch. The Activity Director then pulled the wheelchair into the van, locked the wheelchair into the van and secured the ADON into the wheelchair with safety belts. The Activity Director stated, there was no room to turn the wheelchair once inside the van so the resident would be facing the back window while driving. Review of the facility's Risk Management Policies and Procedures; Transportation Rules to be followed revised (MONTH) 2010, revealed; .5.Seat belts are to be used at all times. 6. Residents must be strapped in or properly secured at all times. .23. If there is an incident inside the vans, away from the company the transporter must call 911 and report the incident and notify the staff company by phone of the incident . Review of an Event Report dated 02/01/18 concerning Resident #47 fall, reflected; .Possible Contributing Factors .Were restraints/adaptive equipment in use at the time of the fall? No Review of the Operators Manual for Series 04 L955 Consumer Wheelchair Lifts revealed Read manual before operating lift. Failure to do so may result in serious bodily injury . .Pre-Lift Notes and Details . Dual handrails are provided for wheelchair passengers (or standee) use. The handrails automatically unfold to the deployed position when the platform unfolds .The passenger may choose to grip the handrails when on the lift platform . .Passenger Orientation (Boarding Direction) .The wheelchair passenger must face outward whenever on the platform. The passenger must be positioned in the center of the platform to prevent side-to-side load imbalance. Other persons should not ride on the platform with the wheelchair passenger .Lift Operation Safety .Position and secure (buckle, engage, fasten etc.) the wheelchair-equipped occupant seat belt (torso restraint) before loading onto the wheelchair lift platform . Review of a Transportation Staff Competency Check-Off signed by the Transportation Aide and the Maintenance Supervisor on 10/19/17 reflected; .12. If a resident falls . If fall occurs in route or at another facility, keep resident as immobile as possible and either call 911 or if at a nursing facility, hospital of physician's office call for medical staff immediately. (may still need to call 911). Report this immediately to (facility name) nursing staff. Review of the facility's Safety and Emergency Preparedness Policies and Procedures Revised (MONTH) 2010 revealed .Injuries to bones and joints can be recognized by pain, swelling, inability to use a limb and the irregular shape of the limb or joints. The best first aid for such injuries is to hold the limb steady and prevent movement until medical aid arrives . Review of the facility's Safe Handling for CNA's dated 04/21/14 revealed Injuries to Patients. Patients are also at risk of multiple injuries when they are manually lifted . There is the risk of pain and discomfort as well as anxiety with being moved. Patients may be dropped during a lifting activity and sustain fractures . Review of a Resident Roster which was undated and supplied by the Administrator on 02/23/18 revealed 33 residents were wheelchair bound and had utilized the transport van within the previous six months.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for 1 (Resident #1) of 9 residents reviewed for accidents. 1. CNA A failed to unload Resident #1 in the wheelchair lift according to the Lift Owner's Manual. Resident #1 was unloaded onto the lift platform facing inward instead of facing outward, when the lift side entry roll stop opened and she fell backwards. The resident had pain to her head, wrist, chest bone and shoulder, and bruising to her right wrist and hand. 2. The facility failed to discontinue lift use and have the lift serviced by a certified service personnel according to the Lift Owner's Manual. This failure has the potential to affect 56 residents who could suffer injury as a result from using the facility van wheelchair lift. Findings included: Review of Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was cognitively intact. Review of Resident #101's vital signs reflected she weighed 286 pounds on 01/04/18. Review of the Facility Event Summary Report, dated 12/06/17, reflected Resident #101 being transferred from van and wheelchair tumped (sic) over causing resident to fall into parking lot of facility. Resident c/o (complained of) head pain, wrist pain, chest bone pain, shoulder pain, 911 contacted and EMS here to transfer resident to emergency room .van lift checked and ok (sic), re-ed (sic) on transport safety, res(ident) to be transported with two or ride and safe. Review of the facility Accident/Incident Investigation Witness Statement dated 12/06/17 by CNA A reflected that after transporting resident #1 to an appointment at the clinic she unloaded resident #1 from the van in her wheelchair onto the van lift. Once on the lift the wheels were locked and the chair was on the center of the lift. As CNA A began to lower the lift the side entry roll stop on the lift came down and the chair shifted causing resident #1 and her chair to flip backward off the lift and onto the parking lot. Resident #1 landed on the back of her head and upper body. CNA A attempted to call into the facility to get help but her phone would not connect. CNA A told resident #1 she was going to get help. CNA A ran as fast as she could into the building to get help and then ran back out to resident #1. Resident #1 was transported to the emergency room . Review of the Incident/Accident Investigation dated 12/06/17 reflected the administrator and maintenance did van lift inspection and checked for malfunction and none found. Resident #1 will be transported with 2 staff members or using alternative city transport. The root cause of the injury was determined to be resident #1 leaned to side when wheelchair in lift and going down and wheelchair turned over to side and off lift since no deficit noted to van lift. Interview on 01/29/18 at 11:34 a.m. and 01/30/18 at 11:20 a.m. with Resident #1 revealed one month ago she fell out of the van. She stated she felt like she was dying she hurt so bad. She had bruises and was sent to the hospital. The lift broke when staff were getting her out and she was in her wheelchair on the lift and fell two feet to the ground. Staff are still driving that van. There was only one staff member present. Interview on 02/09/18 at 9:36 a.m. with Resident #1 revealed she was facing forward, inward, toward the front of the facility van, when she fell out of the van. Interview on 01/30/18 at 12:10 p.m. with the DON revealed CNA A was driving the facility van when Resident #1 fell from the lift. CNA A no longer worked at the facility. CNA A left voluntarily and did not give a reason for leaving the facility. Interview on 01/30/17 at 2:13 p.m. with CNA A revealed the facility van was older and not in the best shape. She had brought Resident #1 back from an appointment and had folded the lift gate out. She had positioned the chair and locked the brakes. The chair was oriented facing forward, toward the front of the van. About halfway down the lift malfunctioned and the side entry roll stop came open, and when it did, the resident just flipped backward and landed on her neck in her wheelchair in the parking lot. There is a side entry roll stop that opened and she just flipped off. There are not any straps or seatbelts fitted on the lift platform. The roll stops open automatically when the lift is on the ground. Interview on 01/30/18 at 1:12 p.m. with the maintenance supervisor revealed he was not working on 12/06/17 and did not speak with the van driver about what happened with the lift. He was not sure if the lift was taken to a mechanic, but he did look at the lift the next day and bounced on it, and the roll stops came up and latched. He pulled on the roll stops of the lift and was unable to open them. Interview on 01/30/18 at 1:30 p.m. with the DON revealed the facility concluded CNA A used the lift properly and the lift probably malfunctioned due to Resident # 1's weight. They were unable to reproduce the malfunction, the side entry roll stop of the lift opening, during their investigation, so they concluded that it was probably the weight of Resident #1 in her wheelchair pressed against the side entry roll stop of the lift that caused it to open. They are going to use two staff with bariatric residents in the lift or use a city transport service. Interview on 01/30/18 at 2:25 p.m. with the DON revealed the facility van was so old they did not have the vehicle owner's manual or the lift owner's manual. Interview on 01/30/18 at 2:20 p.m. with the maintenance supervisor revealed he called the lift manufacturer and downloaded and Lift Specifications for their Lift model. The lift specifications had an 800 pound limit. Resident #1 would ride in a wheelchair that weighed about 20 to 30 pounds. Resident #1's weight and her wheelchair would total approximately 316 pounds. Observation and interview on 01/30/18 at 2:30 p.m. with the maintenance supervisor revealed the lift platform lowered from the rear of the facility van with approximately four inch side roll stops on the outboard, left, and right sides of the lift. On the left and right sides were foot long side entry roll stops. The maintenance supervisor lowered the lift and once the lift was on the ground the roll stops lowered outwards flat. There were no straps or harnesses on the lift. The left side entry roll stop of the lift opened when Resident #1 was being lowered and it should not have opened while the lift was being lowered. They were unable to determine why the plate opened suddenly, and he has tried to pull on it when it is closed and he has been unable to open it. Review of the Lift Specifications, dated 2003, reflected the lift shall have 800 pound rated lifted capacity. The base plate shall be of a welded box design to provide flexural rigidity to minimize lift deflection when placed under load. Interview on 01/30/18 at 2:50 p.m. with the DON revealed the administrator tried to get someone to check the lift but no one in town does that. She stated pretty much everyone in the facility rides in the van. Interview on 01/31/18 at 10:30 a.m. with the Administrator revealed the facility does not have the lift owner's manual and it was installed in the vehicle separately. She stated they thought Resident #1 leaned back in her wheelchair and pushed on that side entry roll stop and she fell over. Her wheelchair brakes were on. They do not know what else could have happened. She tried pulling on the side entry roll stop and was unable to reproduce the same results of the side entry roll stop opening when it was not supposed to. The Administrator revealed they did not take the van to a specialist or mechanic. She did not know how often they were supposed to have the lift checked or serviced. She stated the hydraulic system for the lift was working, but the lower button did not work but the emergency switch button works to lower the lift. She did not know how often they needed to have the fluids checked in the hydraulic system because they did not have the Lift Owner's Manual. They did not know what routine maintenance the lift required to work properly. They could have the van looked at that day. Review of the Facility Maintenance Log Book revealed that no maintenance had been done on the van or the lift. The lift had not had any maintenance after 12/06/17 when the side entry roll stop opened during use. Interview on 01/31/18 at 11:29 a.m. with the Administrator revealed they had a full time van driver who quit in (MONTH) of (YEAR) and who was in charge of vehicle maintenance. She assumed the maintenance supervisor would take over vehicle maintenance but he has not done so. He will be taking over vehicle maintenance from now on. Interview on 01/31/18 at 11:55 a.m. with the Maintenance Supervisor revealed the wheelchair lift was a(NAME)Millennium Series Model # L955SE 8 Serial # A4- . Interview on 01/31/18 at 12:55 p.m. with the Administrator revealed they had ordered a Lift Owner's Manual. Interview on 01/30/18 at 2:55 p.m. with the DON revealed that the facility uses the van almost daily and pretty much everyone uses the van. 26 residents rode in the van in (MONTH) of (YEAR) and (MONTH) of (YEAR). Interview on 02/08/18 at 8:48 a.m. with the(NAME)Lift Manufacturer Project Specialist revealed that if the lift were to malfunction during use, the owner would need to bring it in to a certified lift dealer to have it serviced. Wheelchair lifts required a minimum of twice a year routine service by a certified lift dealer, or more frequently depending on use. The owner's manual and service manual will have more technical information. He would recommend taking the wheelchair lift in to the dealer if a side entry roll stop opened during use. They never recommend frequent use of the mechanical override switch, the emergency switch, instead of using the down switch. The owner would need to get the wheelchair lift to the dealer immediately to have it inspected. The(NAME)Lift Manufacturer Project Specialist provided the(NAME)L955 Millennium Series Fully Automatic Wheelchair Lifts Operator's Manual for: Series 04 L955 Consumer Wheelchair Lifts, dated 01/2003, and the(NAME)L955 Millennium Series Fully Automatic Wheelchair Lifts Installation/Service Manual for: Series 04 L955 Consumer Wheelchair Lifts, dated 02/2002, they are the lift manuals for the Series Model # L955SE 8 Serial # A4- . Review of the(NAME)L955 Millennium Series Fully Automatic Wheelchair Lifts Operator's Manual for: Series 04 L955 Consumer Wheelchair Lifts, dated 01/2003, reflected the following warnings; read manual before operating lift. Failure to do so may result in serious bodily injury and /or permanent damage. Keep manual in lift storage pouch. Inspect lift before operation. Do not operate if you suspect lift damage, wear or any abnormal condition. Maintenance and lubrication procedures must be performed as specified in this manual by authorized (certified) service personnel. Failure to follow these safety precautions may result in serious bodily injury and/or property damage. Discontinue lift use immediately if any lift component does not operate properly. Failure to do so may result in serious bodily injury and/or property damage. Review of the(NAME)L955 Millennium Series Fully Automatic Wheelchair Lifts Operator's Manual for: Series 04 L955 Consumer Wheelchair Lifts, dated 01/2003, reflected the following; Automatic Roll Stops: The L955SE platform is equipped with an outboard roll stop and a side entry roll stop Discontinue lift operation immediately if either roll stop does not operate properly. WARNING Discontinue lift use immediately if any lift component does not operate properly. Failure to do so may result in serious bodily injury and/or property damage. Review of the(NAME)L955 Millennium Series Fully Automatic Wheelchair Lifts Operator's Manual for: Series 04 L955 Consumer Wheelchair Lifts, dated 01/2003, reflected the following; Lift Passengers: Do not attempt to load or unload a passenger in a wheelchair or other apparatus that does not fit on the platform area. Do not exceed the 800 pound limit. Passenger Orientation (Boarding Direction): The wheelchair must face outward whenever on the platform. The passenger must be positioned in the center of the platform to prevent side-to-side load imbalance. Other persons should not ride on the platform with the wheelchair passenger. The wheelchair brakes must be locked, the roll stops must be in the fully-up (vertical) position and outboard roll stop latch must be fully engaged whenever a wheelchair passenger is on the platform If the roll stops, bridge plate, hand rails or any other lift component does not operate as outlined in this manual, discontinue lift use immediately. Review of the(NAME)L955 Millennium Series Fully Automatic Wheelchair Lifts Operator's Manual for: Series 04 L955 Consumer Wheelchair Lifts, dated 01/2003, reflected the following; Maintenance is necessary to ensure safe and trouble-free lift operation .if the scheduled maintenance and lubrication procedures are not being performed, or if there is any sign of lift damage, wear, abnormal condition or improper operation, discontinue lift use immediately .WARNING Maintenance and lubrication procedures must be performed by authorized service personnel as specified in the applicable installation/service manual. Failure to do so may result in serious bodily injury and/or property damage. Review of the(NAME)L955 Millennium Series Fully Automatic Wheelchair Lifts Installation/Service Manual for: Series 04 L955 Consumer Wheelchair Lifts, dated 02/2002, reflected WARNING Maintenance and lubrication procedures must be performed as specified by an authorized service technician. Failure to do so may result in serious bodily injury and/or property damage .All listen inspection, lubrication, and maintenance procedures should be repeated at '4 week or 100 cycle' intervals following the schedules '1 year or 1250 cycles' maintenance. These intervals are a general guideline for scheduling maintenance procedures and will vary according to lift use and conditions. Lifts exposed to severe conditions (weather, environment, contamination, heavy usage, etc.) may require inspection and maintenance procedures to be performed more often than specified. Discontinue lift use immediately if maintenance and lubrication procedures are not properly performed, or if there is any sign or wear, damage or improper operation. Contact your sales representative .one of our Product Support representatives will direct you to an authorized service technician who will inspect your lift. Review of the(NAME)L955 Millennium Series Fully Automatic Wheelchair Lifts Installation/Service Manual for: Series 04 L955 Consumer Wheelchair Lifts, dated 02/2002, reflected the following Maintenance and Lubrication Schedule; at 4 weeks or 100 Cycles inspect for wear, damage, or any abnormal condition or rattles, apply light oil; at 3 months or 300 Cycles inspect outboard roll stops for proper operation, correct or replace defective parts, inspect and make adjustments to bridge plate, handrails, platform sensor, microswitches, make sure lift operates smoothly, at 1 year or 1250 Cycles check Hydraulic fluid pump, change fluid if visible contamination or fill is fluid is low, inspect, tighten, replace, repair, or correct bridge plate, pivot pins, external snap rings, pump module cover, cylinders, roll stop cylinder hose assembly, parallel arms, bushings, and pivot pins, handrails, gas springs, power cables, mounting, decals, automatic door operators. Interview on 02/06/18 at 6:10 p.m. with the DON revealed that the facility had 56 residents in their wheelchair most or all of the time.

Based on observation, interview, and record review, the facility failed to immediatelyl consult with the resident's physician where there was a significant change in the resident's physical status for one (Resident #2) of eight residents reviewed for physician notification. The facility failed to immediately consult with Resident #2's physician when she experienced a decline in her ability to walk and exhibited signs of pain on 12/06/16 and failed to provide timely intervention and treatment. As a result, Resident #2 went three days without adequate care and services to identify an acute [MEDICAL CONDITION] which required surgical repair. Theses failures placed all 77 residents at risk for not receiving timely and appropriate care in the event of a change in condition. Findings included: Resident #2's MDS assessment, dated 09/19/16, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with inattention and disorganized thinking. She also experienced hallucinations, delusions, and had verbal behavioral symptoms directed towards others. The resident was able to walk with limited assistance and required extensive assistance with transfers. Resident #2's Care Plan, dated 07/22/16, reflected the resident had impaired expressive and receptive communication related to confusion and memory loss due to a [DIAGNOSES REDACTED]. Resident #2's Nurse's Progress Notes revealed the DON entered a late entry for 12/06/16 on 12/14/16 at 1:36 p.m., which reflected the resident usually walked quickly down the hallways without using her walker, but now the resident yelled out, Don't kill me! Don't treat me this way!, when assisted to the dining room. The DON assessed the resident who stated her right ankle hurt, and the resident's family stated the resident had a prior history of this complaint. Resident #2's Nurse's Progress Notes entered by LVN A on 12/07/16 at 3:59 a.m. reflected the resident had begun to just sit in a wheelchair and stare at staff as they repeatedly requested for her to assist with undressing and putting on night wear and then transfer into bed. The notes reflected Resident #2 made no effort to stand or assist in the transfer in any way, and she screamed loudly that the staff member was hurting her when she was lifted and transferred by two people. LVN A documented resident seems to be becoming more depressed and uncooperative with care. An interview with CNA I on 01/03/17 at 1:14 p.m. revealed she worked the 6:00 p.m. to 6:00 a.m. shift. She stated on 12/06/16 Resident #2 was sitting in the dining room and would not move when she was asked to get up from her chair. CNA I stated she had to use a gait belt to transfer the resident into a wheelchair and move her to her room. She stated she had never known the resident to require a wheelchair. CNA I stated two CNAs had to assist Resident #2 transfer to her bed, and the resident complained of pain when she was touched anywhere on her body. CNA I stated she notified LVN A who told her the resident would be monitored. An interview with LVN A on 12/20/16 at 2:40 p.m. revealed she worked the 6:00 p.m. to 6:00 a.m. shift. She stated on 12/07/16 Resident #2 had been walking in the hallway as usual; however, the resident began screaming and complaining of pain when staff transferred her to bed that evening. LVN A stated she thought the resident may have been attention-seeking so she did not contact the physician. She stated she would have contacted the physician and requested an x-ray if she thought the resident had an injury. Resident #2's Nurse's Progress Notes entered by LVN B on 12/07/16 at 9:16 a.m. reflected Resident #2 required an extra amount of assistance and encouragement to ambulate, and she now required the assistance of two people. The resident complained of left leg pain, and two tablets of Tylenol 500 mg were administered per PRN orders. A late entry in Resident #2's Nurse's Progress Notes entered by LVN B on 12/13/16 at 8:39 a.m. reflected Resident #2's primary physician had been notified on 12/07/16 for possible pain control and an order for [REDACTED].>A Nurse's Progress Note, dated 12/08/16 at 12:53 p.m., entered by LVN B reflected Resident #2's physician had been notified today after having been notified 12/07/16 of an increase in left leg pain and a decrease in ambulation. An asterisk next to the date 12/07/16 reflected the Progress Note had been edited, according to information located on the bottom of each page of the copied records. A Radiology Interpretation report, dated 12/08/16 at 10:08 p.m., reflected Resident #2 had a displaced left femoral neck acute fracture. The findings reflected there was a a femoral neck fracture with lateral and superior displacement of the distal fragment, no femoral head dislocation, and no significant [MEDICAL CONDITION] changes. A Progress Note dated 12/08/16 at 11:00 p.m. by LVN C reflected the resident was transferred to the emergency room . A late entry in Resident #2's Nurse's Progress Notes entered by LVN C on 12/09/16 at 6:46 a.m. for the date of 12/08/16 at 8:40 p.m. reflected Resident #2 now required two CNAs to assist her to bed because she was unable to stand on her own. The note reflected Resident #2 yelled loudly that it hurt, and she had evident pain with movement. The resident was noted to have a light yellow bruise on her left hip, and range of motion was very limited due to pain. LVN C documented that the on-call physician was notified and x-rays were ordered. The DON and the resident's family were notified. A Nurse's Progress Note entered by the DON, dated 12/08/16 at 12:28 p.m., reflected the DON had spoken to the nurse at the primary physician's office and notified her Resident #2 had pain. She requested a possible x-ray and [MEDICATION NAME] for pain. Resident #2's December 2016 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #2's December 2016 MAR indicated [REDACTED]. The resident was administered one dose of [MEDICATION NAME] at 7:00 p.m. on 12/08/16. A review of the Pain Flow Sheet for December 2016 reflected the resident had documented pain on the following days: 12/04/16 at 7:35 p.m. complaint of back pain 4/10 12/07/16 at 7:50 p.m. complaint of leg pain 5/10 12/07/16 at 7:30 p.m. complaint of leg pain 4/10 12/08/16 at 08:00 a.m. complaint of leg pain 5/10 A review of the Medication Administration Record [REDACTED]. An interview with the DON on 12/20/16 at 11:25 a.m. revealed Resident #2 was normally very active, and she walked in the hallways without her walker. The DON stated she was notified by LVN B at a morning meeting on 12/08/16 that Resident #2 had a new onset of pain with limited mobility. LVN B informed her that he had faxed the resident's physician on 12/07/16 and received an order for [REDACTED]. An interview with the Administrator on 12/20/16 at 1:00 p.m. revealed all faxes sent to the physician were kept in a binder for the physician to sign. The physician would write an order on the original fax and then fax the order back to the facility. She stated she was unable to find the fax LVN B said he had sent to the physician on 12/07/16 to notify him of the resident's change in status. An interview with LVN B on 01/03/17 at 12:15 p.m. revealed, he worked the 6:00 a.m. to 6:00 p.m. shift. He stated upon arriving at work on 12/07/16 he received report from LVN A, who was the off-goign nurse, and LVN A would have informed him if Resident #2 had increased pain and decreased mobility, but he did not remember if this information was shared. He stated Resident #2 continued to experience increased pain and limited mobility during his shift. He stated there was a possibility Resident #2 had a fracture as a result of a previous fall on 11/29/16, so he faxed the resident's Primary Physician. He stated he sent the fax at the end of his shift and then left the facility. He stated it was usual to send a fax rather than call the physician in that type of situation. Following the discovery of Resident #2's fracture, he had received a one-on-one in-service from the DON who advised him to always call the physician along with faxing in any urgent situation. He stated the nurses on each shift would document changes in a resident's status on a 24-hour written report. A review of the 24-hour report dated 12/07/16 reflected Resident #2 had increased pain in her leg with decreased mobility. The report reflected Resident #2 would not stand or walk and screamed when touched. A review of the 24-hour report dated 12/08/16 reflected Resident #2 had increased pain. The report reflected: [MEDICATION NAME] 50 mg one by mouth twice a day. An observation of Resident #2 on 12/20/16 at 12:27 a.m. revealed the resident resided in the secure unit of the facility. The resident was thin and frail. She was confused but able to communicate; however, she was unable to provide any relevant information about her [MEDICAL CONDITION]. An interview with CNA J on 01/03/17 at 1:30 p.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift. She stated on 12/07/16 Resident #2 was ambulatory but complained of pain when she walked. CNA J stated the resident would sometimes say the pain was located in her ankle. She stated on 12/08/16 Resident #2 complained of pain during sitting and standing. CNA J stated the resident complained of ankle hurting, but she was holding on to her thigh area. CNA J stated she notified LVN B, and he told her he would contact the physician. An interview with the DON on 01/03/17 at 2:20 p.m. revealed she thought the incident with Resident #2 occurred due to the difficulty of assessing pain in a resident with dementia. She also attributed the incident to LVN B faxing the physician instead of calling directly to notify him of changes in the resident's status. The DON stated if a physician did not order an x-ray when the nurse thought it was warranted then she would request an order from the physician on call or the Medical Director. Review of faxes sent to the primary physician regarding Resident #2 revealed one fax dated 12/08/16 at 11:50 a.m. sent by LVN B which reflected Resident #2 was experiencing a significant increase in bilateral leg pain and a decrease in ambulation. The LVN requested a trial of routine [MEDICATION NAME] 50 mg twice a day for pain and an x-ray to rule out any problems. The response was a faxed order for [MEDICATION NAME] 50 mg one tablet twice a day dated 12/08/16. A second fax sent by LVN B, dated 12/08/16 at 6:00 p.m., to Resident #2's Primary Physician requested an order for [REDACTED]. The response dated 12/09/16 was above noted there were no new orders. A communication note written by LVN C to Resident #2's Primary Physician, dated 12/08/16 at 11:30 p.m., reflected the On-call Physician had ordered Resident #2 be sent to the hospital after x-rays had shown a fracture. The facility's Change in Resident's Condition or Status policy and procedure, dated August 2011, reflected the following: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . The Resident Census and Conditions of Residents Form CMS-672 provided by the Administrator on 12/20/16 reflected a census of 77 residents.

Based on interview and record review, the facility failed to ensure each resident was free from neglect for one (Resident #2) of eight residents reviewed for neglect. The facility failed to immediately consult with Resident #2's physician when she experienced a decline in her ability to walk and exhibited signs of pain on 12/06/16 and failed to provide timely intervention and treatment. As a result, Resident #2 went three days without adequate care and services to identify an acute [MEDICAL CONDITION] which required surgical repair. Theses failures placed all 77 residents at risk for not receiving timely and appropriate care in the event of a change in condition. Findings included: Resident #2's MDS assessment, dated 09/19/16, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with inattention and disorganized thinking. She also experienced hallucinations, delusions, and had verbal behavioral symptoms directed towards others. The resident was able to walk with limited assistance and required extensive assistance with transfers. Resident #2's Care Plan, dated 07/22/16, reflected the resident had impaired expressive and receptive communication related to confusion and memory loss due to a [DIAGNOSES REDACTED]. Resident #2's Nurse's Progress Notes revealed the DON entered a late entry for 12/06/16 on 12/14/16 at 1:36 p.m., which reflected the resident usually walked quickly down the hallways without using her walker, but now the resident yelled out, Don't kill me! Don't treat me this way!, when assisted to the dining room. The DON assessed the resident who stated her right ankle hurt, and the resident's family stated the resident had a prior history of this complaint. Resident #2's Nurse's Progress Notes entered by LVN A on 12/07/16 at 3:59 a.m. reflected the resident had begun to just sit in a wheelchair and stare at staff as they repeatedly requested for her to assist with undressing and putting on night wear and then transfer into bed. The notes reflected Resident #2 made no effort to stand or assist in the transfer in any way, and she screamed loudly that the staff member was hurting her when she was lifted and transferred by two people. LVN A documented resident seems to be becoming more depressed and uncooperative with care. An interview with CNA I on 01/03/17 at 1:14 p.m. revealed she worked the 6:00 p.m. to 6:00 a.m. shift. She stated on 12/06/16 Resident #2 was sitting in the dining room and would not move when she was asked to get up from her chair. CNA I stated she had to use a gait belt to transfer the resident into a wheelchair and move her to her room. She stated she had never known the resident to require a wheelchair. CNA I stated two CNAs had to assist Resident #2 transfer to her bed, and the resident complained of pain when she was touched anywhere on her body. CNA I stated she notified LVN A who told her the resident would be monitored. An interview with LVN A on 12/20/16 at 2:40 p.m. revealed she worked the 6:00 p.m. to 6:00 a.m. shift. She stated on 12/07/16 Resident #2 had been walking in the hallway as usual; however, the resident began screaming and complaining of pain when staff transferred her to bed that evening. LVN A stated she thought the resident may have been attention-seeking so she did not contact the physician. She stated she would have contacted the physician and requested an x-ray if she thought the resident had an injury. Resident #2's Nurse's Progress Notes entered by LVN B on 12/07/16 at 9:16 a.m. reflected Resident #2 required an extra amount of assistance and encouragement to ambulate, and she now required the assistance of two people. The resident complained of left leg pain, and two tablets of Tylenol 500 mg were administered per PRN orders. A late entry in Resident #2's Nurse's Progress Notes entered by LVN B on 12/13/16 at 8:39 a.m. reflected Resident #2's primary physician had been notified on 12/07/16 for possible pain control and an order for [REDACTED].>A Nurse's Progress Note, dated 12/08/16 at 12:53 p.m., entered by LVN B reflected Resident #2's physician had been notified today after having been notified 12/07/16 of an increase in left leg pain and a decrease in ambulation. An asterisk next to the date 12/07/16 reflected the Progress Note had been edited, according to information located on the bottom of each page of the copied records. A Radiology Interpretation report, dated 12/08/16 at 10:08 p.m., reflected Resident #2 had a displaced left femoral neck acute fracture. The findings reflected there was a a femoral neck fracture with lateral and superior displacement of the distal fragment, no femoral head dislocation, and no significant [MEDICAL CONDITION] changes. A Progress Note dated 12/08/16 at 11:00 p.m. by LVN C reflected the resident was transferred to the emergency room . A late entry in Resident #2's Nurse's Progress Notes entered by LVN C on 12/09/16 at 6:46 a.m. for the date of 12/08/16 at 8:40 p.m. reflected Resident #2 now required two CNAs to assist her to bed because she was unable to stand on her own. The note reflected Resident #2 yelled loudly that it hurt, and she had evident pain with movement. The resident was noted to have a light yellow bruise on her left hip, and range of motion was very limited due to pain. LVN C documented that the on-call physician was notified and x-rays were ordered. The DON and the resident's family were notified. A Nurse's Progress Note entered by the DON, dated 12/08/16 at 12:28 p.m., reflected the DON had spoken to the nurse at the primary physician's office and notified her Resident #2 had pain. She requested a possible x-ray and [MEDICATION NAME] for pain. Resident #2's December 2016 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #2's December 2016 MAR indicated [REDACTED]. The resident was administered one dose of [MEDICATION NAME] at 7:00 p.m. on 12/08/16. A review of the Pain Flow Sheet for December 2016 reflected the resident had documented pain on the following days: 12/04/16 at 7:35 p.m. complaint of back pain 4/10 12/07/16 at 7:50 p.m. complaint of leg pain 5/10 12/07/16 at 7:30 p.m. complaint of leg pain 4/10 12/08/16 at 08:00 a.m. complaint of leg pain 5/10 A review of the Medication Administration Record [REDACTED]. An interview with the DON on 12/20/16 at 11:25 a.m. revealed Resident #2 was normally very active, and she walked in the hallways without her walker. The DON stated she was notified by LVN B at a morning meeting on 12/08/16 that Resident #2 had a new onset of pain with limited mobility. LVN B informed her that he had faxed the resident's physician on 12/07/16 and received an order for [REDACTED]. An interview with the Administrator on 12/20/16 at 1:00 p.m. revealed all faxes sent to the physician were kept in a binder for the physician to sign. The physician would write an order on the original fax and then fax the order back to the facility. She stated she was unable to find the fax LVN B said he had sent to the physician on 12/07/16 to notify him of the resident's change in status. An interview with LVN B on 01/03/17 at 12:15 p.m. revealed, he worked the 6:00 a.m. to 6:00 p.m. shift. He stated upon arriving at work on 12/07/16 he received report from LVN A, who was the off-goign nurse, and LVN A would have informed him if Resident #2 had increased pain and decreased mobility, but he did not remember if this information was shared. He stated Resident #2 continued to experience increased pain and limited mobility during his shift. He stated there was a possibility Resident #2 had a fracture as a result of a previous fall on 11/29/16, so he faxed the resident's Primary Physician. He stated he sent the fax at the end of his shift and then left the facility. He stated it was usual to send a fax rather than call the physician in that type of situation. Following the discovery of Resident #2's fracture, he had received a one-on-one in-service from the DON who advised him to always call the physician along with faxing in any urgent situation. He stated the nurses on each shift would document changes in a resident's status on a 24-hour written report. A review of the 24-hour report dated 12/07/16 reflected Resident #2 had increased pain in her leg with decreased mobility. The report reflected Resident #2 would not stand or walk and screamed when touched. A review of the 24-hour report dated 12/08/16 reflected Resident #2 had increased pain. The report reflected: [MEDICATION NAME] 50 mg one by mouth twice a day. An observation of Resident #2 on 12/20/16 at 12:27 a.m. revealed the resident resided in the secure unit of the facility. The resident was thin and frail. She was confused but able to communicate; however, she was unable to provide any relevant information about her [MEDICAL CONDITION]. An interview with CNA J on 01/03/17 at 1:30 p.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift. She stated on 12/07/16 Resident #2 was ambulatory but complained of pain when she walked. CNA J stated the resident would sometimes say the pain was located in her ankle. She stated on 12/08/16 Resident #2 complained of pain during sitting and standing. CNA J stated the resident complained of ankle hurting, but she was holding on to her thigh area. CNA J stated she notified LVN B, and he told her he would contact the physician. An interview with the DON on 01/03/17 at 2:20 p.m. revealed she thought the incident with Resident #2 occurred due to the difficulty of assessing pain in a resident with dementia. She also attributed the incident to LVN B faxing the physician instead of calling directly to notify him of changes in the resident's status. The DON stated if a physician did not order an x-ray when the nurse thought it was warranted then she would request an order from the physician on call or the Medical Director. Review of faxes sent to the primary physician regarding Resident #2 revealed one fax dated 12/08/16 at 11:50 a.m. sent by LVN B which reflected Resident #2 was experiencing a significant increase in bilateral leg pain and a decrease in ambulation. The LVN requested a trial of routine [MEDICATION NAME] 50 mg twice a day for pain and an x-ray to rule out any problems. The response was a faxed order for [MEDICATION NAME] 50 mg one tablet twice a day dated 12/08/16. A second fax sent by LVN B, dated 12/08/16 at 6:00 p.m., to Resident #2's Primary Physician requested an order for [REDACTED]. The response dated 12/09/16 was above noted there were no new orders. A communication note written by LVN C to Resident #2's Primary Physician, dated 12/08/16 at 11:30 p.m., reflected the On-call Physician had ordered Resident #2 be sent to the hospital after x-rays had shown a fracture. The facility's Change in Resident's Condition or Status policy and procedure, dated August 2011, reflected the following: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . The facility's current Abuse Prevention Program Policy and Procedure dated August 2006 reflected the following: .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Resident Census and Conditions of Residents Form CMS-672 provided by the Administrator on 12/20/16 reflected a census of 77 residents.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for one (Resident #2) of eight residents reviewed for neglect. The facility failed to immediately consult with Resident #2's physician when she experienced a decline in her ability to walk and exhibited signs of pain on 12/06/16 and failed to provide timely intervention and treatment. As a result, Resident #2 went three days without adequate care and services to identify an acute [MEDICAL CONDITION] which required surgical repair. Theses failures placed all 77 residents at risk for not receiving timely and appropriate care in the event of a change in condition. Findings included: The facility's current Abuse Prevention Program Policy and Procedure dated August 2006 reflected the following: .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Resident #2's MDS assessment, dated 09/19/16, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with inattention and disorganized thinking. She also experienced hallucinations, delusions, and had verbal behavioral symptoms directed towards others. The resident was able to walk with limited assistance and required extensive assistance with transfers. Resident #2's Care Plan, dated 07/22/16, reflected the resident had impaired expressive and receptive communication related to confusion and memory loss due to a [DIAGNOSES REDACTED]. Resident #2's Nurse's Progress Notes revealed the DON entered a late entry for 12/06/16 on 12/14/16 at 1:36 p.m., which reflected the resident usually walked quickly down the hallways without using her walker, but now the resident yelled out, Don't kill me! Don't treat me this way!, when assisted to the dining room. The DON assessed the resident who stated her right ankle hurt, and the resident's family stated the resident had a prior history of this complaint. Resident #2's Nurse's Progress Notes entered by LVN A on 12/07/16 at 3:59 a.m. reflected the resident had begun to just sit in a wheelchair and stare at staff as they repeatedly requested for her to assist with undressing and putting on night wear and then transfer into bed. The notes reflected Resident #2 made no effort to stand or assist in the transfer in any way, and she screamed loudly that the staff member was hurting her when she was lifted and transferred by two people. LVN A documented resident seems to be becoming more depressed and uncooperative with care. An interview with CNA I on 01/03/17 at 1:14 p.m. revealed she worked the 6:00 p.m. to 6:00 a.m. shift. She stated on 12/06/16 Resident #2 was sitting in the dining room and would not move when she was asked to get up from her chair. CNA I stated she had to use a gait belt to transfer the resident into a wheelchair and move her to her room. She stated she had never known the resident to require a wheelchair. CNA I stated two CNAs had to assist Resident #2 transfer to her bed, and the resident complained of pain when she was touched anywhere on her body. CNA I stated she notified LVN A who told her the resident would be monitored. An interview with LVN A on 12/20/16 at 2:40 p.m. revealed she worked the 6:00 p.m. to 6:00 a.m. shift. She stated on 12/07/16 Resident #2 had been walking in the hallway as usual; however, the resident began screaming and complaining of pain when staff transferred her to bed that evening. LVN A stated she thought the resident may have been attention-seeking so she did not contact the physician. She stated she would have contacted the physician and requested an x-ray if she thought the resident had an injury. Resident #2's Nurse's Progress Notes entered by LVN B on 12/07/16 at 9:16 a.m. reflected Resident #2 required an extra amount of assistance and encouragement to ambulate, and she now required the assistance of two people. The resident complained of left leg pain, and two tablets of Tylenol 500 mg were administered per PRN orders. A late entry in Resident #2's Nurse's Progress Notes entered by LVN B on 12/13/16 at 8:39 a.m. reflected Resident #2's primary physician had been notified on 12/07/16 for possible pain control and an order for [REDACTED].>A Nurse's Progress Note, dated 12/08/16 at 12:53 p.m., entered by LVN B reflected Resident #2's physician had been notified today after having been notified 12/07/16 of an increase in left leg pain and a decrease in ambulation. An asterisk next to the date 12/07/16 reflected the Progress Note had been edited, according to information located on the bottom of each page of the copied records. A Radiology Interpretation report, dated 12/08/16 at 10:08 p.m., reflected Resident #2 had a displaced left femoral neck acute fracture. The findings reflected there was a a femoral neck fracture with lateral and superior displacement of the distal fragment, no femoral head dislocation, and no significant [MEDICAL CONDITION] changes. A Progress Note dated 12/08/16 at 11:00 p.m. by LVN C reflected the resident was transferred to the emergency room . A late entry in Resident #2's Nurse's Progress Notes entered by LVN C on 12/09/16 at 6:46 a.m. for the date of 12/08/16 at 8:40 p.m. reflected Resident #2 now required two CNAs to assist her to bed because she was unable to stand on her own. The note reflected Resident #2 yelled loudly that it hurt, and she had evident pain with movement. The resident was noted to have a light yellow bruise on her left hip, and range of motion was very limited due to pain. LVN C documented that the on-call physician was notified and x-rays were ordered. The DON and the resident's family were notified. A Nurse's Progress Note entered by the DON, dated 12/08/16 at 12:28 p.m., reflected the DON had spoken to the nurse at the primary physician's office and notified her Resident #2 had pain. She requested a possible x-ray and [MEDICATION NAME] for pain. Resident #2's December 2016 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #2's December 2016 MAR indicated [REDACTED]. The resident was administered one dose of [MEDICATION NAME] at 7:00 p.m. on 12/08/16. A review of the Pain Flow Sheet for December 2016 reflected the resident had documented pain on the following days: 12/04/16 at 7:35 p.m. complaint of back pain 4/10 12/07/16 at 7:50 p.m. complaint of leg pain 5/10 12/07/16 at 7:30 p.m. complaint of leg pain 4/10 12/08/16 at 08:00 a.m. complaint of leg pain 5/10 A review of the Medication Administration Record [REDACTED]. An interview with the DON on 12/20/16 at 11:25 a.m. revealed Resident #2 was normally very active, and she walked in the hallways without her walker. The DON stated she was notified by LVN B at a morning meeting on 12/08/16 that Resident #2 had a new onset of pain with limited mobility. LVN B informed her that he had faxed the resident's physician on 12/07/16 and received an order for [REDACTED]. An interview with the Administrator on 12/20/16 at 1:00 p.m. revealed all faxes sent to the physician were kept in a binder for the physician to sign. The physician would write an order on the original fax and then fax the order back to the facility. She stated she was unable to find the fax LVN B said he had sent to the physician on 12/07/16 to notify him of the resident's change in status. An interview with LVN B on 01/03/17 at 12:15 p.m. revealed, he worked the 6:00 a.m. to 6:00 p.m. shift. He stated upon arriving at work on 12/07/16 he received report from LVN A, who was the off-goign nurse, and LVN A would have informed him if Resident #2 had increased pain and decreased mobility, but he did not remember if this information was shared. He stated Resident #2 continued to experience increased pain and limited mobility during his shift. He stated there was a possibility Resident #2 had a fracture as a result of a previous fall on 11/29/16, so he faxed the resident's Primary Physician. He stated he sent the fax at the end of his shift and then left the facility. He stated it was usual to send a fax rather than call the physician in that type of situation. Following the discovery of Resident #2's fracture, he had received a one-on-one in-service from the DON who advised him to always call the physician along with faxing in any urgent situation. He stated the nurses on each shift would document changes in a resident's status on a 24-hour written report. A review of the 24-hour report dated 12/07/16 reflected Resident #2 had increased pain in her leg with decreased mobility. The report reflected Resident #2 would not stand or walk and screamed when touched. A review of the 24-hour report dated 12/08/16 reflected Resident #2 had increased pain. The report reflected: [MEDICATION NAME] 50 mg one by mouth twice a day. An observation of Resident #2 on 12/20/16 at 12:27 a.m. revealed the resident resided in the secure unit of the facility. The resident was thin and frail. She was confused but able to communicate; however, she was unable to provide any relevant information about her [MEDICAL CONDITION]. An interview with CNA J on 01/03/17 at 1:30 p.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift. She stated on 12/07/16 Resident #2 was ambulatory but complained of pain when she walked. CNA J stated the resident would sometimes say the pain was located in her ankle. She stated on 12/08/16 Resident #2 complained of pain during sitting and standing. CNA J stated the resident complained of ankle hurting, but she was holding on to her thigh area. CNA J stated she notified LVN B, and he told her he would contact the physician. An interview with the DON on 01/03/17 at 2:20 p.m. revealed she thought the incident with Resident #2 occurred due to the difficulty of assessing pain in a resident with dementia. She also attributed the incident to LVN B faxing the physician instead of calling directly to notify him of changes in the resident's status. The DON stated if a physician did not order an x-ray when the nurse thought it was warranted then she would request an order from the physician on call or the Medical Director. Review of faxes sent to the primary physician regarding Resident #2 revealed one fax dated 12/08/16 at 11:50 a.m. sent by LVN B which reflected Resident #2 was experiencing a significant increase in bilateral leg pain and a decrease in ambulation. The LVN requested a trial of routine [MEDICATION NAME] 50 mg twice a day for pain and an x-ray to rule out any problems. The response was a faxed order for [MEDICATION NAME] 50 mg one tablet twice a day dated 12/08/16. A second fax sent by LVN B, dated 12/08/16 at 6:00 p.m., to Resident #2's Primary Physician requested an order for [REDACTED]. The response dated 12/09/16 was above noted there were no new orders. A communication note written by LVN C to Resident #2's Primary Physician, dated 12/08/16 at 11:30 p.m., reflected the On-call Physician had ordered Resident #2 be sent to the hospital after x-rays had shown a fracture. The facility's Change in Resident's Condition or Status policy and procedure, dated August 2011, reflected the following: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . The Resident Census and Conditions of Residents Form CMS-672 provided by the Administrator on 12/20/16 reflected a census of 77 residents.

Based on observation, interview and record review, the facility failed ensure each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (Resident #2) of eight residents reviewed for appropriate care. The facility failed to immediately consult with Resident #2's physician when she experienced a decline in her ability to walk and exhibited signs of pain on 12/06/16 and failed to provide timely intervention and treatment. As a result, Resident #2 went three days without adequate care and services to identify an acute [MEDICAL CONDITION] which required surgical repair. Theses failures placed all 77 residents at risk for not receiving timely and appropriate care in the event of a change in condition. Findings included: Resident #2's MDS assessment, dated 09/19/16, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with inattention and disorganized thinking. She also experienced hallucinations, delusions, and had verbal behavioral symptoms directed towards others. The resident was able to walk with limited assistance and required extensive assistance with transfers. Resident #2's Care Plan, dated 07/22/16, reflected the resident had impaired expressive and receptive communication related to confusion and memory loss due to a [DIAGNOSES REDACTED]. Resident #2's Nurse's Progress Notes revealed the DON entered a late entry for 12/06/16 on 12/14/16 at 1:36 p.m., which reflected the resident usually walked quickly down the hallways without using her walker, but now the resident yelled out, Don't kill me! Don't treat me this way!, when assisted to the dining room. The DON assessed the resident who stated her right ankle hurt, and the resident's family stated the resident had a prior history of this complaint. Resident #2's Nurse's Progress Notes entered by LVN A on 12/07/16 at 3:59 a.m. reflected the resident had begun to just sit in a wheelchair and stare at staff as they repeatedly requested for her to assist with undressing and putting on night wear and then transfer into bed. The notes reflected Resident #2 made no effort to stand or assist in the transfer in any way, and she screamed loudly that the staff member was hurting her when she was lifted and transferred by two people. LVN A documented resident seems to be becoming more depressed and uncooperative with care. An interview with CNA I on 01/03/17 at 1:14 p.m. revealed she worked the 6:00 p.m. to 6:00 a.m. shift. She stated on 12/06/16 Resident #2 was sitting in the dining room and would not move when she was asked to get up from her chair. CNA I stated she had to use a gait belt to transfer the resident into a wheelchair and move her to her room. She stated she had never known the resident to require a wheelchair. CNA I stated two CNAs had to assist Resident #2 transfer to her bed, and the resident complained of pain when she was touched anywhere on her body. CNA I stated she notified LVN A who told her the resident would be monitored. An interview with LVN A on 12/20/16 at 2:40 p.m. revealed she worked the 6:00 p.m. to 6:00 a.m. shift. She stated on 12/07/16 Resident #2 had been walking in the hallway as usual; however, the resident began screaming and complaining of pain when staff transferred her to bed that evening. LVN A stated she thought the resident may have been attention-seeking so she did not contact the physician. She stated she would have contacted the physician and requested an x-ray if she thought the resident had an injury. Resident #2's Nurse's Progress Notes entered by LVN B on 12/07/16 at 9:16 a.m. reflected Resident #2 required an extra amount of assistance and encouragement to ambulate, and she now required the assistance of two people. The resident complained of left leg pain, and two tablets of Tylenol 500 mg were administered per PRN orders. A late entry in Resident #2's Nurse's Progress Notes entered by LVN B on 12/13/16 at 8:39 a.m. reflected Resident #2's primary physician had been notified on 12/07/16 for possible pain control and an order for [REDACTED].>A Nurse's Progress Note, dated 12/08/16 at 12:53 p.m., entered by LVN B reflected Resident #2's physician had been notified today after having been notified 12/07/16 of an increase in left leg pain and a decrease in ambulation. An asterisk next to the date 12/07/16 reflected the Progress Note had been edited, according to information located on the bottom of each page of the copied records. A Radiology Interpretation report, dated 12/08/16 at 10:08 p.m., reflected Resident #2 had a displaced left femoral neck acute fracture. The findings reflected there was a a femoral neck fracture with lateral and superior displacement of the distal fragment, no femoral head dislocation, and no significant [MEDICAL CONDITION] changes. A Progress Note dated 12/08/16 at 11:00 p.m. by LVN C reflected the resident was transferred to the emergency room . A late entry in Resident #2's Nurse's Progress Notes entered by LVN C on 12/09/16 at 6:46 a.m. for the date of 12/08/16 at 8:40 p.m. reflected Resident #2 now required two CNAs to assist her to bed because she was unable to stand on her own. The note reflected Resident #2 yelled loudly that it hurt, and she had evident pain with movement. The resident was noted to have a light yellow bruise on her left hip, and range of motion was very limited due to pain. LVN C documented that the on-call physician was notified and x-rays were ordered. The DON and the resident's family were notified. A Nurse's Progress Note entered by the DON, dated 12/08/16 at 12:28 p.m., reflected the DON had spoken to the nurse at the primary physician's office and notified her Resident #2 had pain. She requested a possible x-ray and [MEDICATION NAME] for pain. Resident #2's December 2016 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #2's December 2016 MAR indicated [REDACTED]. The resident was administered one dose of [MEDICATION NAME] at 7:00 p.m. on 12/08/16. A review of the Pain Flow Sheet for December 2016 reflected the resident had documented pain on the following days: 12/04/16 at 7:35 p.m. complaint of back pain 4/10 12/07/16 at 7:50 p.m. complaint of leg pain 5/10 12/07/16 at 7:30 p.m. complaint of leg pain 4/10 12/08/16 at 08:00 a.m. complaint of leg pain 5/10 A review of the Medication Administration Record [REDACTED]. An interview with the DON on 12/20/16 at 11:25 a.m. revealed Resident #2 was normally very active, and she walked in the hallways without her walker. The DON stated she was notified by LVN B at a morning meeting on 12/08/16 that Resident #2 had a new onset of pain with limited mobility. LVN B informed her that he had faxed the resident's physician on 12/07/16 and received an order for [REDACTED]. An interview with the Administrator on 12/20/16 at 1:00 p.m. revealed all faxes sent to the physician were kept in a binder for the physician to sign. The physician would write an order on the original fax and then fax the order back to the facility. She stated she was unable to find the fax LVN B said he had sent to the physician on 12/07/16 to notify him of the resident's change in status. An interview with LVN B on 01/03/17 at 12:15 p.m. revealed, he worked the 6:00 a.m. to 6:00 p.m. shift. He stated upon arriving at work on 12/07/16 he received report from LVN A, who was the off-goign nurse, and LVN A would have informed him if Resident #2 had increased pain and decreased mobility, but he did not remember if this information was shared. He stated Resident #2 continued to experience increased pain and limited mobility during his shift. He stated there was a possibility Resident #2 had a fracture as a result of a previous fall on 11/29/16, so he faxed the resident's Primary Physician. He stated he sent the fax at the end of his shift and then left the facility. He stated it was usual to send a fax rather than call the physician in that type of situation. Following the discovery of Resident #2's fracture, he had received a one-on-one in-service from the DON who advised him to always call the physician along with faxing in any urgent situation. He stated the nurses on each shift would document changes in a resident's status on a 24-hour written report. A review of the 24-hour report dated 12/07/16 reflected Resident #2 had increased pain in her leg with decreased mobility. The report reflected Resident #2 would not stand or walk and screamed when touched. A review of the 24-hour report dated 12/08/16 reflected Resident #2 had increased pain. The report reflected: [MEDICATION NAME] 50 mg one by mouth twice a day. An observation of Resident #2 on 12/20/16 at 12:27 a.m. revealed the resident resided in the secure unit of the facility. The resident was thin and frail. She was confused but able to communicate; however, she was unable to provide any relevant information about her [MEDICAL CONDITION]. An interview with CNA J on 01/03/17 at 1:30 p.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift. She stated on 12/07/16 Resident #2 was ambulatory but complained of pain when she walked. CNA J stated the resident would sometimes say the pain was located in her ankle. She stated on 12/08/16 Resident #2 complained of pain during sitting and standing. CNA J stated the resident complained of ankle hurting, but she was holding on to her thigh area. CNA J stated she notified LVN B, and he told her he would contact the physician. An interview with the DON on 01/03/17 at 2:20 p.m. revealed she thought the incident with Resident #2 occurred due to the difficulty of assessing pain in a resident with dementia. She also attributed the incident to LVN B faxing the physician instead of calling directly to notify him of changes in the resident's status. The DON stated if a physician did not order an x-ray when the nurse thought it was warranted then she would request an order from the physician on call or the Medical Director. Review of faxes sent to the primary physician regarding Resident #2 revealed one fax dated 12/08/16 at 11:50 a.m. sent by LVN B which reflected Resident #2 was experiencing a significant increase in bilateral leg pain and a decrease in ambulation. The LVN requested a trial of routine [MEDICATION NAME] 50 mg twice a day for pain and an x-ray to rule out any problems. The response was a faxed order for [MEDICATION NAME] 50 mg one tablet twice a day dated 12/08/16. A second fax sent by LVN B, dated 12/08/16 at 6:00 p.m., to Resident #2's Primary Physician requested an order for [REDACTED]. The response dated 12/09/16 was above noted there were no new orders. A communication note written by LVN C to Resident #2's Primary Physician, dated 12/08/16 at 11:30 p.m., reflected the On-call Physician had ordered Resident #2 be sent to the hospital after x-rays had shown a fracture. The facility's Change in Resident's Condition or Status policy and procedure, dated August 2011, reflected the following: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . The Resident Census and Conditions of Residents Form CMS-672 provided by the Administrator on 12/20/16 reflected a census of 77 residents.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #9) of 14 residents reviewed for accident hazards received adequate supervision to prevent accidents. Resident #9 fell out of her wheelchair resulting in a fracture of her left orbital wall (bone below the eye) when there was one CNA on the secure unit, and her back was turned to the resident. On 05/27/14, there was only one CNA on the secure unit, who was giving a resident a shower. These failures could affect the other nine residents, who were marked as a high fall risk on the secure unit, by placing them at risk for falls with significant injuries. Findings included: Resident #9's MDS assessment, dated 02/28/14, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS also reflected Resident #9 was not able to complete a BIMS due to her impaired cognition. She required extensive assistance of two people for transfers and was marked to be unsteady, only able to stabilize with staff assistance. A Fall Risk Evaluation, completed on 02/27/14, reflected Resident #9 scored an "18" out of 20. Residents with a score over 10 or higher are at risk. Resident #9's care plans, created on 06/06/13, and updated on 05/17/14 reflected: "Resident is at risk for falls related to: Cognitive impairment Unsteady gait Goal: Dignity will be maintained. Resident will not experience injuries from falls. Approaches: ...Resident is on the falling star program Provide prompt assistance Try to anticipate needs of resident." An incident report, dated 05/17/14, reflected Resident #9 was found on the floor in front of her wheelchair. CNA B was gathering equipment for patient care in the dining room of Hall 2 when she heard the resident yell. Another resident in the activity room said she saw her lean forward too far and Resident #9 fell forward. Injuries were noted to her head and she was sent to the ER for evaluation. Review of the report from the hospital, dated 05/17/14, revealed Resident #9 had suffered a Fracture to the Inferior Orbital Wall as a result from a fall. Observation on 05/27/14 at 10:45 AM, revealed Resident #9 was residing on the secure unit, and was in the TV room sitting in the recliner while a CNA stroked her hair. Bruising was noted to the resident's left eye and cheek. It extended from the left side of her chin up around her eye. The bruising was dark purple in color. Observation on 05/29/14 at 10:15 AM, revealed Resident #9 was in bed turning herself. The bed was in the low position with the bed alarm in place. There was a CNA giving a shower to a resident, the door was open and an accordion privacy panel was placed around the shower door. There were three residents in the TV room and two other residents sitting at the dining room table unsupervised. At 10:30 AM, CNA D was observed walking into the secure unit holding a soda can. Interview on 05/29/14 at 10:30 AM with CNA D revealed she had been on her break. She stated there were always two staff members on the secure unit unless one of them was on break. CNA D stated after breakfast things were calm so she decided to take her 15 minute break. Interview on 05/29/14 at 10:15 AM with CNA B revealed she was taking laundry out of the unit the day of the incident after giving Resident #9 a shower, and had gone ahead and taken a quick break. When she went back into the secure unit "everyone" was there and Resident #9 was on the floor. Resident #9 had a bed alarm and a history of leaning forward when she was in her wheelchair. Staff would usually try to put Resident #9 to bed when she began to lean because that was an indication she was tired. CNA B also stated there were always two staff members on the secure unit during the day unless one of them was on break and that would leave one staff member on the unit. Interview on 05/29/14 at 10:39 AM with CNA C revealed on the day of the incident, CNA B had taken linens out of the unit and CNA C had just finished blow drying Resident #9's hair. Resident #9 had wheeled away while CNA C had her back turned, and she heard Resident #9 yell. When she turned she saw Resident #9 on the floor. She then got a charge nurse to assist. Resident #9 was a high fall risk due to her mental state. Resident #9 would always lean in her wheelchair and that usually meant she was tired and staff would assist her to bed. Another resident on the unit who was fairly cognitive told CNA C that Resident #9 had leaned forward and fell out of her chair. CNA C also stated there was always two staff members on the secure unit unless one was on break, leaving one staff member on the unit. Interview on 05/29/14 at 10:55 AM with LVN A revealed she was out to lunch when the incident with Resident #9 occurred. When she returned, a CNA told her that Resident #9 had just gotten showered and the other CNA had taken linens out of the unit. While the CNA's head was turned she heard Resident #9 yell and saw her on the floor. Resident #9 was always leaning in her wheelchair and grabbing for things. LVN A also stated Resident #9 had falls in the past when she was first admitted to the facility. Interview on 05/29/14 at 11:05 AM with the DON revealed during the day, there were two CNAs on the secure unit. When one of them took a break, they should have someone relieve them so there was always two staff members on the unit, unless they believed things were calm and then they could leave for break. She stated the facility staff had been in-serviced in the past regarding adequate supervision on the secure unit. The DON stated she did not believe it was a reportable incident because they knew what happened and another resident had witnessed it. An undated Fall Management Policy, provided by the DON on 05/29/14, reflected the following: "1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. 2. Qualified staff will complete the Fall Risk Evaluation to determine of patient/resident is a fall risk. 3. A patient/resident fall management program will be implemented that educates staff in creative functional strategies while recognizing patients/residents and their need to maintain the highest practical level of function." A list provided by the DON on 05/29/14, reflected there were 10 residents who were a high fall risk on the secure unit. .