Every finding on record at Bonne Vie

Based on interview and record review, the facility failed to assess each resident once every three months, using the quarterly review instrument specified by the state and approved by CMS, for 1 of 26 residents (Resident #1) reviewed for quarterly assessments. The facility failed to ensure Residents #1 had a quarterly MDS assessment completed within three months from the previous assessment.This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings included:Record review of Resident #1's face sheet, dated 03/04/2026, indicated Resident #1 was [AGE] year-old male, admitted [DATE], with diagnoses of dementia (a decline in mental ability - specifically memory, thinking, and reasoning) and hypertension (elevated blood pressure). Record review on 03/04/2026 at 10:00 a.m., Resident #1's medical record indicated an admission MDS was completed on 10/29/2025 and a subsequent quarterly MDS ARD was 01/29/2026. Further record review indicated a Quarterly MDS for Resident #1 was not initiated nor completed. During a joint interview on 03/04/2026 at 10:50 a.m., MDS Nurse A said Resident #1 was on managed care for over 100 days. She said their computer system failed to trigger a quarterly MDS as being due. She said Resident #1 was still on skilled services. She said unless she went in and looked at each resident, she did not know when MDSs were overdue while receiving skilled services. She said this was an oversight on her part and she just missed it. MDS Nurse B said Resident #1 was on skilled services for over 100 days and Resident #1's quarterly MDS was missed. MDS Nurse A and MDS Nurse B both said they were educated on MDS accuracy. MDS Nurse B said not completing MDS assessments could possibly result in care plan inaccuracy, negative outcomes to the residents, and could also affect payor source. During an interview on 03/04/2026 at 12:50 p.m., the DON said the MDS nurses were responsible for the timely completion of each MDS assessment. She said her expectations were for all MDS assessments to be completed accurately and timely, as the MDS reflected the resident and necessary care and services provided. During an interview on 03/04/2026 at 12:55 p.m., the EDO said he expected all MDS assessments to be completed timely per guidelines. Record review of facility policy titled, MDS 3.0 completion, dated October 2025, indicated, . Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. 2.e. Quarterly Assessment - completed using an ARD no > (longer than) 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD).Review of the RAI manual, dated October 2019, indicated, quarterly assessments are completed by calculating from the ARD (assessment reference date) of the previous assessment plus 92 calendar days.

Based on interview and record reviewed, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 26 residents records reviewed for MDS assessments. (Residents #127) The facility failed to ensure the discharge MDS assessment was completed and transmitted as required for Resident #127. This failure could place residents at risk for MDS assessments not being transmitted and not receiving care and services as needed. Findings included: Record review of admission record for Resident #127, dated 03/04/2026, indicated Resident #127 was admitted on [DATE], [AGE] years old with diagnoses of anxiety, high blood pressure, heart failure and chronic pain. The admission record included the date of discharge was 09/09/2025. Record review of Resident #127's transfer record, dated 09/09/2025, indicated she was transferred to the local hospital with physician's orders. Record review of Resident #127's discharge MDS assessment, dated 09/09/2025, indicated she was discharged on 09/09/2025 however the MDS was not completed, signed or transmitted. Record review of the electronic record for Resident #127 indicated a list of MDSs, dated 08/30/2025 to 09/9/2025, revealed the discharge MDS was not completed, signed or transmitted. The discharge MDS assessment indicated the status was in progress and was 162 days late. During an interview on 03/04/2026 at 11:00 a.m., MDS Nurse B said Resident #127's discharge assessment was not completed, signed or transmitted. She said she was unsure who started the discharge MDS assessment and said she would complete the assessment. During an interview on 03/04/2026 at 12:50 p.m., the DON said the MDS nurses were responsible for the timely completion and transmitting each MDS assessment. She said her expectations were for all MDS assessments to be completed accurately and timely as the MDS reflected the resident and necessary care and services provided. During an interview on 03/04/2026 at 12:55 p.m., the EDO said he expected all MDS assessments to be completed timely per guidelines. Record review of facility policy titled, MDS 3.0 completion, dated October 2025, indicated, . Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. f. Discharge Assessment-completed using the discharge date as the ARD. Must be completed within 14 days of the discharge date /ARD. Review of the RAI manual, dated October 2024, indicated, Discharge Assessment - return anticipated (Non-Comprehensive) completion date was discharge date plus 14 calendar days and MDS Completion Date plus 14 calendar days.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #21) reviewed for activities of daily living. The facility failed to clean, trim, and clip Resident #21's fingernails. This failure could place residents at risk of not receiving care and services to meet their needs, feelings of poor self-esteem, and lack of dignity and health.Findings included: Record review of Resident #21's face sheet, dated 03/03/2026, indicated a [AGE] year-old male, re-admitted [DATE]. Diagnoses included injury to unspecified level of lumbar spinal cord (a spinal cord injury that does not have a clearly defined location or severity, impacting motor and sensory functions in the lower body), paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body), pain, personal history of traumatic brain injury (brain injury that is caused by an outside force) and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #21's MDS, dated [DATE], indicated a BIMS score of 13, indicating he was cognitively intact. Record review indicated he was dependent on staff to provide self-care including oral hygiene, toileting, shower/bathe, upper and lower bod dressing, putting on/taking off footwear and personal hygiene. He had impaired range of motion to both lower extremities and required an electric wheelchair for mobility. Record review of Resident #21's care plan, dated 03/09/2025, indicated he had a self-care performance deficit and was dependent on staff for most ADLs. Record review indicated an intervention for bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Record review of Resident #21's bedside electronic system utilized for documenting, organizing and easily referencing resident information, indicated on 03/03/2026, his task of bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During a record review of Resident #21's task assignments for bathing, dated 02/03/2026 to 03/02/2026, indicated he received a bed bath three times a week by the CNAs with no indication of nail care offered or provided. During an observation and interview on 03/02/2026 at 11:05 a.m., Resident #21's fingernails were not clean, trimmed, nor cut. His nails on fingers and thumbs of both hands were uneven, jagged edged, and were approximately 1.5 cm in length, and all his fingernails had brown substance underneath. During an interview with Resident #21, he said he liked his fingernails cleaned and cut. He said he did not like his nails that long and the staff had not offered to cut his nails. He said he bathed three times a week, but the CNA did not offer to cut or trim his nails during his bath. He said he would like his nails trimmed for comfort. During an observation on 03/03/2026 at 1:21 p.m., Resident #21 was visiting with family in the front lobby. His fingernails remained long with jagged edges, and dirty. During an observation and interview on 03/04/2026 at 12:20 p.m., Resident #21 was up in his electric wheelchair in his room. He said CNA C provided him with a bath yesterday evening and cut, cleaned, and trimmed his fingernails. His fingernails were clean, trimmed, and well-manicured. During an interview on 03/04/2026 at 1:18 p.m., CNA C said she worked as a prn CNA, and she was the CNA assigned to care for Resident #21 on 03/03/2026 for the 2:00 p.m. - 10:00 p.m. shift. CNA C said she provided Resident #21 with a bed bath. CNA C said she trimmed and cleaned his fingernails because they were too long, jagged and dirty. She said that trimming and cleaning nails were part of a bath and residents' nails should be kept trimmed and cleaned to prevent scratching and poor hygiene. CNA C said she received training regarding nail care procedures. During an interview with the DON on 03/04/2026 at 1:45 p.m., she said staff should have cleaned, trimmed, and cut Resident #21's nails, and all residents' nails should be kept clean and trimmed, if desired. She said it is the CNAs responsibility to clean and trim nails during routine baths except for the brittle diabetic residents, whose r nails are trimmed by nursing or podiatry. The DON said if residents' nails are not cleaned, trimmed, or cut it would increase risk of skin impairment, infection, and/or decrease in activities of daily living (difficulty picking up objects/food). During an interview with the EDO on 03/04/2025 at 2:0 p.m., he said he expected staff to clean, trim, and cut Resident #21's nails as desired. He said he expected staff to provide nail care to all residents' nails regularly and as needed for good hygiene. Record review of the facility's policy titled, Nail Care, dated 10/01/2025, indicated, Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. c. The person(s) responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). 6. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file fingernails of residents with diabetes. Toenails of residents with diabetes or circulation problems shall be filed only. c. If a resident has a toe infection, diabetes mellitus, neurologic disorders, renal failure, or PVD, toenail trimming should be performed by a physician or practitioner. d. Resident without complicating disease processes, may have their toenails clipped by staff who have received education and training to provide this service within professional standards of practice and as per facility policy. e. Each resident will have his/her own nail care equipment (e.g., clippers, emery boards, files, etc.). Equipment will not be shared between residents. Clean equipment after each use and before storing.

Based on observation, interview and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 8 medication carts (Medication cart D) reviewed for medication storage. The facility failed to ensure the narcotic box was attached and secured with double locks in Medication cart D. This failure could place residents at risk for drug diversion. Findings included: During an observation and interview on 03/04/2026 at 10:40 a.m., LVN D said this was the medication cart D. During observations of items in the medication cart, the narcotic box was not attached to the drawer and the narcotic box lifted off the drawer. The narcotic box freely slid out of the medication cart and exposed the narcotics. The medication cart drawer was the bottom of the box, which left the narcotics only secured by one lock on the medication cart. LVN D said she was unaware the narcotic drawer was loose and not secured. She said narcotics required two locks to prevent the risk of drug diversion. During an interview on 03/04/2026 at 10:45 a.m., the Maintenance Supervisor said he was not told the drawer was broken or not attached. He said he does not normally check medication carts routinely. The Maintenance Supervisor said if the nurses reported a concern, he would have fixed it. During an interview on 03/04/2026 at 10:47 a.m., the DON said she ordered a new medication cart every month for the last few months; however, she was unaware of this cart having an unsecured narcotic box. She said now she was aware the narcotic box could be lifted out; she would have nurses check that when they count each shift. Record review of Medication Storage policy dated 2025 indicated Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. 2. Narcotics and Controlled Substances: a. Schedule II drugs and back -up stock of Schedule III, IV and V medications are stored under double-lock and key.

Based on interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for quality of care. The facility failed to conduct a comprehensive bowel elimination assessment and document 's bowel pattern in the electronic health record for 2 of 3 shifts on 11/28/2025 and 2 of 3 shifts on 11/29/2025. This failure could place residents at risk for not receiving bowel assessments leading to fecal impactions. Findings included: Record review of Resident #1's face sheet, dated 12/03/2025, indicated she was a 72- year- old female, re-admitted [DATE], with diagnoses of constipation (hard stool), anemia (reduced oxygen to body), dementia (decline in cognitive function, (affecting memory, and thinking), pain, cognitive communication deficit (difficulty communicating). Record review of Resident #1's care plan, dated 11/17/2025, indicated she was incontinent of bowel and at risk for constipation. The listed goal was for Resident #1 not to experience constipation and have a normal bowel pattern elimination. The listed intervention was to assess and document Resident #1 for usual bowel movement history, describing her usual pattern, time of day, amount/ frequency, color, and consistency of stool. RNs and LVNs to assess and RNs, LVNs, and CNAs to document findings. Record review of Resident #1's Minimum Data Set, dated [DATE], indicated she had a BIMS score of 4 indicating severe cognitive impairment. Section GG- Functional Abilities, indicated Resident #1 was dependent on staff to meet her urinary and bowel incontinent needs. Section H- Bladder and Bowel, indicated Resident #1 was always incontinent of bowel. Record review of Resident #1's medication administration record, dated November 2025 indicated she received scheduled Acetaminophen- codeine (Opioid- pain medication) tablet 300-60 milligram by mouth four times a day and tizanidine (sedative/ hypnotic- muscle relaxant) tablet 2 milligram by mouth two times a day. Record review of Resident #1's order summary, dated 12/02/2025, indicated she had orders for the facility to monitor opioid side effects: In part- closely monitor for constipation every shift. Record review of Resident #1's order summary, dated 12/02/2025, indicated she had orders for the facility to monitor sedative/ hypnotic side effects: In part- observe closely for significant side effects of sedative/ hypnotic medication including constipation every shift. Record review of Resident #1's hospital notes dated 11/21/2025-11/24/2025 indicated she was admitted to the hospital with bradycardia (slow heart rate) and received two units of blood due to low blood count. The hospital report indicated patient is having stool impaction she received enema last night, but it did not help. Will consult surgery. Resident #1 had the fecal impaction removed during a colonoscopy. Discharge diagnosis of fecal impaction, bradycardia. Record review of Resident #1's assessments dated 11/28/2025-11/29/2025 indicated there was no nursing bowel assessment initiated nor completed by an RN or LVN when she went without a bowel movement four days after hospital discharge for fecal impaction, and bradycardia (slow heart rate). Record review of nursing staff schedule and bowel elimination dated 11/28/2025-11/29/2025 indicated: 11/28/2025-Shift: 6 a.m.- 2:00 p.m.- LVN A did not assess Resident #1 bowels nor document if resident had a bowel movement. 6 a.m.- 2:00 p.m.- CNA D did not document if Resident #1 had a bowel movement. 10:00 p.m.- 6:00 a.m.- LVN B did not assess Resident #1 bowels nor document if resident had a bowel movement. 10:00 p.m. -6:00 a.m.- CNA E did document if Resident #1 had a bowel movement. 11/29/2025-Shift: 2:00 p.m.- 10:00 p.m.- RN C did not assess Resident #1 bowels nor document if resident had a bowel movement. 2:00 p.m.- 10:00 p.m.- CNA F did not document if Resident #1 had a bowel movement. During an attempted interview with Resident #1 on 12/02/2025 at 10:50 a.m., she was being transported out of the facility to the hospital by medical transport unrelated to constipation. Resident #1 did not return to the facility during investigation. During an interview with the facility nurse practitioner on 12/02/2025 at 1:30 p.m., he said nursing should have done a bowel assessment on Resident #1 when she had not had a bowel movement for two days due to her recent fecal impaction that was surgically removed four days ago. He said he had not given the facility an order for a two-day assessment. During an interview with the facilities physician on 12/02/2025 at 2:00 p.m., he said Resident #1 was sent to the hospital due to a syncope episode and bradycardia. The hospital discovered she was impacted with stool in her colon that the hospital removed. He said the nurses were responsible for assessing, monitoring, documenting and reporting changes in Resident #1's bowel patterns. During an interview with unit manager G on 12/02/2025 at 2:15 p.m., she said nurses were responsible for assessing, monitoring, documenting and reporting changes in Resident #1's bowel patterns. She said the CNAs was also responsible for documenting Resident #1's bowel patterns each day in the electronic medical records. The unit manager G said she expects the nurses to assess Resident #1's bowel each shift to ensure no impaction was forming due to and CNAs to follow Resident #1's care plan for her bowels. She said documentation indicated LVN A, LVN B, RN C did not assess Resident #1 bowels on 11/28/2025-11/29/2025 nor document it in the electronic medical records. She said CNA D, CNA E, CNA F failed to document if Resident #1 had a bowel movement on 11/28/2025-11/29/2025. During an interview with the DON on 12/02/2025 at 2:45 p.m., she said a bowel assessment should have been completed and documented by the LVN A, LVN B, RN C to ensure Resident #1 was not constipated. She said the CNA's are expected to document if a resident had a bowel movement or not per shift and report it to their nurse. She said it is her responsibility to ensure assessments were initiated and facility policy complied and follow up with staff to ensure assignments are carried out. She said the CNA D, CNA E, and CNA F did not document or report to their nurses whether Resident #1 had a bowel movement on their shift. She said if the CNA did not document resident's bowel movements, then the nurse should have assessed Resident #1 to ensure she was not constipated due to her taking medications that had side effects of constipation. She said when Resident #1 was re-admitted from the hospital the facility physician ordered docusate sodium (stool softener, twice a day), glycolax powder (laxative), and milk of magnesium (laxative- as needed.)(The DON said all staff had been in-serviced on expectations with bowel continence and incontinence on 06/18/2025. She said all staff had been in- serviced on assessments on 07/30/2025. She said nurses physically assessing residents bowels and documenting the findings minimize the risk of fecal impaction to residents. During an interview with the Administrator on 12/02/2025 at 3:05 p.m., he said the nurses were responsible for assessing, monitoring, documenting and reporting changes in Resident #1's bowel patterns. He said the LVN A, LVN B, RN C were responsible to assess and document if she had a bowel movement. He said the CNA D, CNA E, and CNA F were responsible for documenting Resident #1's bowel patterns and reporting findings each day in the electronic medical records and failed to do so. During an interview with LVN A on 12/03/2025 at 12:32 p.m., she said she did not assess Resident #1's bowels on 11/28/2025 on the 6:00 a.m.- 2:00 p.m. shift because she had not showed any symptoms of constipation. She said she was aware that Resident #1 took medication that had side effects of constipation. LVN A said she did not know CNA D did not document Resident #1's bowels for the shift in the electronic medical record. She said she did not follow up with CNA D to ensure bowel pattern was documented on Resident #1 for the 6:00 a.m.-2;00 p.m. shift on 11/28/2025. She said she should have documented Resident #1's bowel pattern on her shift since CNA did not. During an interview with CNA D on 12/03/2025 at 12:38 p.m., she said she did not document Resident #1 bowel pattern in the electronic medical record on 11/28/2025 on the 6:00 a.m.- 2:00 p.m. shift because the computers were not working. She said she did not think to inform LVN A because her nurse had experienced computer problems. During an interview with LVN B on 12/03/2025 at 12:45 p.m., she said she did not assess Resident #1 bowels on 11/28/2025 on the 10:00 p.m.- 6:00 a.m. shift. She said she was aware that Resident #1 took two medications that had side effects of constipation. LVN B said she was aware that Resident #1 had a fecal impaction that required surgery when she cared for her four days after hospital discharge. She said she relied on the computer to alert her when Resident #1 had gone 3 days without a bowel movement. She said a staff member has to enter bowel movement data for the computer system to alert them that a resident had gone 3 days without a bowel movement. She said if residents do not inform her that they are constipated or show signs of constipation then she does not assess/ touch the residents stomachs every day. She said it's the CNA's and the charge nurse's responsibility to ensure residents bowel patterns are recorded. An interview with CNA E was attempted two times by telephone (12/03/2025- 12:05 p.m., 12/03/2025- 12:38 p.m.- voicemail left.) Surveyor was unable to speak with CNA E regarding the reason she did not document Resident #1 bowel pattern in her medical records for 11/28/2025 on the 10:00 p.m.- 6:00 a.m. shift. An interview with CNA F was attempted 12/5/2025 at 1:20 p.m., the DON said CNA F does not have a working telephone. Surveyor was unable to speak with CNA E regarding the reason she did not document Resident #1 bowel pattern in her medical records for 11/29/2025 on the 2:00 p.m.- 10:00 p.m. shift. During an interview with RN C on 12/03/2025 at 1:20 p.m., she said she did not physically assess Resident #1's bowels on 11/29/2025 on the 2:00 p.m.- 10:00 p.m. shift because Resident #1 had not gone past three days without a bowel movement. She said she was aware that Resident #1 took two medications that had side effects of constipation. She said she was not aware that Resident #1 had orders to be monitored every shift for sedative/ hypnotic side effects such as constipation. She said she did not ask Resident #1 about her bowels because the computer did not flag or alert her that Resident #1 went without a bowel movement for three days or more. She said the CNA's cannot assess residents bowels, the nurses must do so. RN C said she knew Resident #1 had a fecal impaction removed surgically four days ago and was not aware of what was on her updated care plan interventions said related to constipation. During an interview with the Regional Director of clinical services on 12/03/205 at 1:45 p.m., she said the facility was unable to provide documentation showing a bowel assessment was completed on 11/28/2025-11/29/2025.She said the nurses were responsible for assessing Resident # 1's bowels and documenting their findings in the electronic medical records. She said she expected the nursing staff to follow facility policy to ensure residents' needs were met. She said nurses assessing resident's bowels and documenting the finds minimized the risk of fecal impaction. During an interview with Resident #1's family member on 12/03/2025 at 2:00 p.m. he said Resident #1 was impacted with stool in her colon and required surgery to remove the hard stool. Resident #1's family member stated, her stool was the size of a 20-ounce tumbler. Resident #1's family member said he expected Resident #1 to be checked for constipation every shift and as needed because she cannot verbalize her needs because of her advanced dementia. Record review of facility policy CONTINUING CARE NETWORK PATIENT CARE MANAGEMENT SYSTEM 6 -Continence dated 09/2025 indicated: 1. The continence status of all patients will be evaluated upon admission, readmission, quarterly, and as needed through the completion of a Bowel and Bladder Assessment by a licensed nurse. Based on the total outcome score, the patient will be evaluated for candidacy of an appropriate continence maintenance program. See the attached Continence Management Protocols. 2. If the Patient scores 0 through 6 on the Bowel and Bladder Assessment, the Patient must be placed on the Incontinence Care Protocol.4. A Bowel and Bladder Management Record must be initiated for each Patient based on the elimination pattern documented on the Continence Diary. The Patient Care Plan and Daily Care Guide/ Kardex must be updated to reflect interventions related to continence/incontinence. 5. A Patient on a Continence Management Program must have a Weekly Continence Progress Note completed by the charge nurse at least every 7 days.

41057 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 3 of 24 residents reviewed for care plans. (Residents #28, #42, & #87) The facility did not include interventions and goals for Resident #28's hospice care plan. The facility did not have a care plan to address Resident #42's use of Trazadone. The facility did not have a care plan to address that Resident #87 was PASRR positive and refusing services. These failures could place residents at risk of not having their individual needs met and not receiving needed services. Findings included: 1. Record review of a face sheet dated 12/18/24 indicated Resident #28 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included cerebral infarct (stroke). Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #28 had a BIMS score of 14 indicating cognitively intact and indicated she received hospice care. Record review of physician''s orders dated 12/18/24 indicated Resident #28 was admitted to hospice services as of 08/23/24 for diagnoses of cerebral infarct. Record review of Resident #28''s care plans printed 12/18/24 indicated Resident #28 required hospice services but did not include any goals or interventions related to the hospice services. During an observation on 12/16/24 at 09:30 a.m., Resident #28 was lying in bed, she said she was treated well but was unsure if she received hospice services. 2. Record review of a face sheet dated 12/16/24 indicated Resident #42 was a [AGE] year-old male admitted on [DATE]. Her diagnoses included depression (a mental health condition that can affect how a person thinks, feels, and behaves). Record review of the most recent admission MDS assessment dated [DATE] indicated Resident #42 had a BIMS score of 10 indicating moderately impaired of cognition with no mood symptoms in the last 14 days and no behavior symptoms in the last 7 days. Record review of physician''s orders dated 12/18/24 indicated Resident #42 was prescribed trazadone 50 mg at bedtime for depression with a start date of 11/19/24. Record review of Resident #42''s December 2024 MAR indicated she received trazadone 50 mg daily at bedtime for depression with a start date of 11/19/24. Record review of Resident #42's care plans printed 12/17/24 did not indicate Resident #5 received the antidepressant medication trazadone. During an observation 12/17/24 at 09:54 a.m., Resident #42 was lying in bed, he said he was unsure of what medications he received. 3. Record review of a face sheet indicated Resident #87 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs) and major depressive disorder (a serious mental illness that affects how people feel, think, and act). Record review of a PASRR (Preadmission Screening and Resident Review) level 1 Screening dated 3/5/24 indicated Resident #87 was PASRR positive due to a mental illness. Record review of an annual MDS assessment dated [DATE] indicated Resident #87 had a BIMS score of 13 indicating her cognition with intact and she was currently by state level II PASRR process to have serious mental illness. Record review of a quarterly PASRR Comprehensive Service Plan (PCSP) dated 09/05/24 indicated Resident #87 was refusing PASRR services. Record review of a care plan last updated 09/20/24 indicated Resident #87 had no care plan identifying she was PASRR positive and was refusing PASRR services. During an interview on 12/17/24 at 9:57 a.m., Resident #87 said she felt well balanced and good at the facility. She said she was receiving psychiatric services. She said she didn't need other services and had refused services offered in the PASRR meetings. During an interview on 12/18/24 at 10:48 a.m., LVN C said she was providing care for Resident #28 and #42 on 12/18/24. She said Resident #28 received hospice services and should have been care planned for the hospice services with goals and interventions and was not. She said Resident #42 received trazadone daily and should have been care planned for trazadone and was not. LVN C said the Unit Managers were responsible for care plans. During an interview on 12/18/24 at 10:50 a.m., Unit Manager A said she was responsible for care planning Resident #28's hospice goals and interventions. She said the goals and interventions should have been care planned but were not. Unit Manager A said she was responsible for care planning Resident #42's trazadone. She said it should have been care planned but was not. She said they were overlooked. Unit Manager A said she was educated on care plans and was aware to care plan the hospice goals and interventions and the antidepressant medication. She said the resident risk of Resident #28 not care planned for her goals and interventions for hospice and Resident #42's antidepressant medication was the nurses could be unaware of the care and services the resident's received. During an interview on 12/18/24 at 11:08 a.m., MDS Nurse D said she was responsible for writing PASRR care plans. She said Resident #87 qualified for PASRR services but was refusing the services. She said the resident should have a care plan to address that she was PASRR positive, refused PASRR services, and quarterly meetings were being held to offer services and document Resident #87's refusal. She said she just overlooked writing a PASRR care plan because the resident was not receiving PASRR services. She said she had received PASRR training through HHSC, her corporate office, and webinars. She said a possible negative outcome of not having a PASRR care plan was staff would not be aware Resident #87 was PASRR positive, refused services, and the quarterly meetings held. During an interview on 12/18/24 at 11:18 a.m., the DON said she and other nursing administration were responsible for overseeing care plans and nursing administration met quarterly to review care plans for accuracy. She said the nursing staff were educated on accuracy and completeness of care plans. She said the missed care plans were overlooked. The DON said the resident risk of missed care plans was the potential risk of the nurses being unaware of the resident plan of care. She said she expected all care plans to be updated and completed timely. During an interview on 12/18/24 at 11:22 a.m., the Administrator said nursing was responsible for completed care plans. He said the staff were educated on care planning. The Administrator said the resident risk of services or medication not care- planned was potentially the nurses may not know the plan of care. He said he expected all care plans to be completed timely and accurately. Record review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022 indicated . The comprehensive person-centered care plan: a. includes measurable objectives and time frames; B. describes the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASRR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice and problem areas and conditions.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure LVN A did not verbally abuse Resident #1 when she yelled, screamed, and made intimidating remarks at the resident on 12/05/2023. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Record review of Resident #1's face sheet, dated 11/11/2024, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (loss of cognitive functioning), transverse myelitis (is a rare, acquired focal inflammatory disorder often presenting with rapid onset weakness, sensory deficits, and bowel/bladder dysfunction), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), calculus of kidney (kidney stones - hard deposits made of minerals and salts that form inside your kidneys), hypertension (a condition in which the force of the blood against the artery walls is too high), atherosclerotic heart disease of native coronary artery (a condition where the blood vessels become narrowed and hardened due to buildup of fats in the blood vessel wall), and history of falls. Record review of Resident #1's quarterly MDS Assessment, dated 12/06/2023, indicated he was usually able to make himself understood and usually understood others. He had moderate difficulty hearing. He had moderate cognitive impairment, identified with a BIMS score of 8. Record review of Resident #1's care plan, effective on 08/10/2022, indicated the resident was at risk for falls and had a fall 12/05/2023. The interventions included placed call bed/light within easy reach and keep areas free of obstruction to reduce the risk of falls or injuries. The resident had potential risk for injury due to unsafe independent transfer as identified by the nursing/rehab assessment. The interventions include educate patient/responsible party on proper lift/transfer; patient to transfer with assistance of two or more and use of gait belt or stand aid; if staff feels the transfer technique is in appropriate, notify supervisor immediately to determine a safe and appropriate manner of transfer; notify the DON/physician and responsible party of any incident involving transfers; and encourage patient to requested needed assistance in all transfers and keep call light in reach. Record review of Resident #1 progress note dated 12/05/2023 at 5:21 p.m. authored by LVN A indicated Resident #1 sitting on floor at foot of bed, no apparent injury noted or voiced. IV team here to put in IV to left upper arm. Record review of the Incident Self Report, dated 12/05/2023, indicated Resident #1 was verbally abused by LVN A speaking to him in a verbally abusive tone. During the investigation, a witness interview with LVN B corroborated the statement. Assessment of Resident #1 showed no signs of physical injury or emotional distress. Record review of a Facility Investigation Report, dated 12/05/2023, indicated the incident was reported on 12/05/2023 and occurred between 5:00 p.m. and 5:30 p.m. on 12/05/2023. LVN C provided head to toe assessment to Resident #1 on 12/05/2023 indicating no signs of physical injury or emotional distress. The Administrator and DON interviewed Resident #1 individually as part of the facility investigation and he reported feeling safe at the facility. The investigation summary confirmed (and witnessed) verbal abuse. LVN A's employment was terminated effective immediately. Provider action taken post investigation was continued education and in service on prevention of abuse and neglect. The alleged perpetrator (LVN A) was placed on suspension during the investigation and terminated during the investigation process. Facility staff were in-serviced on Abuse Neglect and Resident Rights. During an interview on 11/11/2024 at 1:45 p.m., LVN B said he was working on 12/05/2023 and was requested to assist LVN A to get Resident #1 off the floor after a fall. LVN B said when he entered the room, LVN A was already in the room standing near Resident #1 and he heard LVN A say, he should be restrained to the bed, and he had fallen multiple times today. LVN B said that during the transfer Resident #1 appeared upset with LVN A and he tried to speak calmly to the resident. LVN B said while transferring Resident #1 back to bed that Resident #1 and LVN A made negative statements like don't touch me, you are always grabbing your dick with those hand (s) and pervert, nasty person. LVN B said that during the transfer Resident #1 scratched LVN A and she said, hope I don't get an infection from the scratch from that nasty person. LVN B said that LVN A left the room, and he tried to calm Resident #1. LVN B said that another person (Outside Vendor X) was in the room and witnessed some of the incident. LVN B said Outside Vendor X started talking with Resident #1 and he seemed calmer, and she began providing care, so he (Vendor X) exited the room. LVN B said that he considered the incident as verbal abuse towards Resident #1 because LVN A was using verbal aggressive behaviors while caring for resident. LVN B said he reported the incident to the UM, DON, and the Administrator/AC and that the other person (Outside Vendor X) in the room had already reported the incident as well. During an interview on 11/12/2024 at 11:27 a.m., UM C said she recalled the incident between Resident #1 and LVN A, she said she was notified concurrently by DON and facility staff of the incident. UM C said she immediately returned to the facility and contacted LVN A prior to her arrival to facility and directed her to not provide any care to any residents and complete any unfinished documentation for her shift. UM C said she arrived at the facility in less than 30 minutes, briefly discussed allegation and suspended LVN A, took report, did medication cart count, and directed LVN A to leave the facility and told her she would be contacted during the investigation process. UM C said she took over the responsibilities of CN for LVN A. UM C said she immediately assessed Resident #1 and identified no injuries or distress. UM C said that during the follow-up assessment that Resident #1 was confused which was a preexisting issue, and he was unable to give details of the incident. During an interview on 11/12/2024 at 1:00 p.m., LVN A said she recalled the incident with Resident #1 on 12/05/2023 and said Outside Vendor X had reported to her that Resident #1 was on the floor. LVN A said she requested LVN B to assist her to get him up off the floor. LVN A said, the facility accused me of verbally abusing the resident, but I do not remember saying anything abusive. LVN A said [Resident #1] scratched her during the transfer, but she did not recall her response. LVN A questioned if she assessed resident after fall she said, I am sure I asked him if he was OK, but I don't recall. LVN A said [Resident #1] was known to pleasure himself or play with himself. LVN A said she was contacted by UM C immediately after the incident and was instructed to not perform any additional care on any residents, complete any charting and she would be at the facility shortly. LVN A said UM C arrived at the facility and briefly discussed with her the allegation of abuse and that she would need to leave the facility (suspended) until the investigation was completed. LVN A said the incident with Resident #1 occurred between 5:00 and 5:30 p.m. on 12/05/2024 and the UM C contacted her around 5:45 p.m. regarding the incident/allegation and told her not to provide any patient care and complete her current shift documentation. She said UM C arrived at the facility around 6:00 p.m. they completed report, and cart counts, and she completed her shift documentation and left the facility. LVN A said that she did not provide any care to any resident once she was directed by UM C not too. LVN A said she was contacted by the Administrator later that same day and terminated her for a confirmed allegation of abuse. LVN A said she was provided training by the facility regarding abuse and neglect during orientation and routinely. During an interview on 11/12/2024 at 1:30 p.m., the Administrator stated he was the abuse coordinator and abuse allegation between Resident #1 and LVN A was confirmed and witnessed. The Administrator said Resident #1 was hard of hearing and was unsure if he heard the verbal aggression by LVN A. The Administrator said he interviewed Resident #1 following the incident and he did not exhibit any signs of fear or distress. The Administrator said safe surveys were conducted with other residents on that hall and no other incidents were reported. The Administrator said the facility investigation confirmed verbal abuse and LVN A was suspended during the investigation process and terminated immediately with the confirmation of the allegation. The Administrator said resident abuse was not tolerated at the facility and confirmation of resident abuse was an immediate termination. The Administrator said the facility trained staff on abuse and neglect and management staff made rounds with residents to monitor for abuse. Attempts to interview Outside Vendor X were unsuccessful. Two attempts were made to reach her by telephone on 11/11/2024 at 10:00 a.m., 11/12/2024 at 7:23 a.m., and via email on 11/11/2024 at 7:31 p.m. No return call or email was received prior to exit. Record review of a statement from Outside Vendor X indicated Outside Vendor X said the purpose of this email is to report an incident concerning a patient and a nurse in your facility. I was called in for vascular access placement for [Resident #1]. Upon arrival 12/5/23 around 5:00 p.m. the patient was found on the ground asking for help. I immediately found the nurse [LVN A] and notified her of the patient being on the floor. [LVN A] proceeded to tell me It's the fifth time. We approached the patient's room to assist the patient to the bed. He was sitting on the ground with a wheelchair in front of him. [LVN A] moved the wheelchair as I turned the light on, and the patient screamed. [LVN A] screamed at the patient I did not hit you. (I did not witness if he was hit or not) she also told the patient You're getting on my last nerve. You need to be tied up, if this was the good old days, you'd be tied up already. As she is walking my way towards the door she states, 1'm not touching him with no gloves his hand is always on his dick. She proceeded to grab gloves from her cart and asked another nurse for assistance. As they were assisting the patient up to the bed the patient tried to hold on to the nurse for stability, but she started screaming Don't touch me! Do not touch me! while swinging arm to get loose from him. The patient expressed his anger as well. The patient was assisted on to the mattress. When [LVN A] and [LVN B] stepped out of the room the patient was upset and very apologetic to me about what had happened. He attempted to communicate about the nurse and said the word screaming but I am unaware if he was referring to this instance or a prior instance. His speech was delayed and not very clear but was understandable. I reassured him he had nothing to apologize for. He did not have any apparent injury. I am unaware of the patient's baseline. He complained of pain but was unable to communicate the location of pain. Bed was lowered and call light was given to patient as well as instructed to press call light and not to attempt getting out of bed himself. He was no longer upset when I was leaving at around 5:30 p.m. I notified [LVN A] I was leaving the facility. This incident has been reported to my chain of command as well as Texas Health and Human Services. Record review of employee time records indicated that UM C returned/ clocked in at 6:00 p.m. on 12/05/2023. LVN A clocked in at 12:50 p.m. and clocked out at 7:13 p.m. Record review of LVN A's employee file indicated she received training regarding abuse, neglect, and misappropriation of property during initial orientation on 7/12/2023. LVN A was suspended and terminated on 12/05/2023 for abuse allegation. Record review of the facility's Abuse Prohibition Protocol, dated August 2024, indicated The patient has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treating the patient's symptoms.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 15 residents (Resident #1 and #2) reviewed for infection control. 1. CNA A failed to wash or sanitize her hands or change gloves while performing incontinent care for Resident #1. 2. CNA D failed to wash or sanitize her hands or change gloves while performing incontinent care for Resident #2. These failures could place residents at risk of exposure to communicable diseases and infections. Findings include: 1. Record review of Resident #1's face sheet, dated 04/10/24, reflected a male who was admitted to the facility on [DATE], he was [AGE] years old, and his diagnoses included paraplegia (impairment in motor or sensory function of the lower extremities), flaccid neuropathic bladder (doesn't contract enough-leads to urinary retention or the inability to fully empty the bladder) and overactive bladder (muscles of the bladder start to tighten on their own even when the amount of urine in the bladder is low). Record review of Resident #1's quarterly MDS assessment, dated 01/23/24, reflected he was able to make himself understood and understood others, was cognitively intact (BIMS score of 13), utilized a wheelchair for mobility, had an indwelling catheter and was always incontinent of bowel. Record review of Resident #1's care plan, dated 08/07/23 reflected Resident #1 was at risk for infection related to indwelling catheter. Interventions included clean around catheter with soap and water or may use wipes as appropriate and report any sign of infection, wash hands before and after procedure. During an observation on 04/02/24 at 5:30 p.m., CNA A assisted by CNA B, performed incontinent care for Resident #1. CNA A and CNA B entered Resident #1's room, washed hands and put on gloves and gown (enhanced barrier precautions). CNA A explained care provided to Resident #1 and performed peri-care/indwelling catheter care by wiping Resident #1's penis and scrotum area with wipes and held the catheter tubing and wiped the catheter tubing. Resident #1 was incontinent of stool and the brief was soiled. CNA A then removed her gloves and put on a pair of new gloves without washing or sanitizing her hands. CNA A and CNA B rolled Resident #1 on his left side. CNA A took a wet wipe and wiped Resident #1's rectal area and removed stool. CNA A removed the used brief from underneath Resident #1 and placed it in the trash. CNA A then took a clean brief placed it under the resident, while wearing the same soiled gloves that were used to wipe the resident's rectal area and removed the old brief. CNA B commented to CNA A she should have changed her gloves. CNA A removed the soiled gloves, sanitized her hands, and placed on a pair of new gloves, then applied Vaseline to Resident #1's coccyx/buttocks area, CNAs A and B positioned Resident #1 on his back and fastened the brief. CNA A and CNA B positioned Resident #1 to a comfortable position. CNA A and CNA B removed their PPE, placed it in the trash and removed the trash from Resident #1's room upon exit. During interview on 04/02/24 at 5:45 p.m., CNA A said she was aware she should have changed her gloves after she wiped the resident's rectum and removed stool. She said the gloves were considered soiled. She said she should have washed or sanitized her hands and applied new clean gloves. During an interview on 04/10/24 at 9:40 a.m., CNA A said she was aware she should have changed her gloves and washed or sanitized her hands when she performed incontinent care for Resident #1. She said she was trained in orientation, on 03/12/24, and after the incident on 04/02/24 on infection control and incontinent care. 2. Record review of Resident #2's face sheet, dated 04/11/24, reflected a female who was admitted to the facility on [DATE], she was [AGE] year old, and her diagnoses included obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow )and dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of Resident #2's quarterly MDS assessment, dated 02/22/24, reflected she was able to make herself understood and understood others, had moderate cognitive impairment (BIMS score of 11), utilized a walker and a wheelchair for mobility, had an indwelling catheter and was always incontinent of bowel. Record review of Resident #2's care plan 09/18/23 reflected Resident #2 was at risk for infection related to an indwelling catheter. Interventions included clean around catheter with soap and water or may use wipes as appropriate and report any sign of infection, wash hands before and after procedure. During an observation on 04/02/24 at 6:00 p.m., CNA D was assisted by CNA C and performed incontinent care for Resident #2. CNA D and CNA C entered Resident #2's room, washed hands and put on gloves and gowns (enhanced barrier precautions). CNA D explained care provided to Resident #2 and performed peri-care by wiping the Resident #2's peri area from top to bottom with wipes. CNA D then removed her gloves and washed/sanitized her hands and applied a new pair of gloves. CNA D used a wet wipe and wiped Resident #2's rectal area, then removed the old brief from underneath Resident #2 and placed it in the trash. CNA D then took a clean brief placed it under Resident #2, applied barrier cream, while wearing the same gloves that were used to remove the old brief. CNA D and CNA C positioned Resident #2 to a comfortable position. CNA D and CNA C removed their PPE, placed it in the trash and removed trash from room upon exit. During interview on 04/02/24 at 6:10 p.m., CNA D said she was aware she should have changed her gloves after she removed Resident #2's old brief. She said the gloves where considered soiled. She should have washed or sanitized her hands and applied new clean gloves. During interview on 04/02/24 at 6:12 p.m., CNA C said CNA D should have changed her gloves after she had removed Resident #2's old brief. During an interview on 04/10/24 at 9:15 a.m., the DON said staff should have changed gloves and performed hand hygiene per the facility's protocol for incontinent care. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. She said staff were trained upon hire in orientation regarding the facility's protocol for incontinent care and as needed. Record review of the facility's, undated, Incontinent Care Skills Checklist reflected .9. Wash from front towards rectum, front to back, using clean stroke, repeat if necessary with a new wipe as all feces must be cleaned off. With a new wipe, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock. 10. Wash and sanitize hands. Apply clean gloves.

Based on record review and interview, the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility did not ensure the arbitration agreement contained the required element of informing residents of their right to rescind in 30 calendar days of signing the agreement. This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, cause a loss of their legal rights, and cause negative psychological issues. Findings included: During an interview and record review during the entrance conference on 10/23/23 at 8:30 a.m., the Administrator provided a copy of the facility's admission packet, and the binding Arbitration Agreement was included in the admission packet. The Arbitration Agreement did not include information on the right to rescind the agreement within 30 days of signing. During an interview on 10/24/23 at 4:00 p.m., the Administrator said the arbitration agreement in the admission packet did not include the information on the right to rescind the agreement within 30 calendar days of signing. The Administrator said the right to rescind the agreement within 30 calendar days of signing was to protect the resident's rights. He said the facility had 40 to 50 admissions in the last 30 days. Record review of undated Admission Agreement, undated included: .page 23 ARBITRATION AGREEMENT In accordance with the provisions of the Federal Arbitration Act 9 . and in further consideration of the duties and obligations contracted for in the admission and financial Agreement, . the parties to the Admission Agreement hereby understand and agree that any dispute, controversary or claims arising out of or relating to the Admission Agreement, or the services performed thereunder, the breach thereof or any dispute in tort or in medical malpractice . shall be resolved through arbitration . By signing the Admission Agreement, it is understood and agreed by the parties that the right to a jury or court trial . is waived.

Based on interview and record reviewed, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 25 residents records reviewed for MDS assessments. (Residents #35) The facility did not ensure the discharge MDS assessment was completed and electronically transmitted as required for Resident #35. This failure could place residents at risk of not having their assessments transmitted timely. Findings included: Record review of Resident #35's Admission record dated 10/25/23 indicated she was admitted on [DATE] with a discharge date of [DATE]. Resident #35's diagnoses included joint replacement surgery. Record review of the MDSs for Resident #35 indicated the discharge MDS assessment was completed on 06/26/23. The discharge MDS assessment was marked current not transmitted or accepted. Record review of the nurse's notes from 06/16/23 to 06/26/23 indicated Resident #35 was discharged home on 06/26/23. During an interview on 10/25/23 at 9:30 a.m., LVN C said she did not transmit Resident #35 discharge MDS assessment. She said she had received training on completing, preparing, signing and transmitting the MDS assessment to CMS. LVN C said Resident #35's MDS should have been sent so the resident records would be complete. During an interview on 10/25/23 at 9:45 a.m., the DON said when Resident #35 was discharged home, there should have been a discharge MDS completed and submitted. She said LVN C was responsible for transmitting and the used the RAI manual for the policy. During an interview on 10/25/23 at 10:00 a.m., the Administrator said he expected the discharge MDS assessments to be completed and transmitted. Review of the CMS's RAI Version 3.0 Manual obtained on 10/25/23 from the CMS website, https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2023.pdf indicated the following: CMS's RAI Version 3.0 Manual indicated . Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below). This assessment includes clinical items for quality monitoring as well as discharge tracking information. RAI OBRA-required Assessment Summary .Discharge Assessment - return not anticipated (Non-Comprehensive) A0310F = 10 discharge date + 14 calendar days .

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 24 residents reviewed for indwelling catheters. (Resident #63) The facility failed to prevent Resident #63's urinary catheter drainage bag from touching the floor. This failure could place residents at risk for urinary tract infections. Findings included: Record review of physician orders dated 10/25/23 indicated Resident #63, admitted [DATE], was a [AGE] year-old male with a diagnosis of disorder of the urinary system. The resident had an indwelling urinary catheter (a catheter which is inserted into the bladder to drain urine). The resident had a history of urinary tract infections and was ordered a prophylactic antibiotic Macrobid 100 mg 1 tablet every day. Record review of the most recent MDS dated [DATE] indicated the resident had a urinary catheter in place. The assessment did not indicate Resident #63 had a urinary tract infection in the last 30 days but did indicate the resident had a diagnosis of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructive flow). Record review of a care plan dated 06/07/21 to present indicated Resident #63 had an indwelling urinary catheter and was at risk for increased urinary tract infections. Hospice prophylactic antibiotic order: Macrobid 100 mg one tablet one time a day. The goal was Foley catheter will remain patent and [Resident #63] will not develop increased incidents of UTI's over the next 90 days. The interventions included catheter care, encourage fluids, change catheter per order and did not indicate to keep the urinary catheter bag or tubing off the floor. During the following observations, Resident #63's urinary catheter bag was secured to the left side of the bed and the bag was touching the floor mat beside the resident's bed: *10/23/23 at 10:17 a.m., *10/24/23 at 9:40 a.m., and *10/25/23 at 9:59 a.m. During observation and interview on 10/25/23 at 9:59 a.m., CNA A entered Resident #63's room to perform indwelling catheter care. The resident's catheter bag was touching the floor mat upon entrance. CNA A said Resident #63's catheter bag should not be touching the floor or the floor mat. She said germs could get into the catheter. She said she was responsible for making sure the bag was not touching the floor, but she did not notice the catheter bag was on the floor. During observation and interview on 10/25/23 10:02 a.m., LVN B said the indwelling catheter bag was touching the floor mat and should not be. She said all direct care staff were responsible for ensuring the urinary catheters were not touching the floor or floor mat. She said germs could travel up the catheter and cause infection. During an interview on 10/25/23 at 10:05 a.m., the DON said the indwelling urinary catheter bag should not be touching the floor or floor mat. She said the resident could be at increased risk of infection. She said her expectations were for the catheter bags to be kept off the floor. A Catheter Care policy updated March 2019 indicated: Responsibility: Licensed nurse and nursing assistant. Purpose: to prevent infection and prevent irritation. The policy did not indicate the indwelling catheter should be kept off the floor.

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure kitchen equipment was clean and staff used sanitary measures while preparing food. This failure could place the residents at risk of food borne illnesses. Findings included: During initial observations of the kitchen on 08/22/22 at 8:38 a.m., the following were noted: *There was a brown splattered substance on the surface area surrounding the coffee dispenser spigots; and *There was a buildup of black substance to the surrounding surface area of the juice dispenser spigots. During observation and interview on 08/22/22 at 8:40 a.m., the DM said the coffee and juice machines were not clean and she began wiping the surrounding area of the juice machine spigots off with a white towel she had in her hand. After wiping the juice machine, the white towel had a black substance smeared on it. The DM said the coffee and juice machines were dirty and should be kept clean. She said the possible negative outcome would be contamination. During an observation on 08/22/22 at 8:49 a.m., there were multiple wet, beige, and brown particles on the top front left of the dish machine down to the top back of the dish machine. The particles in the back under the electrical wiring were stuck to the top of the dish machine. During an interview on 8/23/22 at 8:52 a.m., the DM said the food from the dish machine splashed up on top of the dish machine when it was in use, and it needed to be cleaned. She said the staff dishwasher was responsible for making sure the dish machine was clean, but she was on vacation. She said it should be cleaned even when the staff dishwasher was out on leave. She said the staff persons who were responsible for keeping the coffee and juice machines clean were also out on either sick or on vacation at this time. She said the kitchen equipment should be kept clean according to the cleaning schedule to prevent contamination. During observation of the steam table preparation for the noon meal on 08/23/22 at 12:01 p.m., Cook A, without washing her hands, walked from the steam table, retrieved her personal thermal cup from a prep table, walked over to the facility ice machine and scooped up a cup of ice using her thermal cup, shut the door, and walked off. During an interview on 08/23/22 at 12:02 p.m., Cook A said she did not wash her hands and she should not have put her cup in the facility ice machine to retrieve the ice. She said she knew she was supposed to wash her hands and use the scoop to retrieve ice from the machine. When asked if she was trained on kitchen sanitation, she said she had been in food service for years and no one had to teach her that. She said the negative outcome would be cross contamination. During an observation and interview on 08/23/22 at 12:08 p.m., the DM said the cook knew better than to put her cup down in the ice machine. She said she would have to drain the ice machine and then she walked over and unplugged the machine. She said the staff should always wash their hands and use the scoop to retrieve ice and should not use their personal cups. She said the possible negative outcome would be contamination of the ice. She said she expected the staff to always use the scoop and to wash their hands before getting into the ice machine bin. Review of the cleaning schedule dated August 2022 indicated each day Monday through Sunday, there were 2 allotted spaces for kitchen staff to initial the coffee machine, juice machine and dish machine were cleaned. The dish machine column indicated there were no initials in 6 allotted spaces. The juice machine column indicated there were no initials in 7 allotted spaces. The coffee machine column indicated there were no initials in 37 allotted spaces. Review of the General Sanitation of Kitchen policy dated November 3, 2004 indicated: The staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule.

Based on observation, interview and record review, the facility failed facility coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 3 residents (Resident #153) reviewed for PASRR. The facility failed to refer Resident #153 for PASRR Level II assessments after their PASARR listed them as having evidence or an indicator of Mental Illness. This failure could place all residents who had a mental illness at risk for not receiving needed assessment, care, and specialized services to meet their needs. Findings included: Record review of face sheet dated August 2022 indicated Resident #153, was admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an admission MDS dated [DATE] indicated Resident #153 was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and Level II Preadmission Screening and Resident Review (PASRR Conditions of A. Serious mental illness; B. Intellectual Disability. Resident #153 had a BIMS of 1 out of 15 indicating severely impaired cognition and decision making and active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a PASRR Level 1 (PL 1) screening dated 8/16/22 completed by MDS Nurse indicated Resident #153 did not have mental illness or developmental disability and was positive intellectual disability. During an interview on 8/23/22 at 12:10 p.m., the MDS Nurse indicated she was responsible for ensuring the PASRR Level 1 was completed accurately for Resident #153. She stated if a hospital incorrectly completed the PASRR 1 and a resident had a qualifying diagnosis, the admitting facility should submit a PL 1 correction so the resident could be evaluated for services. The MDS Nurse stated she was very familiar with the PASRR process as she had been trained on PASRR a year or two ago. She stated when someone was admitted from another nursing facility or hospital, she would input the PASRR information they provided. The MDS Nurse indicated she would call the local authority today, to seek further guidance and would be doing Form 1012 to correct the PASRR to include Resident #153's mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Nurse said if a PL 1 was inaccurate the resident would need a correction form completed. After reviewing Resident #153's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Nurse said possible negative outcomes for inaccurate PASRR Level 1 could be that residents would not receive the specialized services they qualified for through PASRR if the PL 1 was not completed correctly. She said the DON was her supervisor who monitored the PASRRs for accuracy. During an interview on 8/23/22 at 12:53 p.m. the DON said her expectation was for all PL1's to be completed by policy, accurately and timely on all residents. She acknowledged Resident #153's PL 1 did not indicate a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said she was educated on PASRR and had not been monitoring the admission PASRR process but would put a plan in place to start monitoring for accuracy. The DON said the risk of a resident not having a correct PL 1 completed would possibly be not receiving needed and deserved services. The DON stated facility had no policy on PASRR and the facility used HHSC guidelines on completing PL 1. Record review of an undated and untitled bulleted list included in part: PASRR is required of each state's Medicaid program to ensure that those with Mental Illness (MI0/Intellectual or Developmental Disability (IDD) are cared for properly .review PL1 for potential MI, DD or ID and if positive the Local Authority completes PL2 .

Based on 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 23 residents reviewed for care plans. (Resident #15) The facility did not care plan Resident #15 for diabetes (a high level of sugar in the blood) and insulin (a medication used to treat diabetes). This failure could place the residents at risk of not receiving care and services to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #15 had a BIMS of 10 (mental status moderately impaired), had impaired vision (can see large print only), required extensive assistance for personal hygiene and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of care plans dated 08/24/22 indicated Resident #15 did not have a care plan for diabetes and/or insulin. During an interview on 08/22/22 at 09:26 a.m., Resident #15 said he was diabetic and took insulin per sliding scale, when he needed it. He said recently his blood sugar levels had been good and he did not have to take insulin. During an interview on 08/24/22 at 1:32 p.m., the DON said Resident #15 did not have a care plan for insulin or diabetes and should have. She said her expectations were for the resident to be care planned for insulin and diabetes. She said the negative outcome of not having a care plan could be the staff would not know how to take care of the patient. She said the LVN unit manager (unit manager B) was responsible for making sure the care plans were completed. During an interview on 08/24/22 at 1:38 p.m., Unit manager B said Resident #15 had been a diabetic since he came from their sister facility years ago. She said it was her responsibility to complete the care plan for the resident, she had not completed the care plan for the resident's diabetes and insulin, however, she had gone into the system just a minute ago and put the care plan in his chart after surveyor intervention. She said he did need to be care planned for diabetes and insulin and the possible negative outcome could be the staff would not know he was on insulin or to monitor it. Review of the Patient Care Management System policy, titled Assessments, dated November 2017 indicated . 3. Upon admission each patient/resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility will use patient/resident observation, communication, family input and clinical history . 12. The monthly Quality Assurance and Performance Improvement Meeting must include a review of the timely completion and updating of care plans, timely completion of nursing assessment,

Based on observation interview and record review, the facility failed to provide a therapeutic diet when ordered by the physician to maintain adequate nutritional status, to the extent possible to maintain acceptable parameters of nutritional status for 1 of 23 residents reviewed for weight loss. (Resident # 204) The facility did not ensure Resident #204 received a health shake three times a day as ordered by the physician. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission MDS assessment dated [DATE] indicated Resident #204 had a BIMS score of 8 out of 15 (mental status moderately impaired), required supervision (encouragement or cueing) for eating, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the care plan dated 08/24/22 indicated Resident #204 received a therapeutic diet. The goal was for the resident to have adequate nutrition and fluid intake over the next 90 days. Interventions indicated to serve diet as ordered and monitor intake. Record review of Resident #204's weight worksheet indicated the resident refused to be weighed on the admitted [DATE]. The resident weighed 95.8 lbs. on 07/12/22 and 92.2 lbs. on 08/15/22. Record review of Resident #204's breakfast meal ticket dated 08/24/22 indicated there was no documentation the resident had house shakes ordered. During an interview on 08/22/22 at 11:23 a.m., Resident #204 said she was admitted to the facility because she had weight loss. She said she just kept losing weight During observations of Resident #204's meal service, there was not a health shake on the resident's meal tray for the following dates/times: * 08/22/22 at 12:48 p.m. * 08/23/22 at 8:58 a.m.; and * 08/24/22 at 8:26 a.m. During an interview on 08/22/22 at 12:50 p.m. with LVN C when asked if Resident #204 was on supplements for weight loss, LVN C said the resident was on supplement pass three times a day, which was administered during medication pass. He said the resident had lost weight from 95 lbs to 92 lbs since admission. During observation and interview on 8/24/22 at 8:27 a.m., after observation of Resident #204's meal tray, LVN D said the resident did not have a house shake on her meal tray. She said the orders did indicate the resident was supposed to receive a health shake three times a day with meals. LVN D said the resident could continue to lose weight if she did not receive the health shakes as ordered. During an interview on 08/24/22 at 8:30 a.m. the ADON said Resident #204 should have received the health shakes three times a day as ordered. She said the negative outcome would be she could continue to lose weight if she did not receive the shakes. She said LVN D was the staff who wrote the order. She said at the time the order was written, Resident #204 was on Hall 300 where LVN D worked. She said if LVN D wrote the order, she would be the one who was responsible for delivering the order to the kitchen. She said her expectations were for the residents to receive their diet as ordered. During an interview and record review on 08/24/22 at 8:33 a.m., the DM said the house shakes do go to the residents from the kitchen. She said the nurse who writes the order brings the order to her and she puts the order in the computer so it can be implemented. After record review of Resident #204's meal ticket, she said the house shakes were not on the resident's ticket. The DM presented the resident's dietary order to the surveyor and said the resident did not have dietary orders for house shakes. She said the negative outcome of Resident #204 not receiving the house shakes as ordered would be the resident could possibly lose weight. During an interview on 08/24/22 at 8:54 a.m., LVN D said Resident #204 did have orders for health shakes three times a day. She said she did not remember if she had printed Resident #204's dietary order for the health shakes and/or sent them to the kitchen or not. She said once a dietary order was written it was supposed to be hand carried to the kitchen so they could add the new order to the resident's diet; it could not be sent electronically. She said the resident did not eat or drink well, so she got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 08/24/22 at 8:57 a.m., the DON said when the orders were received for meals or health shakes, the order was supposed to be printed and walked to the kitchen. She said the nurse that took the order was responsible for writing the order and bringing it to the kitchen. She said her expectations were for the health shakes to be served to Resident #204 as ordered. She said the possible negative outcome would be the resident would lose weight. During an interview on 08/24/22 at 2:23 p.m., the corporate nurse said the facility did not have a specific policy related to following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments for 1 of 23 residents (Resident #1) and permitted only authorized personnel reviewed for storage of medications. -The facility failed to ensure Resident #1 did not have medication, [MEDICATION(S)] 10mg bottle at the bedside. This failure could place residents at risk for consuming unsafe medications and having access to unauthorized medication that could cause a decline in health status and possible drug diversion. The findings included: Record review of Resident #1's face sheet dated August 2022 indicated Resident #1, admitted [DATE], was a [AGE] year old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of admission MDS ARD dated 8/16/22 indicated Resident #1 had clear speech, ability to understand and be understood by others, BIMS 9 of 15 indicating he had moderately impaired cognition. Record review of Resident #1's electronic record revealed there was no Care Plan addressing to keep medications at bedside and no care plan to self-administer medications. Further review of the electronic record inticated Resident #1 did not have a Self-Administration Medication Assessment initiated or completed for August 2022 Record review of resident #1's August 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation during initial tour, on 8/22/22 at 9:30 A.M. revealed Resident #1 was very hard of hearing, watching TV, sitting on a wheelchair in his room and the door was open. On his bedside table was an open and used bottle of [MEDICATION(S)] 10 mg tablets, with no pharmacy label. Observation on 8/22/22 at 11:30 A.M. revealed Resident #1 was watching TV, sitting on a wheelchair in his room and the door was open. On his bedside table remained the opened and used bottle of [MEDICATION(S)] 10 mg tablets, with no pharmacy label. In an interview and observation on 8/22/22 at 11:33 A.m. Resident #1 stated the [MEDICATION(S)] was his and he took 1 pill when he needed it to get to sleep. Resident #1 said he did not remember the last time he took it but believed it was some time last week. Resident stated he leaves the medication on his table in his room and he thought the nurses should be aware he had the medication because it was in plain eyesight on the bedside table and could be seen every time they walk in the room. He further stated he takes the [MEDICATION(S)] one-tablet at night for sleep but only when need it. Resident #1 stated his family member bought the medication for him, but he could not remember when or when was the last time he took it. Resident #1 said he did not need a doctor's order to take the medication because it was OTC over the counter and no doctor's prescription was necessary for it. On his bedside table was a [MEDICATION(S)] 10 mg bottle, opened and used with no pharmacy label. Observation and interview on 8/22/22 at 12:58 P.M. with LVN C indicated on Resident #1's bedside table was a [MEDICATION(S)] 10 mg bottle, opened and used with no pharmacy label. LVN C stated he did not know when the medication bottle came or who may have brought it in to Resident #1. LVN C said he was the staff person assigned to Resident #1 for medication administration and while looking at the electronic record for Resident #1 LVN stated he did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN C said he makes observations on things like safety, cleanliness, and odors every day on his assigned hall and had not seen any medication at the bedside. LVN C said he would have removed the [MEDICATION(S)] bottle, because medication at the bedside that was not locked up can be dangerous if residents use it the wrong way. LVN C left the room with the [MEDICATION(S)] 10 mg tablets remaining on Resident #1's bedside table. Observation and interview with the DON on 8/22/22 at 1:30 P.M. revealed on Resident #1's bedside table was medication [MEDICATION(S)] 10 mg. The DON stated the resident did not have any sleeping problems that she was aware of or being treated with any sleep aid medication. The DON said she teaches staff on orientation and as needed that medications could not be left out unattended at the resident's bedside and staff assigned to resident were to look for medications and remove them . The DON said her expectation was for nursing staff to follow facility policy and procedure and not leave medications at the bedside. The DON said residents would need a doctor's order and medication self-administration assessment completed before they could be able to keep meds at the bed side and administer themselves but none of the residents had any because it was not allowed in the facility. The DON revealed Resident #1 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1. The DON said leaving medications at the bedside puts residents at risk of not taking properly or giving it to someone else to take. The DON stated she would make sure the medication was removed and the doctors called to see about getting an order to administer the [MEDICATION(S)]. Record review of facility policy Storage of Medications for patient that Self-Administer, dated March 2016 read in part: . Policy . Storage of medications for self-administration remains the responsibility of nursing staff. In accordance with state and federal laws, the facility must store all drugs in locked storage area and permit only authorized individuals to have access to the keys. Procedure: All medications for self-administration will be stored in the Facility's locked medication carts or other locked storage areas. Record review of facility policy Self-Administration of Medications dated March 2016 read in part: . Procedure: An Assessment for Self-Administration of Medications (see [NAME] Form CFS 1-14HH) must be completed on each Patient requesting to self-administer medications and quarterly thereafter. An Assessment for Self-Administration of Medications is kept with the Patient's medical record under the Assessment tab. If it has been determined the Patient is capable of self-administering his/her medications, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's needs, and address the medical, physical, mental, and psychosocial needs for 3 of 24 residents reviewed for comprehensive care plans. (Resident #s 98, 103 and 106) *The facility did not follow physican orders for sliding scale insulin administration for Resident #106. *The facility did not ensure Resident #98's care plan indicated the use of insulin; and *The facility did not develop and implement a care plan for Resident #103's anticoagulant medication [MEDICATION(S)]. These failures could place residents at risk of not having their care needs met. Findings included: 1. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated check blood sugar and follow sliding scale: 61-150 = 0 units 151-200 = 2 units 201-250 = 4 units 251-300 units = 6 units 301-350 = 8 units 351-400 = 10 units 401 or greater = 12 units and recheck blood sugar in 15 minutes. A care plan dated 6/2/21 indicated Resident #106 was diabetic and required insulin. An intervention indicated to administer the medication as ordered. A MDS assessment dated [DATE] indicated Resident #106 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated check blood sugar and follow sliding scale: 61-150 = 0 units 151-200 = 2 units 201-250 = 4 units 251-300 units = 6 units 301-350 = 8 units 351-400 = 10 units 401 or greater = 12 units and recheck blood sugar in 15 minutes. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/23/21 at 2:15 p.m., the DON reviewed Residents #106's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #106 should have received 2 units of [MEDICATION(S)] insulin since the blood sugar was 192. The DON said she expects medication to be administered according to the physician orders. The DON said it was important for medication to be given according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/23/21 at 2:30 p.m., the administrator said he expected the medication to be administered within the prescribed parameters. The administrator said it was important for the medication to be given within the prescribed parameters to ensure proper care to the patient. A policy dated February 2010 titled, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders to be carried out as stated by physician . 2. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS assessment dated [DATE] indicated Resident #98 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated 5/29/21 gave no indication Resident #98 was receiving/prescribed insulin. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/23/21 at 1:00 p.m., UM A reviewed Residents #98's care plan with surveyor and said the insulin use for Resident #98 was not indicated on the care plan. UM A agreed insulin use should be indicated on the care plan. UM A said it is important to care plan insulin use so staff were aware the resident was taking the medication and so the staff could monitor the resident for the use of the medication. During an interview on 6/23/21 at 1:20 p.m., the DON said UM A was responsible for adding medications to the care plan. The DON said she expected for the care plan to be completed including insulin use. The DON said it was imperative to the care of the patient the insulin be indicated on the care plan so the nurses would know about the insulin use. During an interview on 6/23/21 at 1:40 p.m., the administrator said he expected for the care plan to be completed including insulin use. The administrator said it was important for the insulin use to be care planned to insure adequate care to the patient. 3. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was ordered [MEDICATION(S)] (a blood thinner medication used to prevent blood clots from forming) 5 mg one tablet BID by mouth starting 6/7/21. The clinical record dated 6/5/21 to present did not indicate there was a baseline care plan for Resident #103. The comprehensive care plan initiated 6/5/21 did not indicate Resident #103 was taking an anticoagulant medication. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] indicated Resident #103 received an anticoagulant 6 days in the last week. During an interview on 6/21/21 at 10:07 a.m., Resident #103 said she took an anticoagulant medication. During an interview on 6/23/21 at 1:48 p.m., the DON said the comprehensive care plan for Resident #103 did not address the anticoagulant medication [MEDICATION(S)]. She said it was important to have a care plan in place for the coordination of the resident's care. During an interview on 6/23/21 at 2:02 p.m., LVN B said she had completed Resident #103's initial assessment. She said she could add information to a care plan but could not initiate a care plan. She said the unit manager initiated the care plan for Resident #103. She said the care plan was intitiated for coordination of the resident's care. During an interview on 6/23/21 at 2:17 p.m., UM A said she was responsible for initiating the care plans and Resident #103 did not have one for the anticoagulant [MEDICATION(S)] . She said it was important to have a care plan for coordination of the resident's care needs. During an interview on 6/23/21at 3:27 p.m., the DON said there was not a baseline care plan developed for Resident #103. A policy dated November 2017 titled, Assessments indicated, . 6. A Comprehensive, Person-centered Plan of Care . must be completed . The care plan must be based on assessments . the Patient's/Resident's active record and use the results of the assessments to develop, review, and revise the Patient's/Resident's comprehensive care plan. The Medications policy dated November 2017 indicated: . 3. Anticoagulant medication usage must be care planned. During the exit on 6/23/21 at 4:30 p.m., the administrator was asked for any additional information related to following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to ensure resident's environment remained free of accident hazards for 2 of 8 halls reviewed for accident hazards. (Hall 500 and Hall 600) The facility did not keep chemicals secured and out of reach in a locked janitor closet on hall 500. The facility did not keep chemicals secured and out of reach in a vacant resident room on hall 600. This failure could place residents at risk of injuries. Findings included: During an observation on 6/21/21 at 11:45 a.m., a metal rolling cart was in the entrance of a vacant resident room (610) and the door was open. There was one gallon of hand sanitizer (3/4 full), a gallon of bleach and 32-ounce bottle of polish (1/2 full). The three items were labeled keep out of reach of children and get medical attention if ingested. During an interview on 6/21/21 at 12:25 p.m., the housekeeping supervisor said the metal cart with unsecured chemicals was her cart. She said while working, she was called away and left the cart unattended in the vacant room. She said all staff are trained to keep chemicals secured. She said the reason they must secure chemicals that are not in eye-sight was to protect residents, families and staff from accidental ingestion because the chemicals could be toxic. During an observation on 6/21/21 at 1:15 p.m., the janitor closet on Hall 500 was unlocked and door opened approximately 2 inches. The closet contained 6 automatic dispensers with glass cleaner, peroxide multi surface cleaner and encapsulated carpet cleaner. The dispensers were less than ½ full and all were labeled keep out of reach of children and seek medical attention for accidental ingestion. During an interview on 6/21/21 at 1:25 p.m., the housekeeping supervisor said the janitor closet should be locked. She said the lock was broken, as she inspected the lock. During an interview on 6/22/21 at 9:50 a.m., the administrator said yes chemicals should be locked up and said normally everything was locked up. Hazardous Areas, Devices and Equipment dated July 2017 indicated All hazardous areas, devices . will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. 1.g Access to toxic chemical . Safety and Supervision of Residents dated July 2017 indicated Our facility strives to make the environment as free from accident hazards as possible. Reference obtained per internet on 6/23/21 at https://www.ecolab.com/sds. The safety data sheet for polish dated June 2015 indicated . If swallowed: Rinse mouth. Get medical attention if symptoms occur. If inhaled: Remove to fresh air. Treat symptomatically. Get medical attention if symptoms occur. Reference obtained per internet on 6/23/21 at https://www.ecolab.com/sds. The safety data sheet for bleach dated June 2015 indicated . Immediately call a poison center or doctor. If swallowed: Rinse mouth. Do NOT induce vomiting. Precautionary Statements - Storage: Store locked up. Reference obtained per internet on 6/23/21 at https://www.ecolab.com/sds. The safety data sheet for hand sanitizer dated April 2020 indicated . In case of Ingestion: Do not induce vomiting, get medical attention showing the safety data sheet and label hazardous. Reference obtained per internet on 6/23/21 at https://www.ecolab.com/sds. The safety data sheet for glass cleaner dated May 2019 indicated . If swallowed: Rinse mouth. Get medical attention if symptoms occur. Reference obtained per internet on 6/23/21 at https://www.ecolab.com/sds. The safety data sheet for peroxide multi surface cleaner dated February 2021 indicated .If swallowed: Rinse mouth with water. Do NOT induce vomiting. Never give anything by mouth to an unconscious person. Get medical attention immediately. During an exit conference on 6/23/21 at 4:30 p.m., the administrator was asked for any additional information on accidents/hazards. No additional information was provided.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 24 residents whose medications were reviewed for unnecessary medications. (Resident #103) The facility did not monitor Resident #103 for side effects of [MEDICATION(S)] (a blood thinner medication used to prevent blood clots from forming). This failure could place the residents at risk for adverse effects of medication. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was ordered [MEDICATION(S)] 5 mg one tablet BID by mouth starting 6/7/21. The clinical record dated 6/5/21 to present did not indicate Resident #103 was monitored for the side effects of [MEDICATION(S)]. There was not a baseline care plan for the [MEDICATION(S)]. The comprehensive care plan dated 6/5/21 did not indicate Resident #103 was taking an anticoagulant medication. The admission MDS dated [DATE] indicated Resident #103 received an anticoagulant 6 days in the last week. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR dated June 2021 indicated Resident #103 was not monitored for the side effects of [MEDICATION(S)]. During an interview on 6/21/21 at 10:07 a.m., Resident #103 said she did take an anticoagulant medication. During an interview on 6/23/21 at 1:48 p.m., the DON said Resident #103 was not monitored for the side effects of [MEDICATION(S)]. She said it was important for [MEDICATION(S)] to be monitored to ensure the resident did not have side effects and for coordination of care. During an interview on 6/23/21 at 2:17 p.m., UM A said Resident #103 was not monitored for the side effects of [MEDICATION(S)]. She said the [MEDICATION(S)] should be monitored every shift to ensure the resident did not have side effects to the medication. The Medication Therapy policy revised April 2007 indicated: 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 5. The physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example: a. when a medication is being given in excessive doses, for excessive periods of time, without adequate monitoring, or in the absence of a valid clinical rationale. b. when the results of ongoing assessment, or the presence of clinically significant adverse consequences monitoring, suggest that a medication should be reduced or discontinued entirely; . The Medications policy dated November 2017 indicated: .3. Anticoagulant monitoring must be completed on admission (including readmission) for any patient/resident receiving an anticoagulant medication (including but not limited to aspirin). Anticoagulant medication usage must be care planned. During the exit on 6/23/21 at 4:30 p.m., the administrator was asked for any additional information related to unnecessary medications. No additional information was provided.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 12 residents reviewed for accidents. (Resident #3) The facility did not ensure Resident #3 was adequately supervised when CNA C left Resident #3 alone in the shower and returned to find her on the floor. Resident #3 sustained a fractured left ankle. This failure could place residents with a history of falls at risk for accidents and injuries. Findings included: An MDS dated [DATE] indicated Resident #3, was a [AGE] year-old female admitted on [DATE] with diagnoses of dementia, [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. The MDS indicated Resident #3's had moderate cognitive impairment. Resident #3 discharged home on 3/4/21. An admission assessment dated [DATE] indicated Resident #3 had weak left and right lower extremities with limited range of motion and was high risk for falls. A baseline care plan electronically signed by LVN A on 2/23/21 at 11:48 a.m. indicated Resident #3 required assistance of one staff for showers and was a fall risk. A clinical note dated 2/23/21 at 9:00 p.m. indicated LVN B was notified by CNA C Resident #3 was sitting on the bathroom floor. The nurse indicated the resident was in the wheel chair when she entered the resident's bathroom. The nurse documented Resident #3 said her foot went that way. There were no complaints of pain at that time. During an interview on 4/12/21 at 2:38 p.m., LVN B said did not remember much about Resident #3. She said she did not recall anything about Resident #3 being left in the shower alone. An Accident/Incident Report dated 2/23/21 indicated LVN B was notified by CNA C at 8:00 p.m. Resident #3 was in the bathroom on the floor. The resident was in the wheelchair when the nurse entered the bathroom. The resident denied any pain at the time of the incident. There was no documentation in Resident #3's clinical record of any other incidents, including falls, from 2/23/21 8:00 p.m. until she complained of pain on 2/24/21 at 8:00 a.m. A clinical note dated 2/24/21 at 8:00 a.m. indicated Resident #3 complained of pain to the left leg and ankle. The resident had facial grimacing when the nurse lightly touched the ankle. The resident's left ankle was swollen, and x-rays were ordered. During an interview on 4/13/21 at 10:10 a.m., LVN D said Resident #3's ankle was swollen. She said she called the physician who ordered an x-ray. She could not remember if CNA C asked about the care Resident #3 required. She said her assessment indicated she needed assistance and her lower extremities were weak. An x-ray report dated 2/24/21 indicated Resident #3 had an oblique fractured distal fibula. During an interview on 4/13/21 at 11:04 a.m., CNA C said he took Resident #3 to the shower on 02/23/21 around 8:00 p.m. CNA C said he set everything up for her and put all supplies in her reach and Resident #3 asked him to leave. CNA C said the emergency call light was within reach and he left the room. CNA C said when he returned to the shower room about 10-15 minutes later, Resident #3 was on the floor. He said he did not check the computer for her care plan, he just went by how she transferred the day before. He said he and the nurse picked her up off the floor. She did not complain of pain. CNA C's written statement dated 4/14/21 indicated he had taken care of Resident #3 the evening prior to the fall. He said she was able to transfer independently the evening before the fall. CNA C said he left her in the shower at her request and left all supplies needed for her shower. He said the resident did not want help from him for the shower. She only asked how to work the shower. He said around 10 minutes later he decided to check on her even though her emergency light was not on. When he checked on the resident he saw her sitting on the floor and asked what happened and she said she had slipped trying to get back into her wheelchair. He then went to get her Nurse. He said he told the nurse what had happened. He said based off the day before, talking to her, and seeing how she did her ADLS, he felt it was a reasonable assumption to believe that a patient who is alert, oriented, and physically capable of self-transferring, would also be able to give bathe themselves in a shower chair. He said he chose to not stay with her because he had faith in her ability to maintain her desire of personal dignity. He said what happened to Resident #3 was a terrible accident. CNA C said he did what Resident #3 asked because he had full faith that she could provide self-care based off the evidence he saw prior to the incident. During an interview on 4/13/21 at 11:10 a.m., the DON said CNA C never told her about leaving Resident #3 in the shower. She said there were no injuries at the time of the incident. When the resident complained of pain the next morning, they knew it was from the fall the evening before and did not think it was reportable at that time. During an interview on 4/14/21 at 10:17 a.m., the DON said CNAs should check with the charge nurse for what kind assistance was needed during care if the baseline care plan has not been completed. The facility's Patient Care Management System 12, Assessments dated November 2017 indicated: 4. A Baseline, Person-centered Plan of Care for each patient that includes the instructions needed to provide effective and person-centered are of the patient that meet professional standards of quality of care. The facility's Fall Management Guidelines dated May 2013 indicated When a Patient has indicators of being a fall risk the nursing staff and care team must take steps to manage falls and serious injuries from the moment the patient is admitted .

Based on observation, interview and record review, the facility failed to ensure the right to be free from neglect was provided for 1 of 5 residents reviewed who received [MEDICATION NAME]. (Resident #41) The facility did not have a system in place to determine if orders for medications requiring monitoring by laboratory tests were completed for newly admitted residents. Resident #41 was ordered to receive [MEDICATION NAME] (anti-coagulant/blood thinner). [MEDICATION NAME] is a narrow therapeutic index drug (may require drug monitoring to achieve therapeutic levels and to minimize toxicity). The facility did not obtain an order and/or complete a PT/INR (blood test that indicates how long it takes for the blood to clot) for Resident #41 until surveyor intervention; 48 days after Resident #41 was admitted . A STAT (immediately) PT/INR was obtained on 4/9/19 with critical laboratory test results values of PT 43 and INR 4.3. (Normal reference ranges: PT: 8.4 - 11.5 seconds; INR: 1.0 - 2.0 ratio). This failure could place residents who received a narrow therapeutic index drug at risk of not receiving the therapeutic benefit of their medication, toxicity, hemorrhage, and death. An Immediate Jeopardy was identified on 4/10/19 due to the above failures related to Resident #41. While the Immediate Jeopardy was removed on 4/11/19, the facility remained out of compliance at a pattern for potential for more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Physician orders [REDACTED].#41, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The orders indicated the resident received [MEDICATION NAME] 5 mg five times a week on Monday, Wednesday, Thursday, Saturday and Sunday and [MEDICATION NAME] 7.5 mg two times a week on Tuesday and Friday for [MEDICAL CONDITION]. There was no order for a PT/INR laboratory test to monitor the [MEDICATION NAME]. A baseline care plan dated 2/20/19 for Resident #41 did not address the use of the [MEDICATION NAME]. The admission MDS dated [DATE] indicated Resident #41 was alert, oriented and able to make his needs known. The resident required extensive assistance for ADLs and was on anticoagulant therapy 7 days a week. Laboratory test results dated 11/6/18 through 2/4/19, provided from Resident #41's previous facility indicated the resident had PT/INR laboratory tests with results as follows: *11/6/18- PT=16.8, INR=1.7; *12/4/18- PT=14.4, INR= 1.4; *1/16/19- PT= 13.9, INR= 1.4; *1/28/19- PT= 16.2, INR= 1.6; and *2/4/19- PT= 13.1, INR= 1.3. (Normal reference ranges: PT: 8.4 - 11.5 seconds; INR: 1.0 - 2.0 ratio) A comprehensive care plan with effective date 2/20/19 - present printed on 4/9/19 indicated Resident #41 was at high risk for bleeding related to the use of [MEDICATION NAME]. Interventions included laboratory testing as ordered and to notify the physician of any abnormalities in the laboratory test results. The MARs dated February, (MONTH) and (MONTH) 2019 indicated Resident #41 received [MEDICATION NAME] 5 mg five times a week on Monday, Wednesday, Thursday, Saturday and Sunday and [MEDICATION NAME] 7.5 mg two times a week on Tuesday and Friday from 2/20/19 through 4/9/19. The clinical record for Resident #41 dated 2/20/19 to 4/9/19 indicated there were no orders for a PT/INR laboratory test for Resident #41. The laboratory test log book reviewed from 2/20/19 to 4/9/19 indicated there were no requests for a PT/INR laboratory test for Resident #41. During an observation on 4/8/19 at 9:55 a.m., bruising was noted on Resident #41's upper extremities (one small bruise on right arm near wrist, one small bruise on right arm near antecubital, one small bruise on left arm near hand, one small bruise on inside of left wrist, one small bruise on left arm near antecubital, and one small bruise on left upper arm near bicep). During an interview on 4/9/19 at 10:00 a.m., the DON said Resident #41's PT/INR was overlooked and had not been drawn since he was admitted to the facility on [DATE]. During an interview on 4/9/19 at 2:33 p.m., the DON said the facility found the issue (with missing laboratory tests) last week and did a Performance Improvement Plan (PIP) on it. The DON said one of the laboratory personnel told her the facility was missing orders for several required laboratory tests. A Performance Improvement Plan (PIP) dated 4/5/19 indicated there was a concern with laboratory tests that were never completed as required by physician order. The PIP indicated there was a need to clarify orders for laboratory tests required to determine therapeutic levels for medication monitoring. One of the proposed changes to resolve the concern was that laboratory testing orders would be reconciled daily by the Unit Managers. There was no documentation regarding concerns with Resident #41's PT/INR laboratory test not ordered or drawn. The physician orders [REDACTED].#41 indicated a PT/INR laboratory test was to be drawn STAT (immediately), after surveyor intervention. A shift change report dated 4/9/19 for Resident #41 indicated a new order was received for a STAT PT/INR Now on 4/9/19 at 11:36 a.m. A PT/INR laboratory report dated 4/9/19 at 3:26 p.m. for Resident #41 indicated the PT was 43.0 verified by repeat analysis and the INR was 4.3 verified by repeat analysis. Above the results was noted Critical result called to LVN G on 4/9/19 at 5:03 p.m. Verbal results verified/read back. During an interview on 4/10/19 at 8:20 a.m., the DON said the PT/INR laboratory results for Resident #41 were at a critical level and were too high. During an interview on 4/10/19 at 10:10 a.m., the DON said Resident #41's baseline care plan did not address anticoagulant therapy. The DON said the (MONTH) 2019 MAR indicated [REDACTED]. During an interview on 4/10/19 at 10:52 a.m., the DON provided a computer generated list dated 4/10/19 from the EMR indicating there were four residents who received [MEDICATION NAME]. Resident #41 was not on the list. The DON said Resident #41 was not included on the list of residents who received [MEDICATION NAME]. During an interview on 4/10/19 at 10:58 a.m., the physician said the PT/INR laboratory test for Resident #41 should have been ordered every 2 weeks as a standard order for monitoring the anticoagulant [MEDICATION NAME]. The physician said she missed that the laboratory test was not on the orders for Resident #41 and said the lack of monitoring placed Resident #41 at an increased risk for bleeding. The physician said the resident's level should not be too high because he is frail, thin, and has wounds. The physician said Resident #41 should stay on the low side of the normal range; around 1.4 because of his poor condition. During a telephone interview on 4/10/19 at 11:31 a.m., RN J said she completed the admission process for Resident #41 on 2/20/19 and an order for [REDACTED]. RN J said she did not know why a PT/INR was not ordered. During a telephone interview on 4/10/19 at 11:38 a.m., LVN G said she administered Resident #41's [MEDICATION NAME] at 5:00 p.m. on 4/9/19 and was unaware a STAT PT/INR laboratory test had been ordered and drawn earlier that day, adding no one told me. She said she did not know if a PT/INR was ever ordered on Resident #41 since his admission on 2/20/19. LVN G said she never thought to question the potential side effects of the medication or if a PT/INR had been drawn. LVN G said she was Resident #41's regular evening nurse, and regularly administered the resident's [MEDICATION NAME] since he was admitted . During an interview on 4/10/19 at 11:44 a.m. the DON said when nurses change shifts, they do not give a verbal report to each other regarding any resident issues when leaving or starting their shift; they were expected to read the report in the computer. During an interview on 4/11/19 at 9:15 a.m., the pharmacy consultant said she reviewed medications on 2/20/19 for Resident #41 upon his admission. She said she saw the resident's medication list but was unable to view the physician's orders [REDACTED]. The Pharmacy Consultant report dated 3/20/19 through 3/22/19 indicated the following recommendation for Resident #41. Please make sure INR is being checked due to being on [MEDICATION NAME]. I do not see anything filed. During an observation and interview on 4/11/19 at 9:50 a.m., the pharmacy consultant said she emailed the (MONTH) 2019 recommendations, including the recommendations for Resident #41, to the DON, the administrator, the Unit Manager, the ADON, and RN L on 3/25/19. At this time, the pharmacist consultant showed the email to surveyor from her computer. During an interview on 4/11/19 at 9:20 a.m., the DON said she was unaware of the pharmacy recommendations sent on 3/25/19. During an interview on 4/10/19 at 3:35 p.m., the administrator said there was a lab issue they reviewed in QA, but said it was no longer an issue. He said the action plan was not due until 4/10/19, and was not carried out yet. During an interview on 4/11/19 at 3:20 p.m., the ADON said she received the pharmacy recommendations by email on 3/25/19. The ADON said she did not always print the pharmacy consultant's email the same day she received it, and this sometimes delayed implementation of the recommendations in the emails. The ADON said she, the DON, and Unit Manager A all shared the responsibility of reviewing and following up on the pharmacy recommendations. She said the pharmacy recommendations dated 3/25/19 were not printed or followed up on until today (4/11/19). During a telephone interview on 4/11/19 at 3:58 p.m., the medical director said his expectation was an order for [REDACTED]. During an interview on 4/11/19 at 2:10 p.m., the administrator said in the QA meeting on 3/29/19, they identified issues with the new admission and order process. When reviewing the PIP with the surveyor, the administrator said the PIP did not include a plan to address resident's orders missed on admission. He said he was unaware Resident #41 did not have an order for [REDACTED]. A policy revised (MONTH) 2007, titled Medication Regimen Reviews indicated: . 6. the consultant pharmacist will: . e. Be alert to medications with potentially significant medication-related adverse. 9. The consultant pharmacist will provide the DON and medical director with a written copy of the report, listing the irregularities found and recommendations for their solutions A policy dated (MONTH) (YEAR), titled Medications indicated: 1. Upon admission (including readmission) of each Patient/Resident, the physician orders [REDACTED]. 3. Anticoagulant monitoring must be completed on admission (including readmission) for any Patient/Resident receiving an anticoagulant medication (including but not limited to aspirin). Anticoagulant medication usage must be care planned. 11. Recommendations made in a Consultant Pharmacist's Report must be reviewed and corrections initiated within three business days of the visit. Any change in orders must be entered into the EMR for each recommendation approved by the physician. A Nursing Policy & Procedure dated (MONTH) 4, (YEAR) titled Anticoagulant Therapy indicated: monitor any patient prescribed an anticoagulant therapy for side effects and drug-drug interactions test for therapeutic levels of anticoagulant therapy ([MEDICATION NAME]) as prescribed by the Physician all patients on anticoagulation medications are entered into the electronic Medical Record (EMR) system Lab testing for monitoring is conducted weekly or as requested by physician The website https://packageinserts.bms.com/pi/[MEDICATION NAME].pdf accessed 4/16/19 at 9:05 a.m. indicated . WARNING: BLEEDING RISK . *[MEDICATION NAME] can cause major or fatal bleeding. *Perform regular monitoring of INR in all treated patients.Drugs, dietary changes, and other factors affect INR levels achieved with [MEDICATION NAME] therapy. *Instruct patients about prevention measures to minimize risk of bleeding and to report signs and symptoms of bleeding. *Individualize dosing regimen for each patient, and adjust based on INR response . Monitoring: Obtain daily INR determinations upon initiation until stable in the therapeutic range. Obtain subsequent INR determinations every 1 to 4 weeks. The website https://www.mayoclinic.org/tests-procedures/[MEDICATION NAME]-time/about/pac- 661 accessed on 4/16/19 at 9:10 a.m., indicated: .an INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking [MEDICATION NAME] ([MEDICATION NAME]) for disorders such as [MEDICAL CONDITION] . The facility administrator, facility DON and RN L were notified on 4/10/19 at 4:12 p.m. an Immediate Jeopardy situation had been identified due to the above failures. The Plan of Removal included the following: .*Anticoagulant therapy and other medications requiring lab monitoring will be monitored by obtaining physician orders [REDACTED]. The ADON and unit manager will monitor the eMAR in the EMR system daily; *Nursing staff will accurately order, obtain and report all laboratory testing and results on an anticoagulant tracking log to monitor and nurse manager will reconcile ordered labs and lab results daily. When a lab order is received, it is entered into the EMR and then hand written into the lab communication book. Reconciliation will occur with nurse manager utilizing the lab communication book and the EMR system; *Nurses will review orders, scheduled labs, lab results and ensure notification occurred during the shift to shift report; *A full head to toe assessment was done on Resident #41 with on going anticoagulant monitoring. A PT/INR is to be redrawn on 4/12/19 with resident's [MEDICATION NAME] currently on hold; *Full head to toe assessment completed on residents on anticoagulant therapy with on-going monitoring. Care plans will be updated on all residents that have medications requiring laboratory tests for monitoring; *Staff in-service education sessions were conducted on 4/10/19, led by the DON and will focus on anticoagulant therapy, monitoring, laboratory management, notifications and shift to shift report and will continue until all nurses have been in-serviced; and *Lab values and review of lab protocols will be reviewed and analyzed monthly during QA/QAPI committee meetings with input and recommendations from the Medical Director for any trends identified. Anticoagulant orders and lab values will be reviewed each week by the IDT team with medical director oversite. The pharmacy consultant will monitor weekly the [MEDICATION NAME] ([MEDICATION NAME]) laboratory levels and address accordingly. The survey team confirmed the POR was implemented during interviews on 4/11/19 from 11:05 a.m. to 2:54 p.m. with 3 RNs and 24 LVNs across all three shifts, including weekend and PRN staff. The interviews indicated staff were properly in-serviced on the process of monitoring medications that require laboratory tests to assess therapeutic levels. In-service records and clinical records indicated medications requiring monitoring by laboratory tests were tracked and monitored. On 4/11/19 at 11:05 a.m., the administrator was notified the IJ was lifted. However, the facility remained out of compliance at a severity of more than minimal harm with a scope identified as a pattern. The facility continued to monitor residents who received medications that may require drug monitoring to achieve therapeutic levels and to minimize toxicity to ensure assessments were accurate.

Based on observation, interview and record review, the facility failed to ensure the drug regimen was adequately monitored to prevent unnecessary medications for 2 of 5 residents reviewed who received [MEDICATION NAME]. (Resident #41 and Resident #67) Resident #41 was ordered to receive [MEDICATION NAME] (anti-coagulant/blood thinner). [MEDICATION NAME] is a narrow therapeutic index drug (may require drug monitoring to achieve therapeutic levels and to minimize toxicity). The facility did not obtain an order and/or complete a PT/INR (blood test that indicates how long it takes for the blood to clot) for Resident #41 until surveyor intervention; 48 days after Resident #41 was admitted . A STAT (immediately) PT/INR was obtained on 4/9/19 with critical laboratory test results values of PT 43 and INR 4.3. (Normal reference ranges: PT: 8.4 - 11.5 seconds; INR: 1.0 - 2.0 ratio) The facility did not obtain a PT/INR to monitor Resident #67's use of [MEDICATION NAME]. This failure could place residents who received a narrow therapeutic index drug at risk of not receiving the therapeutic benefit of their medication, toxicity, hemorrhage, and death. An Immediate Jeopardy was identified on 4/10/19 due to the above failures related to Resident #41. While the Immediate Jeopardy was removed on 4/11/19, the facility remained out of compliance at a pattern for potential for more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: 1. Physician orders [REDACTED].#41, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The orders indicated the resident received [MEDICATION NAME] 5 mg five times a week on Monday, Wednesday, Thursday, Saturday and Sunday and [MEDICATION NAME] 7.5 mg two times a week on Tuesday and Friday for [MEDICAL CONDITION]. There was no order for a PT/INR laboratory test to monitor for the [MEDICATION NAME]. A baseline care plan dated 2/20/19 for Resident #41 did not address the use of the [MEDICATION NAME]. The admission MDS dated [DATE] indicated Resident #41 was alert, oriented and able to make his needs known. The resident required extensive assistance for ADLs and was on anticoagulant therapy 7 days a week. Laboratory test results dated 11/6/18 through 2/4/19, provided from Resident #41's previous facility indicated the resident had PT/INR laboratory tests with results as follows: *11/6/18- PT=16.8, INR=1.7; *12/4/18- PT=14.4, INR= 1.4; *1/16/19- PT= 13.9, INR= 1.4; *1/28/19- PT= 16.2, INR= 1.6; and *2/4/19- PT= 13.1, INR= 1.3. (Normal reference ranges: PT: 8.4 - 11.5 seconds; INR: 1.0 - 2.0 ratio) A comprehensive care plan with effective date 2/20/19 - present, printed on 4/9/19, indicated Resident #41 was at high risk for bleeding related to the use of [MEDICATION NAME]. Interventions included laboratory testing as ordered and to notify the physician of any abnormalities in the laboratory test results. The MARs dated February, (MONTH) and (MONTH) 2019 indicated Resident #41 received [MEDICATION NAME] 5 mg five times a week on Monday, Wednesday, Thursday, Saturday and Sunday and [MEDICATION NAME] 7.5 mg two times a week on Tuesday and Friday from 2/20/19 through 4/9/19. The clinical record for Resident #41 dated 2/20/19 to 4/9/19 indicated there were no orders for a PT/INR laboratory test for Resident #41. The laboratory test log book reviewed from 2/20/19 to 4/9/19 indicated there were no requests for a PT/INR laboratory test for Resident #41. During an observation on 4/8/19 at 9:55 a.m., bruising was noted on Resident #41's upper extremities (one small bruise on right arm near wrist, one small bruise on right arm near antecubital, one small bruise on left arm near hand, one small bruise on inside of left wrist, one small bruise on left arm near antecubital, and one small bruise on left upper arm near bicep). During an interview on 4/9/19 at 10:00 a.m., the DON said Resident #41's PT/INR was overlooked and had not been drawn since he was admitted to the facility on [DATE]. During an interview on 4/9/19 at 2:33 p.m., the DON said the facility found the issue (with missing laboratory tests) last week and did a Performance Improvement Plan (PIP) on it. The DON said one of the laboratory personnel told her the facility was missing orders for several required laboratory tests. A Performance Improvement Plan (PIP) dated 4/5/19 indicated there was a concern with laboratory tests that were never completed as required by physician order. The PIP indicated there was a need to clarify orders for laboratory tests required to determine therapeutic levels for medication monitoring. One of the proposed changes to resolve the concern was that laboratory testing orders would be reconciled daily by the Unit Managers. There was no documentation regarding concerns with Resident #41's PT/INR laboratory test not ordered or drawn. The physician orders [REDACTED].#41 indicated a PT/INR laboratory test was to be drawn STAT (immediately), after surveyor intervention. An electronic shift change report dated 4/9/19 for Resident #41 indicated a new order was received for a STAT PT/INR Now on 4/9/19 at 11:36 a.m. A PT/INR laboratory report dated 4/9/19 at 3:26 p.m. for Resident #41 indicated the PT was 43.0 verified by repeat analysis and the INR was 4.3 verified by repeat analysis. Above the results was noted Critical result called to LVN G on 4/9/19 at 5:03 p.m. Verbal results verified/read back. During an interview on 4/10/19 at 8:20 a.m., the DON said the PT/INR laboratory results for Resident #41 were at a critical level and were too high. During an interview on 4/10/19 at 10:10 a.m., the DON said Resident #41's baseline care plan did not address anticoagulant therapy. The DON said the (MONTH) 2019 MAR indicated [REDACTED]. During an interview on 4/10/19 at 10:52 a.m., the DON provided a computer generated list dated 4/10/19 from the EMR indicating there were four residents who received [MEDICATION NAME]. Resident #41 was not on the list. The DON said Resident #41 was not included on the list of residents who recovered [MEDICATION NAME]. During an interview on 4/10/19 at 10:58 a.m., the physician for Resident #41 said the PT/INR laboratory test should have been ordered every 2 weeks as a standard order for monitoring the anticoagulant [MEDICATION NAME]. The physician said she missed that the laboratory test was not on the orders for Resident #41 and said the lack of monitoring placed Resident #41 at an increased risk for bleeding. The physician said the resident's level should not be too high because he is frail, thin, and has wounds. The physician said Resident #41 should stay on the low side of the normal range; around 1.4 because of his poor condition. During a telephone interview on 4/10/19 at 11:31 a.m., RN J said she completed the admission process for Resident #41 on 2/20/19 and an order for [REDACTED]. RN J said she did not know why a PT/INR was not ordered. During a telephone interview on 4/10/19 at 11:38 a.m., LVN G said she administered Resident #41's [MEDICATION NAME] at 5:00 p.m. on 4/9/19 and was unaware a STAT PT/INR laboratory test had been ordered and drawn earlier that day, adding no one told me. She said she did not know if a PT/INR was ever ordered on Resident #41 since his admission on 2/20/19. LVN G said she never thought to question the potential side effects of the medication or if a PT/INR had been drawn. LVN G said she was Resident #41's regular evening nurse, and regularly administered the resident's [MEDICATION NAME] since he was admitted . During an interview on 4/10/19 at 11:44 a.m. the DON said when nurses change shifts, they do not give a verbal report to each other regarding any resident issues when leaving or starting their shift; they were expected to read the report in the computer. During an interview on 4/11/19 at 9:15 a.m., the pharmacy consultant said she reviewed medications on 2/20/19 for Resident #41 upon his admission. She said she saw the resident's medication list but was unable to view the physician's orders [REDACTED]. The Pharmacy Consultant report dated 3/20/19 through 3/22/19 indicated the following recommendation for Resident #41. Please make sure INR is being checked due to being on [MEDICATION NAME]. I do not see anything filed. During an observation and interview on 4/11/19 at 9:50 a.m., the pharmacy consultant said she emailed the (MONTH) 2019 recommendations, including the recommendations for Resident #41, to the DON, the administrator, the Unit Manager, the ADON, and RN L on 3/25/19. At this time, the pharmacy consultant showed the surveyor the email from her computer. During an interview on 4/11/19 at 9:20 a.m., the DON said she was unaware of the pharmacy recommendations sent on 3/25/19. During an interview on 4/10/19 at 3:35 p.m., the administrator said there was a lab issue they reviewed in QA, but said it was no longer an issue. He said the action plan was not due until 4/10/19, and was not carried out yet. During an interview on 4/11/19 at 3:20 p.m., the ADON said she received the pharmacy recommendations by email on 3/25/19. The ADON said she did not always print the pharmacy consultant's email the same day she received it, and this sometimes delayed implementation of the recommendations in the emails. (The ADON said she, the DON, and Unit Manager A all shared the responsibility of reviewing and following up on the pharmacy recommendations. She said the pharmacy recommendations dated 3/25/19 were not printed or followed up on until today (4/11/19). During a telephone interview on 4/11/19 at 3:58 p.m., the medical director said his expectation was an order for [REDACTED]. During an interview on 4/11/19 at 2:10 p.m., the administrator said in the QA meeting on 3/29/19, they identified issues with the new admission and order process. When reviewing the PIP with the surveyor, the administrator said the PIP did not include a plan to address resident's orders missed on admission. He said he was unaware Resident #41 did not have an order for [REDACTED]. 2. Physician orders [REDACTED].#67, admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A physician order [REDACTED]. an order for [REDACTED]. A care plan dated 4/11/19 indicated Resident #67 was at high risk for increased bleeding related to [MEDICATION NAME] therapy. An intervention included labs as ordered. Resident #67's clinical record indicated PT/INR laboratory tests were not done on the following dates with five opportunities missed during the month of March: *3/4/19; *3/7/19; *3/11/19; *3/14/19; and *3/27/19. During a phone interview on 4/10/19 at 3:10 p.m., the Medical Director who was the primary physician, for Resident #67, said he ordered the PT/INR to be performed 2 times a week. He was aware of the PT/INR results and the laboratory tests not drawn as ordered. During an interview on 4/10/19 at 3:19 p.m., the DON said she was aware a few labs were missed during a period of time for Resident #67. A policy revised (MONTH) 2007, titled Medication Regimen Reviews indicated: . 6. the consultant pharmacist will: . e. Be alert to medications with potentially significant medication-related adverse. 9. The consultant pharmacist will provide the DON and medical director with a written copy of the report, listing the irregularities found and recommendations for their solutions A policy dated (MONTH) (YEAR), titled Medications indicated: 1. Upon admission (including readmission) of each Patient/Resident, the physician orders [REDACTED]. 3. Anticoagulant monitoring must be completed on admission (including readmission) for any Patient/Resident receiving an anticoagulant medication (including but not limited to aspirin). Anticoagulant medication usage must be care planned. 11. Recommendations made in a Consultant Pharmacist's Report must be reviewed and corrections initiated within three business days of the visit. Any change in orders must be entered into the EMR for each recommendation approved by the physician. A Nursing Policy & Procedure dated (MONTH) 4, (YEAR) titled Anticoagulant Therapy indicated: monitor any patient prescribed an anticoagulant therapy for side effects and drug-drug interactions test for therapeutic levels of anticoagulant therapy ([MEDICATION NAME]) as prescribed by the Physician all patients on anticoagulation medications are entered into the electronic Medical Record (EMR) system Lab testing for monitoring is conducted weekly or as requested by physician The website https://packageinserts.bms.com/pi/[MEDICATION NAME].pdf accessed 4/16/19 at 9:05 a.m. indicated . WARNING: BLEEDING RISK . *[MEDICATION NAME] can cause major or fatal bleeding. *Perform regular monitoring of INR in all treated patients.Drugs, dietary changes, and other factors affect INR levels achieved with [MEDICATION NAME] therapy. *Instruct patients about prevention measures to minimize risk of bleeding and to report signs and symptoms of bleeding. *Individualize dosing regimen for each patient, and adjust based on INR response . Monitoring: Obtain daily INR determinations upon initiation until stable in the therapeutic range. Obtain subsequent INR determinations every 1 to 4 weeks. The website https://www.mayoclinic.org/tests-procedures/[MEDICATION NAME]-time/about/pac- 661 accessed on 4/16/19 at 9:10 a.m., indicated: .an INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking [MEDICATION NAME] ([MEDICATION NAME]) for disorders such as [MEDICAL CONDITION] . The facility administrator, facility DON and RN L were notified on 4/10/19 at 4:12 p.m. an Immediate Jeopardy situation had been identified due to the above failures. The Plan of Removal included the following: .*Anticoagulant therapy and other medications requiring lab monitoring will be monitored by obtaining physician orders [REDACTED]. The ADON and unit manager will monitor the eMAR in the EMR system daily; *Nursing staff will accurately order, obtain and report all laboratory testing and results on an anticoagulant tracking log to monitor and nurse manager will reconcile ordered labs and lab results daily. When a lab order is received, it is entered into the EMR and then hand written into the lab communication book. Reconciliation will occur with nurse manager utilizing the lab communication book and the EMR system; *Nurses will review orders, scheduled labs, lab results and ensure notification occurred during the shift to shift report; *A full head to toe assessment was done on Resident #41 with on going anticoagulant monitoring. A PT/INR is to be redrawn on 4/12/19 with resident's [MEDICATION NAME] currently on hold; *Full head to toe assessment completed on residents on anticoagulant therapy with on-going monitoring. Care plans will be updated on all residents that have medications requiring laboratory tests for monitoring; *Staff in-service education sessions were conducted on 4/10/19, led by the DON and will focus on anticoagulant therapy, monitoring, laboratory management, notifications and shift to shift report and will continue until all nurses have been in-serviced; and *Lab values and review of lab protocols will be reviewed and analyzed monthly during QA/QAPI committee meetings with input and recommendations from the Medical Director for any trends identified. Anticoagulant orders and lab values will be reviewed each week by the IDT team with medical director oversite. The pharmacy consultant will monitor weekly the [MEDICATION NAME] ([MEDICATION NAME]) laboratory levels and address accordingly. The survey team confirmed the POR was implemented during interviews on 4/11/19 from 11:05 a.m. to 2:54 p.m. with 3 RNs and 24 LVNs across all three shifts, including weekend and PRN staff. The interviews indicated staff were properly in-serviced on the process of monitoring medications that require laboratory tests to assess therapeutic levels. In-service records and clinical record indicated medications requiring monitoring by laboratory tests were tracked and monitored. On 4/11/19 at 11:05 a.m., the administrator was notified the IJ was lifted. However, the facility remained out of compliance at a severity of more than minimal harm with a scope identified as a pattern. The facility continued to monitor residents who received medications that may require drug monitoring to achieve therapeutic levels and to minimize toxicity to ensure assessments were accurate.