Every finding on record at Buena Vida Nursing & Rehab Odessa

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 time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 2 residents (Resident #1) reviewed for care plans in that: The facility failed to ensure there was a care plan in place for Resident#1's dialysis needs. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included:Review of Resident #1's admission Record dated 6/18/26 revealed she was a 74-yeear-old-female admitted to the facility on [DATE] with diagnosis that included reduced mobility, and end stage kidney disease. Review of Resident #1's Quarterly MDS Assessment, dated 5/22/26, revealed:She had a BIMS score of 9 of 15 (indicating moderate cognitive impairment).She received dialysis treatments (process used to remove fluid and waste-products from the body when the kidneys are unable to do so because impaired function) while a resident. Review of Resident #1's Order Summary, dated 6/18/26, revealed orders for dialysis at a local center M/W/F completed by a local transportation company dated 5/27/26. Review of Resident #1's Care Plan, last updated 2/16/26, revealed no care plan for Resident #1's dialysis services. Interview on 6/18/26 at 10:27 a.m., LVN A and LVN B stated care plans were done with the MDS assessments and included diagnosis, medications, fall risk, assistance with ADLs, treatments, allergies and code status. LVN B said dialysis was something that would be care-planned. LVN B checked Resident #1's care plan and said Resident #1's dialysis treatment was not care-planned. LVN A stated she remembered doing the care plan for dialysis. LVN A said Resident #1 went to the hospital and then returned on dialysis. LVN A said she did not know why the facility did not care-plan the dialysis treatment. LVN A said care-plans were checked for accuracy during the interdisciplinary care plan meetings and by the DON. LVN A said she did not know how she missed the care-plan for dialysis when Resident #1 returned to the facility in May 2026. Interview on 6/18/26 at 12:30 p.m. the Administrator stated she thought the care plan was missed because Resident #1 was in and out of the hospital so quickly and was brand new to dialysis. The DON stated LVN A and LVN B overlooked the care plan. Review of the facility's policy and procedures, undated, on Comprehensive Care Planning revealed: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex (what assistance the aides need to provide to the resident), baseline care plans, and task listing.The comprehensive care plan will describe the following:The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for medication errors.The facility failed to administer Resident #1's glimepiride (an oral medication used to manage blood sugar levels in adults with type 2 diabetes). The medication was not available according to the signed MARThis deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health.Findings include:Record review of Resident #1's face sheet dated 09/30/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of type 2 diabetes (chronic medical condition in which the body does not produce enough insulin or does not use insulin effectively), morbid obesity, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #1's most recent quarterly MDS assessment, dated 6/11/25 revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment for daily decision-making skills.Record review of Resident #1's care plan dated 08/08/25 indicated Resident #1 used diabetic medications. Interventions included to provide and document teaching to resident/family/caregiver and address identified roadblocks to compliance Record review of Resident #1's physician orders included the following medications: Glimepiride oral tablet I mg-Give I tablet by mouth one time a day for diabetes mellitus-ordered 12/11/2024 Basaglar Kwik Pen subcutaneous solution Pen-injection 100 unit/ml-Inject 20 unit subcutaneously one time a day relate to type 2 diabetes mellitus-ordered 02/14/25Becton [NAME] duo miscellaneous 30 g X mm. Inject 1 application subcutaneously before meals and at bedtime for diabetes mellitus-ordered 04/14/25. Record review of Resident #1's Medication Administration Record for July 2025 revealed the scheduled medication of glimepiride I mg was not administered on July 27, 28, 29, 30 and 31, 2025. The medication was to be administered I tablet by mouth one time a day. Further review of the MAR revealed MA A documented an UN in the section meant for administered medication indicating unavailable medication for July 28 and 29, 2025. Review also revealed MA C documented UN indicating unavailable for July 27, 30, 31 2025. During an interview on 09/30/2025 at 9:45a.m, RP P stated she was the responsible party for Resident #1. RP P stated on 07/26/25, she had a 90-day supply of glimepiride for diabetes delivered to the facility. The staff lost the medication. The facility informed her that they would have the doctor renew the medication which they did not do as promised. On 07/31/25, the facility still had no medication for the resident. The RP explained she complained to the facility corporate office, and DON assured her the facility will provide the medication and pay for it. She was assured by DON and staff that they had the medication in stock and had been administering the medication to Resident #1. The RP P stated, the resident may have missed his medication for more than four days. The RP P explained the glimepiride was a significant medication used for control of his diabetes mellitus. She stated not taking this medicine will complicate [KS5] the control of his blood sugar resulting in serious harm to his health. In an interview with MA B on 09/30/25 at 1:30p.m, she stated she was the medication aide working on hall 200 where Resident #1 was residing. She said she did not give Resident #1 his glimepiride medication on July 28 and 29, 2025 as ordered. This was because the medication was not available. MA A explained that the family supplies the medication for the resident. She notified the charge nurse that the medication was not available to let the family know. MA A said she could not remember the charge nurse she informed. MA A added that it was a common practice to retrieve the medication from the E-kit (emergency kit) but did not remember if the charge nurse attempted to check the E-kit. She stated the medication was used to treat high blood sugar for diabetic residents. She noted Resident #1 could get diabetic complications [KS7] for not receiving the medication as ordered. During interview with MA C on 09/30/25 at 10:11a.m, she stated she has been working for the facility for 5 years and was responsible for giving medication to Resident #1. MA C confirmed she signed on Resident #1's MAR on July 27, 30 and 31, 2025 that the diabetic medication of glimepiride was not available. She stated one of days the medication was not available the resident's was in the room. The MA C informed wife the resident was out of the medication. MA C said the wife told her she had already filled the medication. MA C stated Resident #1's wife came back the next day and informed her the medication was already delivered and somebody from the facility signed for it. The continued and stated there was no longer a refill left because the order was already filled. MA C said she informed the nurse on duty of resident's information regarding the delivered medication. The medication aide stated she could not remember the charge nurse she informed since it has been more than a month. MA C stated she did not know why it took days before Resident #1 started receiving his medication. She explained, it was normal protocol to retrieve the medication from the E-kit. She did not know if the charge nurse [KS10] ied to get the medication from the E-kit. During an interview with DON on 09/30/25 at 10:43a.m, she stated she was not aware Resident #1 missed his medication of glimepiride for 5 days until the surveyor brought it to her attention. The DON said she communicated with the corporate office about the medication issue. She stated a staff member signed for the medication, but they could not locate the medication. She notified the physician and got the medication refilled. Meanwhile, she was not aware Resident #1 missed so many days. The DON stated it was lack of communication between the staff and herself. She stated, looking at the MAR, it appears Resident #1 did not receive medication of glimepiride for 5 days from July 27 through 31, 2025. In an interview with PH D on 10/01/25 at 10:38a.m, he stated he was familiar and responsible for Resident #1. He said he was made aware that Resident #1 missed some of his medication of glimepiride. PH D stated he was told to reorder the medication because the facility could not find it after it was delivered.Record review of the facility document titled Medication Administration and general guidelines undated reflected the following below. The policy did address the facility E-kit policy.Policy:Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in Link Rx otherwise authorized personnel should refer to Drug Reference material provided by facility.Procedure:1) Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications.2) Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. The interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate.3) The person administering medications adheres to Universal Precautions, using proper hand hygiene, gloves when appropriate, before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident. Gloves will be worn before administration of any ophthalmic, optic, intranasal, inhaled, topical, vaginal, or rectal medication.4) Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with policy and procedure for self-administration of medications.5) Medications are administered at the time they are prepared. Medications are not pre-poured. 6) All current medications and dosage schedules, except topicals used for treatments, are listed on the resident's medication administration record (MAR).

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that could be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #3) of 3 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for using a Geri chair for mobility for Resident #3. This failure could place the residents at risk of a decreased quality of life, and not having their needs met.Findings included: Record review of Resident #3's electronic face sheet 011/6/2025 revealed [AGE] year-old male admitted [DATE] and diagnoses included nontraumatic intracranial hemorrhage (bleeding within the brain that is not caused by trauma), (a condition where paralysis or weakness affects the right side of the body due to damage to the left dominant hemisphere of the brain), muscle weakness (a condition characterized by a decreased ability to generate force in muscles), altered mental status (a significant change in a person's cognitive function, resulting in a decreased level of consciousness and awareness. Record review of Resident #3's Quarterly MDS dated [DATE] revealed resident was sometimes understood and understands others, Resident #3's BIMS (Brief Interview of Mental status) score 0 indicating severe cognitive impairment. Section GG of MDS revealed resident uses a manual wheelchair for mobility. Section O indicated Resident #3 was receiving physical therapy. Section P indicated no restraints were being used. Record review of Resident #3's Care Plan dated 7/302025 revealed no documented Focus, Goal, or Interventions for using a Geri chair (a specialized medical recliner for people with limited mobility to provide comfort, support, and ease of transportation for mobility for Resident #3). Observation on 10/31/2025 at 10:30AM upon entrance to facility Resident #3 was sitting in Geri chair in front lobby. Observation on 10/31/2025 at 12:01PM revealed Resident #3 sitting at dining room table in Geri chair feeding himself. Observation on 10/31/2025 at 1:58 PM revealed Resident #3 in his room in Geri chair in front of TV with call light on. Call light was answered at 2:09PM. Observation on 11/6/2025 at 10:17AM staff was pushing Resident #3 Geri chair down hallway. Interview on 10/31/2025 at 12:00PM with Director of Rehab revealed Resident #3 is currently receiving physical therapy for contractures and standing. Director of Rehab stated he has attempted to use a wheelchair for Resident #3 but resident has poor trunk control. Director of Rehab stated when Resident #3 is in wheelchair nursing staff states he leans forward and tries to get up. Director of Rehab stated Resident #3 has right side hemiplegia (paralysis and weakness on the right side of the body) and the right leg is flaccid (soft and hanging loosely). Director of Rehab stated Resident #3 requires assistance of 2 staff members for most ADLs. Director of Rehab stated he does think resident will progress out of the Geri chair when therapy is completed. Interview on 10/31/2025 at 3:00PM with Regional Nurse Consultant revealed facility does not have a policy on use of Geri chairs. Regional Nurse Consultant stated he would expect Geri chairs to be care planned because that is what residents use for mobility. Also stated the interdisciplinary team is responsible for ensuring the goals/interventions are met. Interview on 11/6/2025 at 2:41PM with LVN C she stated Resident #3 uses a Geri chair. She stated Resident #3 has had several falls from bed and wheelchair. During an interview on 11/6/2025 at 3:26 PM with MDS Coordinator stated the facility completed care plans as a team and each department did their section. The MDS Coordinator stated she would expect for the Geri chair to be care planned and she did not know how the failure occurred. The MDS coordinator stated the DON usually updates changes on the care plan to reflect residents' condition within 3 days. The MDS Coordinator stated this failure could impact the resident's quality of life, and safety by staff not recognizing that Resident #3 utilized a Geri chair for mobility. During an interview on 11/6/2025 at 3:46PM the DON stated the MDS coordinator updates all comprehensive care plans. The DON stated it was her responsibility to update acute care plans. The DON stated she was responsible for checking care plans quarterly and when a resident had a change in condition that required additional interventions on care plan. She stated she updates the care plans as needed. She stated a risk for not having this care planned is staff might not know the resident utilizes a Geri chair. Record review of facility's policy titled Comprehensive Care Planning (not dated) revealed:The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that include measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following---The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and addresses the resident's medical, physical, mental and psychosocial needs. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment. The facility will ensure that services provided or arranged are delivered by individuals who have the skills, experience, and knowledge to do a particular task or activity. This includes proper licensure or certification if required.

Based on interviews and record review, the facility failed to ensure the appropriate treatment and services to prevent complications was provided for 1 of 1 resident reviewed for feeding tube management (Resident #1). The facility failed to ensure Resident #1 had a physician order for the volume, frequency, and type of flush to administer via the gastrostomy feeding tube (a surgically created abdominal opening into the stomach for the purpose of administering feedings). The facility failed to ensure Resident #1 had a physician order on the frequency of cleaning and the care of the site on the gastrostomy feeding tube. These failures placed the resident at risk for tube obstruction, malfunction, dysfunction, abdominal discomfort, and infection.Findings included: Record review of Resident #1's face sheet dated 10/31/25 revealed Resident #1 was a [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses including unspecified protein-calorie malnutrition (is a condition caused by an inadequate intake of protein and calories, leading to a deficiency in essential nutrients and impacting body composition and function), dysphagia (difficulty swallowing), Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination), abnormal weight loss (a significant decrease in body weight without intentional effort). Record review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 was understood and had the ability to understand others. Resident #1 had a BIMS score of 8 which indicated moderate cognitive impairment. Section K of MDS revealed Resident #1 had received mechanically altered diet and therapeutic diet while a resident was not receiving gastrostomy tube feedings (is a method of providing nutrition and fluids directly into the stomach or small intestine through a tube) during last 7 days while a resident. Section K also revealed no significant weight loss or weight gain in the last 180 days. Record review of Resident #1's care plan dated 10/16/25 revealed Resident #1 had a puree diet with nectar thickened liquids. Care plan also revealed resident requires tube feeding related to dysphagia but chooses to eat by mouth instead of tube feeding. Interventions include cleanse insertion site daily, monitor for signs and symptoms of infection or skin breakdown, and monitor/document report to MD as needed infection at tube site, tube dysfunction or malfunction, resident is dependent with flushes. Record review of Resident #1's consolidated physician order dated 8/1/25 revealed all enteral feed orders were discontinued on 8/3/2025. Resident #1 continued with gastrostomy tube even though she was not receiving nutrition via tube. Record review of Resident #1's Medication administration record and treatment administration record revealed no enteral feeding care including flushes to maintain patency and monitor for malfunction or site care was administered from 8/3/2025 to 10/23/2025 when Resident #1 discharged to the hospital. Record review of facility in-service to staff dated 10/28/2025 conducted by Regional Nurse Consultant revealed: If feedings are discontinued and the peg tube is not removed staff must keep the peg tube patent by flushing every shift and continue to monitor and treat the site of the feeding tube until it is removed by the physician. At no time should a peg tube not in use not have an order to continue flushing or monitoring. Interview on 10/31/25 at 3:30 p.m., LVN G said she primarily worked on the hall where Resident #1 resided. She said the nurses are responsible for obtaining feeding tube orders. She said residents with feeding tubes should have flush orders and cleaning orders. She said Resident #1 often declined feeding and requested to eat food by mouth. She stated Resident #1 typically had a good appetite and ate most of her food on her shift. She said it was important to clean the gastrostomy site to prevent infections. She said it was important to have physician orders because some staff may come through and not follow the best nursing practices. She stated they have not provided gastrostomy care in a while as resident did not want them messing with it. She stated she did not realize the orders were discontinued. Interview on 11/6/2025 at 11:04 AM with Resident #1's Primary Care Physician he stated if gastrostomy tube feedings were discontinued, he would expect general maintenance such as flushing tube every shift to maintain patency (the condition of not being blocked or obstructed) and management of site skin care to continue. He stated not managing or monitoring the gastrostomy tube site could lead to skin breakdown infection, and stomach pain. Interview on 11/6/25 at 3:15 PM, the DON stated the nurse was responsible for obtaining physician orders for a resident with a feeding tube. She stated nursing management was responsible for ensuring the nurses obtained physician orders. She was unaware the orders to flush and cleanse site were discontinued. She stated she monitors new orders put into system in the morning clinical meeting. She uses a report pulled from the electronic medical record system of any new orders that have been put into computer. She was aware the feeding orders were discontinued. She stated it was important to have physician orders for site care and flushing to maintain accuracy of the resident's electronic medical record. She stated residents could experience patency issues and infection if physician orders were not in place. She stated nursing management was to audit residents' physician orders to ensure accuracy. Interview on 11/16/25 at 3:23 p.m., the Regional Nurse Consultant stated the nurses were responsible for obtaining physician orders for a resident with a feeding tube. He stated he knew if the resident did not have cleaning orders, it placed the resident at risk for infections. He stated the DON was responsible for ensuring the nursing staff obtained physician orders. Record review of a facility's Gastrostomy Tube Care policy with no date indicated .included in the management of a gastrostomy tube is the care of the stoma site. The clean technique is utilized in the care of the insertion site. The policy did not indicate information regarding flushing, care or cleaning of the insertion site.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 3 medication carts (#1, #2 and #3) reviewed for medication storage. The nurse medication carts used for halls 100, 200, 300 and 400 had an insulin vial that had been opened but had no open date. There were insulin pens that had expired since being opened as indicated by the manufacturer's instructions. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.The findings were: During an observation and interview on 08/05/2025 at 9:04 AM the nurse medication cart #3 used for halls 300 and 400 was inspected with RN A present. There was one insulin pen that had an open date of 06/17/2025. RN A said that insulin pen should have been removed from the cart as it had expired since they were good for thirty days only. RN A said she worked at the facility as needed so she was not at the facility every day. RN A said as far as she knew it was each nurse's responsibility to check the insulins in their cart. RN A said she did not notice that the insulin pen had already expired when she took over the nurse's medication cart. RN A said if an expired insulin was used it might not produce the desired effects. During an observation and interview on 08/05/2025 at 9:14 AM the nurse medication cart #1 used for hall 100 was inspected with LVN B present. There was one insulin pen with an open date of 06/25/2025. LVN B said the insulin pen should have been removed since it had expired. LVN B said it was each nurse's responsibility to check their nurse's medication cart and inspect it for expired medications. LVN B said if a resident received an expired medication that it might not cause the desired effect as it was intended for. During an observation and interview on 08/05/2025 at 9:26 AM the nurse medication cart #2 used for hall 200 was inspected with LVN C present. There was one insulin vial which had been opened but did not have an open date written on it. LVN C said she had not noticed that the vial did not have an open date on it. LVN C said as far as she knew it was each nurse's responsibility to monitor their carts for undated or expired insulin pens and vials. LVN C said if the insulin vial was not dated then they would not know when the insulin would expire as they were good for 30 days after opening. During an interview on 08/07/2025 at 4:34 PM the DON said the expectation was for nursing staff to date the insulin pen or vial after they opened it or else how could they tell when the insulin expired. The DON said once the insulin container was opened they were usually good for 28 to 30 days. The DON said that the expectation was for nursing staff to discard any insulin pens that had expired. The DON said if insulin that had expired was used then it could lead to adverse effects and not be as effective. The DON said it basically was each nurse's responsibility to inspect their medication cart for any expired or undated medications and discard them. The DON believed the failure occurred because the nursing staff failed to inspect their medication carts. During an interview on 08/07/2025 at 4:54 PM the Administrator said the nursing staff should have dated the insulin once they opened it and discarded the expired one. The Administrator said the nurses were expected to inspect their medication carts and remove any expired or non-dated insulins. The Administrator said if an expired insulin was administered then it might not be as effective. Record review of the facility document titled Insulin pen use and dated 4/1/15 indicated in part: Storage instructions. Once you take the insulin pen out of cool storage you can use it for up to 28 days. Ensure that the pen is dated when placed into use. During this time it can be safely kept at room temperature up to 86 degrees Fahrenheit. Do not use it after this time.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #7) of 3 residents reviewed for infection control. LVN D failed to use PPE when she administered Resident #7's medication via his IV central line (A central line is a catheter placed into a large vein. A central line provides access to a person's blood supply, which allows the patient to receive medications, fluids or additional blood). This failure could place residents at risk for cross contamination and the spread of infection.Finding include: Record review of Resident #7's admission record dated 08/07/2025 indicated he was admitted to the facility on [DATE] with diabetes with a foot ulcer. He was [AGE] years of age. Record review of Resident #7's care plan dated 04/22/2025 indicated in part: Focus: Resident is on enhanced barrier precautions. Goal: There will not be any transmission of infection from or to the resident. Interventions: Gloves and gown should be donned if any of the following activities are to occur: wound care, enteral feeding care, catheter care or other high-contact activity. Record review of Resident #7's MDS assessment dated [DATE] indicated in part: Does this resident have one or more unhealed pressure ulcers/injuries? Yes. Special Treatments, Procedures, and Programs - IV Medications. Record review of Resident #7's order summary report dated 08/07/2025 indicated in part: Flush IV line with 10 ml of normal saline before and after medication. Aztreonam (antibiotic) Injection Solution Reconstituted 1 GM. Use 1 application intravenously every 8 hours for right heel wound infection for 4 Weeks. Order date 07/28/2025. During an observation on 08/06/2025 at 4:14 PM LVN E administered Resident #7's medication (Aztreonam) via his IV central line. LVN E entered the resident's room, sanitized her hands and put on a pair of gloves. LVN E then took a syringe that contained normal saline fluid and connected it to the IV central line and flushed it. LVN E then connected the antibiotic medication to resident #7's IV central line. LVN E then removed her gloves and was done with the administration. LVN E only wore gloves and not a gown. During an observation and interview on 08/06/2025 at 4:30 PM there was a document posted outside Resident #7's door that indicated the resident was on EBP precautions. The document indicated Enhanced barrier precautions. Providers and staff must also wear gloves and a gown for the following high contact resident care activities - device care or use - central line. LVN E was asked if she was supposed to have used a gown during Resident #7's medication administration, LVN E said she was not sure if she had to and did not recall if she had seen other staff use the gown during medication administration via the IV central line. LVN E said she thought that the reason Resident #7 was on EBP precautions was because he had a pressure sore and PPE had to be worn when wound care was performed. During an interview on 08/07/2025 at 4:32 PM the DON said the expectation was for nursing staff to use PPE when assisting Resident #7 with his central line. The DON said the nurse that assisted Resident #7 should have known she had to use PPE but that the nurse probably got nervous and forgot. The DON said if the nurse did not wear PPE as indicated then it could lead to the resident being exposed to infections. During an interview on 08/07/2025 at 4:50 PM the Administrator said the nursing staff should have worn PPE when they assisted a resident on EBP. The Administrator said if staff did not wear PPE, then it could possibly lead to the spread of infections. Record review of the facility's undated policy titled Enhanced Barrier Precautions indicated in part: Multidrug-resistant organisms (MDROs) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBPs) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employ targeted gown and glove using high contact resident care activities. EBP are indicated for residents with any of the following: Indwelling medical device examples include central lines. Record review of the facility's policy titled Infection control plan and dated 03/2024 indicated in part: Infection control - The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will establish an infection control program under which it, investigates, controls and prevents infections in the facility. Decides what procedures, such as isolation, should be applied to an individual resident and maintains a record of incidents and corrective actions related to infections.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #81) reviewed for transfers in that: CNA D and LVN C transferred Resident #81 from her bed to her wheelchair by grabbing her from the back of her pants and her under arms. These failures could put residents at risk of accidents and injuries which could result in a reduced quality of life. Findings included: Record review of Resident #81's admission record dated 08/07/2025 indicated she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and paraplegia. (Paraplegia is the loss of muscle function in the lower half of the body, including both legs). She was [AGE] years of age. (Paraplegia is the loss of muscle function in the lower half of the body, including both legs). Record review of Resident #81's MDS assessment dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Moderately impaired. Functional Abilities - Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) = Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #27's 81's care plan dated 04/17/2025 indicated in part: Focus: The resident has an ADL Self Care Performance Deficit. Goal: The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers,. Interventions: Transferring: requires staff x2 for assistance During an observation on 08/05/2025 at 12:02 PM CNA D and LVN C transferred Resident #81 from her bed to her wheelchair. Both staff members took the resident from under her arm pits and the back of her pants to transfer her. Resident #81 did not appear to have been bearing weight during the transfer as her legs were partially contracted. During an interview on 08/08/2025 at 8:58 AM LVN C said that she had not transferred Resident #81 safely from her bed to her wheelchair. LVN C said she should have used a gait belt but had forgotten to use one. LVN C said if they did not use a gait belt then it could possibly lead to accidents such as dropping the resident or they themselves getting hurt. During an interview on 08/08/2025 at 9:04 AM CNA D said she should have used a gait belt when they transferred Resident #81 from her bed to the wheelchair. CNA D said she had not used a gait belt because she did not have one readily available and she should have had one. CNA D said they could have dropped or injured the resident by not using a gait belt. During an interview on 08/07/2025 at 04:38 PM the DON said the CNA and nurse should have used a gait belt to transfer Resident #81. The DON said staff used the gait belts to prevent falls or injuries. The DON said the failure probably occurred because the staff got nervous and forgot to use the gait belt. During an interview on 08/07/2025 at 05:12 PM the Administrator said the nursing staff was expected to use a gait belt when transferring residents manually. The Administrator said the nursing staff should have not taken Resident #81 from the back of her pants as that could make the transfer uncomfortable for the resident plus the staff could have dropped her. Review of the facility's undated policy titled Moving a resident bed to chair/chair to bed indicated in part: Purpose - The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the procedure. This procedure may require two (2) persons. Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable. If the resident requires two person (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her on the edge of the bed.

Based on observation, interview and record review the facility failed to provide supervision to prevent accidents for 5 (Resident #1, Resident #2, Resident #3, Resident#4, and Resident #5) of 11 Residents reviewed for residents having lighters. The facility failed to ensure Resident #1, Resident #2, Resident #3, Resident#4, and Resident #5 were not in possession of an unauthorized lighter. 1 of the 5 residents (Resident #1) used a lighter to burn the gauze bandage, which was secured to her right foot, resulting in second degree burns to her right foot. An Immediate Jeopardy (IJ) situation was identified on 4.4.25. The IJ template was provided to the facility on 4.4.25 at 3:10pm. While the IJ was lowered on 4.6.25 at 5:52 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of a isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could put residents at risk of burn injuries related to smoking paraphernalia that is not monitored/secured by the facility. Findings included: Resident #1 was a [AGE] year-old female admitted to the facility on 4.4.24with diagnoses of traumatic amputation, urinary tract infection, cognitive communication deficit, dementia, and type 2 diabetes. Resident #1's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident was safe to smoke unsupervised, at this time. Resident #1's quarterly BIMS was completed on 2.27.25 with a score of 13, indicating no cognitive impairment. Resident #2 was a [AGE] year-old male admitted to the facility on 1.10.25 with diagnoses of hypertension, pneumonia, and dementia. Resident #2's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident was safe to smoke. Resident #2's initial BIMS was completed on 1.16.25 with a score of 9, indicating moderate cognitive impairment. Resident #3 was a [AGE] year-old male admitted to the facility on 6.7.24 with diagnoses of pneumonia, Alzheimer's disease, and type 2 diabetes. Resident #3's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident was safe to smoke. Resident #3's quarterly BIMS was completed on 3.27.25 with a score of 14, indicating no cognitive impairment. Resident #4 was an [AGE] year-old male admitted to the facility on 8.28.20 with diagnoses of hypocalcemia (a condition where the level of calcium in the blood is too low), amputation of leg below left knee, and anemia. Resident #4's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident is safe to smoke. Resident #4's quarterly BIMS was completed on 2.20.25 with a score of 13, indicating no cognitive impairment. Resident #5 was a [AGE] year-old female admitted to the facility on 11.21.22 with diagnoses of seizures, anemia, and muscle weakness. Resident #5's Safe Smoking Assessment was completed, dated 3.25.25. Stating resident knew area for smoking, could get to smoking area independently, and that the resident is safe to smoke. Resident #5's quarterly BIMS was completed on 1.8.25 with a score of 13, indicating no cognitive impairment. During an observation on 4.1.25 at 11:15am Resident #1 had one large blister on the side of right foot and 3 smaller blisters on top of the right foot. Record review of EMS report dated 3.31.25 at 8:18 pm indicated: patient stated that she was trying to cut a piece of her bandage off her foot and then light that cut piece on fire. The cut piece was still attached to the rest of the bandage on her foot, and it all caught on fire including her foot. Patient had superficial burns to her right foot. First degree burns 9%. Record review of assessment dated 4.1.25 completed by LVN A (treatment nurse) indicated: Right dorsal with blister 8cm x 4 cm and multiple small blisters on lateral right food. Type of burn: 2nd degree burn. Wound assessment: length 8cm width 4 cm and depth 0.1 cm. Record review of Resident #1's medical record from local hospital dated 3.31.25 indicated: Resident #1 arrived at local hospital for assessment but refused both assessment of burns and treatment. Record review of facility's Event Nurses' Note-Burn dated 4.2.24 by RN A indicated that on 3.31.25 at 6:53 pm- While this nurse was on break, was alerted by staff that resident #1 had set her bandage on fire. Found water on ground where the aid put out fire. Resident was angry and stated that she wanted water on her burn; attempted to explain that we needed immediate treatment at hospital and that they would be able to assess severity of burn. Resident refused initially to go to hospital despite EMS and police presence. Was able to convince resident to go to hospital but resident decided against treatment. Interview with Resident #1 on 4.1.25 at 11:35 am who was alert and oriented to person, place and event stated she had gauze wrapped around her right foot that was hurting and too tight. She stated she requested help and was told someone would be right there. She stated she began to unwrap the gauze off her foot and to cut the gauze she used a lighter. She stated the fire moved quickly down the gauze onto her foot and burned her foot. During an interview on 4.1.25 at 2:10 pm CNA A stated she was working the night of the incident. She stated that she went down to Resident #1's room because her call light was on. She stated she went to her room and the resident stated her wrapping on her foot was too tight and was hurting. She stated she will let the nurse know and come back. She stated she went to the nurse's station and let the nurse know- - because charge nurse was on her break. She stated that nurse said OK give me a few minutes and she will go help the resident. She stated not even 10mins went by and she was walking hallway 100 when she looked into Resident 1's room and there was a fire going on her foot. During an interview on 4.1. 25 at 2:25 pm RN A stated she was on break when the incident occurred. She stated that the resident is usually very good with her. She stated the resident is extremely impatient. She stated that this behavior is very abnormal for the resident. She stated the night of the incident she was in the breakroom on hallway 300. She stated she heard yelling and stopped her break and went to see what was going on. She stated that when she went into the resident's room there was water all over the floor and gauze was singed and wet laying on top of the resident's foot. She stated the resident was yelling in pain. She stated she told staff to call EMS and police to get someone here asap because she was not sure how bad the burn was. She stated the resident was extremely upset and was yelling in pain. She stated she ultimately calmed the resident down. She stated EMS showed up and the resident refused to go with EMS, same with the police that showed up as well. She stated EMS left and told her if she does need them to come back to please call them. She stated about 15min later she convinced the resident to go to the ER and just let them look at it. She stated she called EMS back, the resident went. She stated she is not exactly sure how long it was, but the hospital called stating they are sending the resident back because the resident is refusing everything, and the facility needs to come get her. She stated they got the resident back; she was still very upset. During an interview on 4.1.25 at 2:35 pm RN B stated she was one of the RNs on shift during the incident. She stated that she was sitting at the nurse's station when a CNA went and checked the residents call light and came back to report that Resident #1 was saying her wrapping on her foot was too tight and that she wanted it to be changed. She stated she told the CNA that she would go and look at it shortly, just to let her finish up what she was doing. She stated the next thing she knew; the CNA was walking back down hall 100 and started yelling for help. She stated as she got close to the resident's door the CNA yelled, fire and grabbed a water cup and put out the flame. She stated she saw the water and singed gauze on the resident's foot. She stated shortly after showed up and was the one who started to assess and try to help calm down the resident. She stated police and EMS were contacted. She stated EMS did come to the facility, but the resident would not allow them to assess or help her. She stated EMS left but did return because the resident finally agreed to go to the ER. Interview with Administrator on 4.1.25 at 12:35 pm stated she was contacted by phone at 6:57 pm on 3.31.25 with details of the incident. She stated she went to the facility immediately. She stated she spoke with all 11 smokers, and ultimately confiscated 5 lighters from the Residents. She stated none of the residents could notate exactly where they got the lighters from or how long they had had them for. She stated that they have verbally discussed the procedure with the staff that do take the residents out to smoke, but the facility does not have a written procedure. Interview with Staff A on 4.1.25 at 2:55 pm stated he was not exactly sure how any of the residents got the lighters they had. He stated that there was a possibility that when he handed a resident their lighter to light the cigarette and he never asked for the lighter back. He stated there was a policy in place that he knew about regarding smoking residents, but no procedure in place. Interview with SW on 4.1.25 at 2:40 pm she stated that she does take the residents out to smoke each day. She stated she has no idea how they got the lighters but should not have had them. She stated she is not sure if other employees are giving the residents lighters and not getting the lighters back. Interview with Staff B on 4.2.25 at 2:45 pm stated that she does not believe there is a procedure in place for smoking or taking the residents out to smoke. she stated there is a policy but no actual procedure she can think of that is in place for taking the residents out to smoke. She stated this was why she believed residents had lighters. During an interview with the Administrator on 4.1.25 at 12:05 pm she stated that Resident #1 should not have had a lighter on her person. She stated the incident occurred Monday night, 3.31.25. She stated she came up to the facility immediately. She stated upon speaking with her staff, she understood that Resident #1 was trying to cut the gauze from her foot because it was too tight. She stated Resident #1 used a lighter to cut the gauze resulting in burns to her foot. She stated she never imagined anything like this ever happening. She stated after the incident that night she did rounding on all smoking residents and found that Residents #1, #2, #3, #4, and #5 all had lighters on them. She stated she did confiscate them. She stated the policy states residents are not supposed to have lighters. She stated the policy was not followed and due to this, Resident #1 got injured. During an interview with the DON on 4.1.25 at 12:35 pm she stated she received a call from her staff around 7:00 pm stating that Resident #1 had burned her foot with a lighter. She stated she came up to the facility and upon speaking with her staff, she found out that Resident #1 was trying to remove gauze from her foot because it was too tight. She stated she had never had anything like this happen before. She stated the policy stated that no resident was to have a lighter or anything like that on them. She stated there were multiple other lighters confiscated by the Administrator from other residents. She stated policies and procedures were in place for the residents' safety, but the policy and procedures were not followed. During interview with Resident # 2 on 4.2.25 at 3:15 pm he stated that when he goes out to smoke with the group daily, after the residents were done smoking, he was never asked by any employee if he had a lighter on him. He stated he knows multiple Residents have lighters on them all the time because staff do not ask for them back. He stated he knows about the smoking policy, but never thought about having a lighter as an issue. During an interview with Resident #3 on 4.2.25 at 3:35 pm stated there has been many times where the employees will take the group outside give them everything including the lighter and then go back inside to work. He stated there have been a few times where he will get back to his room and look down and realize he still has the lighter he was given to smoke with outside. He stated the employee's do not ask for the lighters back if they gave lighters to the residents. Interview with DR A stated on 4.1.25 he was informed of the incident and did not know the severity of the burns or how many on the night of the incident 3.31.25. He stated but the blisters started to form on the morning of 4.1.25 and this was communicated to him by LVN A who did an assessment of Resident #1's food. He stated he has no idea where Resident #1 got a lighter, but she should not have had one. Record review of Resident #1's orders dated 4.1.25 indicated Dr. A ordered silver sulfadiazine 1% cream to be used one time a day for burn on foot. During phone interview with NP on 4.3.25 at 12:50 pm she stated she was at the facility on 4.2.25 to see Resident #1. She stated Resident #1 had gauze on right foot that was clean and intact. She stated she did not remove the gauze to assess the injury. Record review of facility policy dated 11.1.17 indicated: 1. Matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in a resident's room. Record review of facility smoking procedure indicated: Facility does not have a written smoking procedure. This was determined to be an Immediate Jeopardy (IJ) on 4.4.25 at 3:10 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 4.4.25 at 3:10. Record review of Plan of Removal accepted on 4.5.25 at 3:37 PM reflected the following: 4/4/25 Plan of Removal Problem: IJ F689 Free of Accidents/Hazards/Supervision/Devices called on 04/04/2025 Interventions: On 3/31/2025 Resident #1 was sent to the emergency department for assessment after initially refusing any treatment. She turned the first away, so a second ambulance had to be dispatched after facility administrator got her agreement. The hospital records did not indicate injury, and she returned to the facility with antibiotic for diagnosis of cellulitis. was contacted and assessed for psychiatric screening for inpatient psychiatric care, the resident refused screen. Resident placed on 1:1 observation until 4/3/2025. Psychiatric services in facility referral were made. All other residents who smoke including those discovered with cigarette lighters had a skin assessment completed on 4/1/2025 with no visible signs of injury related to cigarettes or lighters. On 3/31/2025 the facility administrator, director of nurses and regional compliance swept all resident rooms for items not allowed in resident's rooms and to check for cigarette lighters. They removed those offending items found from the resident rooms. A log was completed with items found of items removed. Facility administrator/DON/Compliance nurse will keep a log of any medications/items to include cigarette lighters not allowed found at bedside during champion rounds five times weekly. Any items discovered will be reported to the DON/Administrator at the time of discovery. On 4/4/2025, the Regional Compliance Nurse in serviced the DON and administrator on items not allowed. If a resident is found with a cigarette lighter, the item is to be removed from the room. Smoke breaks are to be supervised by the facility staff assigned to the scheduled smoke breaks, and residents will not give a lighter to keep during that smoke break. The facility staff member will light the cigarette for the resident and return the lighter to the smoking lock box after use. A log will be placed in the lock box to verify the count of cigarette lighters at the start and end of the smoke break. The facility staff education provided on the new process on 4/3/2025 with a completion date of 4/4/2025. This was done both in person and via Covr. The facility administrator, director of nursing or compliance nurse will review this log 5x weekly for discrepancies. Staff were given a copy of the new process and verbal checks by DON and compliance nurses are being conducted each shift to verify understanding. On 4/4/2025, Regional Compliance Nurse educated the DON/Administrator that this incident and any other incident related to smoking paraphernalia including cigarette lighters to be reviewed monthly by the QAPI committee. The Area Director of Operations or Regional Compliance Nurse attend QAPI committee meetings and will verify continued compliance. On 3/31/2025 nursing staff education was begun by the Director of Nurses with a completion date of 4/4/2025 to ask residents that return from being out of facility to smoke if they have cigarette lighters in possession. If they returned with any items that are not allowed to include cigarette lighters, we are to re-educate and take them items or return them to the family. These incidents are to be reported to the DON/Admin immediately. Facility staff have been given written fact sheets to keep with them during the learning process and verbal questioning is being done of three staff members at least 5 times weekly and PRN. On 3/31/2025, Facility completed education/notification in form of an email to all RPs of residents with a list of the items not allowed in residents rooms to include cigarette lighters and the smoking policy. A physical copy of the items not allowed in residents rooms will be mailed out to resident RP's on 4/5/2025 For all future residents, list of items not allowed in room will be provided upon admission as part of the admission packet. On 3/31/2025 education/in-service begun for all staff by facility director of nursing to reiterate the policy of items not allowed in residents rooms to include cigarette lighters, smoking policy, by phone, COVR (scheduling portal/message board) and in person. Staff will not be able to return to work until education has been provided. Education will be completed by 4/5/2025. Signature or acknowledgement of this education will be confirmed by an audit list. This will be monitored for continuous compliance to include new hires by the Administrator, DON, or Regional Compliance Nurse. Facility staff have been given written fact sheets to keep with them during the learning process and verbal questioning is being done of three staff members at least 5 times weekly and PRN. On 3/31/2025 The Facility provided a copy of list of items not allowed to include cigarette lighters and the smoking policy to residents and keep a singed copy. Residents that are alert but unable to physically sign will be confirmed by two witnesses. This was completed by facility on 4/1/2025. The signed copy is scanned into the documents section of the resident's electronic medical record. 100% was completed and verified by the regional compliance nurse and facility administrator. On 4/4/2025, a sign was placed at the front door of the facility with the items not allowed to include cigarette lighters and the smoking policy for reference and education. On 4/1/2025 The physical environment of all residents was observed to include the closet, nightstands, and any other storage containers to ensure that no cigarette lighters were retained in their room by the facility administrator, director of nurses and the regional compliance nurse. This was completed on 4/1/2025. On 4/4/2025 MD was notified of IJ F689 Free of Accidents/Hazards/Supervision/Devices On 4/4/2025 All facility staff were educated by the director of nursing that no residents may be left alone on the smoking patio, staff are to light the resident cigarettes and return lighter to the receptacle for safe keeping. The facility administrator will review the lighter logs 5x weekly for compliance. All in-service education will be completed by new hires at orientation and before assuming duties in the facility. This will be verified by the Administrator, Director of Nurses, or the Regional Compliance Nurse. Monitoring: Facility department heads or weekend manager on duty will conduct champion rounds 5x a week indefinitely in every resident room and look for items not allowed per written company guidelines to include cigarette lighters. They will remove items not allowed if they identify any then report to DON/Administrator. Monitoring will start 4/5/2025. Regional Compliance Nurse will monitor during weekly visits and ask DON and Administrator what items are not allowed in residents room to include cigarette lighters and what to do if any are identified. They will be questioned about the smoking policy and any identified violations. Monitoring will start 4/5/2025 and will continue for at least 8 weeks and prn thereafter. The administrator / DON will assess five resident rooms for posted items not allowed to include cigarette lighters, 5 days a week to ensure residents do not have any items not allowed in room to include cigarette lighters. Regional Compliance Nurse will assess for compliance with posted items not allowed to include cigarette lighters, once weekly by verification of completion of facility assigned monitoring as listed above and visual verification of five rooms each week. Monitoring will start 4/5/2025and will continue for at least 8 weeks and prn thereafter. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 4.6.25. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record review from 4.5.25 at 3:37 PM to 4.6.25 at 5:52 PM as follows: During an interview on 4.6.25 at 10:10 am FT stated she is one of the employees that takes them out for the smoke break. M-F 7a to 4p. She does the smoking break from 8:30-8:50 am. She stated she attended an In-service on items not allowed in room-she stated that they went over a list of items residents should not have in their rooms. She stated items such as scissors, lighters, glasses, anything that says, keep out of reach of children, corded things like air dryers, etc. she stated this was done to make sure there is nothing in the room that anyone could hurt themselves with. She stated she was to keep an eye out for any of these items while working throughout the day. She stated if she does find something she would let the DON or Administrator know and they would go take care of it. She stated she attended an in-service on smoking policy-she stated there were no real changes to the smoking policy. She stated it was still to watch the residents if you are the one that takes them out. Residents are to have one cigarette at a time. And that the residents are to not be left alone at any time while outside smoking. She stated that residents should not have lighters or any other smoking related items. She stated she attended an in-service on smoking procedure-she stated that the new process for taking residents out to their smoking break was to get the smoking box which has all residents' cigarettes in it. She stated there was one lighter in the box now and you sign out that one lighter onto the log sheet, also you put the time the smoke break is happening on the log sheet. She stated you give each resident one cigarette, you light the cigarette, do not let resident do it, and watch the residents while they smoke. She stated once everyone has completed their cigarette, and everyone is back inside, you sign the one lighter back in and return the smoke box back to the med room. Record review of in-services completed by FT with signature for the smoking policy on 3.31.25, items not allowed on 4.4.25, and smoking procedure on 4.3.25. During an interview on 4.6.25 at 10:15 am Staff B stated she was the employee Monday through Friday that would take residents out to smoke break from 6:15 am to 6:35 am Monday through Friday. She stated she attended an in-service on items not allowed in room-she stated the discussion covered all items that could be used to hurt themselves or others, may it be intentional or by accident. She stated things like sharp objects, aerosol cans, she said anything that can hurt anyone. She stated if she were to see anything in a resident's room that was not allowed, she would take the item to DON or Administrator and have them explain to the resident why it was not allowed, or she would just inform either one of them of the item. She stated she attended an in-service on smoking policy she stated the smoking policy is pretty much the same, they just went over it. She stated it covers who can smoke, when to smoke, what is allowed, where its allowed. She stated the smoking policy is straight forward. She said oh, an assessment must be completed by any resident that is out there for a safe smoker assessment. She stated she attended an in-service on smoking procedure- she stated the new procedure was to get the box with all the residents' cigarettes in it. She stated that once everyone was outside, she would give each residents a cigarette, if they wanted a second cigarette, they must finish the first one first. She stated she would then light the cigarette for the residents individually, never giving the lighter to any of them. She stated that after everyone was done smoking and back inside, she would fill out the smoking log which indicated how many lighters she started the break with, how many ended with and her signature, with time of the smoke break. Record review of in-services completed by Staff B with signature for the smoking policy on 3.31.25, items not allowed on 3.31.25, and smoking procedure on 4.4.25. During an interview on 4.6.25 at 10:30 am CNA B stated she normally works 6a to 2p. She stated she is one of the employees that will take the residents out on smoke break. She stated she attended an in-service on items not allowed in room, she stated this was one she kind of all did already, but it was nice to see it written. She stated basically while she was working at any time, she was to keep a look out for any items in residents' rooms or on their persons that was not allowed. She stated these items were like scissors, glasses, aerosols, electrical wires, etc. she stated this was being done to protect the residents and make sure everyone is safe in the building and no accidents to occur. She stated she attended an in-service on smoking policy she stated the smoking policy did not change. She stated that it was an overview of the smoking policy and the importance of sticking to it. She stated it covers what residents were allowed to smoke, where they were allowed to go what items should not be left with them etc., she stated it was straight forward. She stated she attended an in-service on smoking procedure she stated that the new procedure is to get the smoking box and check for a lighter and how many. She stated she was to go outside with the residents, hand out 1 smoke to each resident, light the smoke for them, and monitor the residents while they were outside smoking. She stated that she was to fill out the smoking log sheet, which indicated how many lighters smoke break started with, how many ended with, smoke break time and her signature indicated she did take them out and that the lighter was returned. Record review of in-services completed by CNA B with signature for the smoking policy on 3.31.25, items not allowed on 3.31.25, and smoking procedure on 4.4.25. During an observation on 4.6.25 at 10:30 am smoke break with employee CNA B she handed all resident one cigarette at this time, she individually lit the residents a cigarette. She watched all the residents until they were done, and they all headed inside. Once they were all inside, she signed the log she indicated the one lighter was still with her and she returned the box to the med room. Observation of log was documented and fully completed since yesterday 4.5.25. During a phone interview on 4.6.25 at 10:50 am LVN B stated she works Monday through Saturday. She stated she usually takes the residents out for the 10:30pm smoke break every day. She stated that this week was a lot of in-services, covering smoking procedure, smoking policy, and items not allowed. She stated she attended an in-service on items not allowed in room-she stated that the was not just focused on lighters but focused on all items that could be harmful to the resident. She stated that the in-service was done to have all staff look out for lighters, scissors, electrical wires, glass that could break, etc. she stated basically anything that could be used or could be an accident to the resident was removed from the residents' rooms and family member was contacted regarding the item that was removed. She stated she attended an in-service on smoking policy she stated the smoking policy is the same, assessment must be completed on any resident going out to smoke. She stated where they are allowed to smoke, monitoring the resident while smoking. She stated never leaving the residents alone and that none of the items can be kept on the residents that have to do with smoking. She stated she attended an in-service on smoking procedure-she stated the new procedure is to get the smoke box with all the cigarettes for the residents, take the residents out, give each resident 1 smoke, light it for them, once finished if the resident wants a second cigarette they are allowed if the first was completed. She stated once everyone was done smoking, she would fill out the log indicating that she started with one lighter and ended with one lighter. She stated that if she were to find the box with no lighter, she would inform the administrator or don immediately. Record review of in-services completed by LVN B with signature for the smoking policy on 3.31.25, items not allowed on 3.31.25, and smoking procedure on 4.4.25. During an interview on 4.6.25 at 11:10 am HR stated she works m-f from 8a to 5p. she stated she is the staff that takes the resident outs for smoke break at 4pm. She stated she attended an in-service on items not allowed in room she stated that this in-service was over all the items that are not allowed in residents rooms that could cause harm to them or their roommates or anyone in the building. She stated that she was to look out for items such as lighters, electrical devices like coffee makers and items like that. she stated anything that could cause any sort of harm. She stated anything that had a label that stated keep out of reach of children would be removed as well. She stated she was part of the champion rounds which would be done daily by her and other heads of departments. She stated they were to look for those items, removed those items if found, inform administrator or don and they would educate the resident on the item and reason for removal. She stated she attended an in-service on smoking policy she stated that policy remained the same. She stated its about who and where which residents could go to smoke and are allowed to smoke. She stated it covered the process to be notated as a smoker in the facility. She stated it covered monitoring of the residents and overall compliance of smoking in the facility. She stated she attended an in-service on smoking procedure-she stated that the new process is to take all residents out with the smoke box. She stated there should only be one lighter in the box. She stated she was to give each resident one cigarette and only allow them one at a time. She stated she was to

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A and CNA B failed to perform hand hygiene and change gloves as appropriate while providing incontinence care to Resident #1 on 02/25/2025. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #1's face sheet dated 02/27/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Covid-19, gangrene (death of body tissue due to lack of blood flow or infection), acquired absence of right leg above knee (amputation), acquired absence of left leg above knee (amputation), and muscle weakness. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 required substantial/maximal with most activities of daily living (ADLs) and always incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 03/15/24 revealed he has bowel and bladder incontinence. The goal was for the resident to remain free of skin breakdown due to incontinence and brief use through the review date. Observation on 02/25/25 at 3:30 p.m. of incontinence care on Resident #1 revealed CNA A and CNA B washed their hands before donning gloves. Resident #1's brief was completely soiled with fecal matter. CNA A and CNA B removed Resident #1's soiled brief. CNA A wiped the resident from front to back. The wipes were visibly soiled with fecal matter, but she continued to use it. She did not wash hands, change gloves, or perform any form of hand hygiene before then applying skin protector on Resident #1. CNA A then retrieved the clean brief with same soiled gloves and fastened it to Resident #1. CNA A used the same soiled gloves throughout the incontinent care process. Meanwhile, CNA B who was assisting CNA A wiped the Resident #1's back perineal side after repositioning. She did not change gloves before helping to fasten the clean brief. CNA A picked up the trash and walked out of the resident room without washing hands. CNA B completed incontinence care and washed her hands before exiting Resident #1's room. In an interview on 02/25/25 at 3:41 p.m., CNA A said she had been employed in the facility for 3 months and received infection control training during orientation. CNA A stated cross contamination was combining clean with dirty. CNA A stated she should have changed gloves before applying skin protector, picking up the clean brief and fastening it on Resident #1. She added Resident #1 could get an infection for not following good infection control practice. She added she was nervous and that was reason for not following good infection practice. During interview on 02/25/25 at 3:37 p.m., CNA B revealed cross contamination was going from clean to dirty. She acknowledged she should have changed gloves before fastening Resident #1's clean brief. CNA B stated he had been employed 6 months in the facility and received infection control training 2 months ago. CNA B said Resident #1 could get sick for not changing her gloves. In an interview on 02/27/25 at 11:52 p.m. the DON acknowledged being aware of some of the concerns raised about infection control practice. She explained she and ADON D was responsible for infection control in the facility. They trained and monitored the staffs by watching them do it. The DON stated aides were expected to follow standard precaution including washing hands and changing gloves while providing care. The facility infection control plan updated 03/2022 reflected, The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection. The facility perineal care policy dated 04/22/2022 stated the following important points: 1) If heavily soiled, use an incontinence pad, brief, towel, or wipes to remove soiling, from front to back, prior to performing perineal care. 2) Do not wipe more than once with the same surface. 3) Doffing and discarding of gloves are required if visibly soiled. 4) Always perform hand hygiene before and after glove use 5) Do not discard pre-moistened cleansing wipes in the toilet unless they are marked flushable.

Based on interviews and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 3 of 12 residents (Residents #24, #69, and #43) reviewed for pharmacy services and medication administration. The facility failed to administer blood pressure medications as prescribed for Residents #24 and #69. The facility failed to ensure Resident #43 had parameters outlining when to hold her short-acting insulin. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Review of Resident #24's Admission Record, dated 6/27/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including stroke and hypertension (high blood pressure). Review of Resident #24's Annual MDS assessment dated [DATE], revealed: He scored a 9 of 15 on his mental status exam (indicating moderate cognitive impairment) and showed signs of delirium including inattention and disorganized thinking. Active diagnoses included hypertension. Review of Resident #24's Care Plan, revised on 2/22/24, documented Resident #24 had a diagnosis of hypertension. The goal was Resident #24 would remain free from signs and symptoms of hypertension through the review date. Identified interventions included: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (blood pressure dropping when standing) and increased heart rate (tachycardia) and effectiveness. Obtain blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently. Review of Resident #24's Order Summary Report, dated 6/27/24, revealed orders: Metoprolol Tartrate Tablet 50 mg, give 1 tablet by mouth two times a day related to hypertension hold if systolic (blood pressure is) less than 100 or heart rate is less than 60. Start date 5/25/24. Review of Resident #24's June 2024 MAR (6/1/24 through the morning of 6/27/24), revealed: Metoprolol Tartrate Tablet 50mg, give 1 tablet by mouth two times a day related to Essential Hypertension hold if systolic (blood pressure is) less than 100 or heart rate is less than 60. 6/13/24 evening dose (time not specified) Blood Pressure 98/61. The medication was initialed as given by MA F. In an interview on 6/27/24 at 11:53 AM the DON stated Resident #24 had a different doctor and different parameters than other residents and she could see how it could confuse nurses and leave the facility open to errors. The DON said Resident #24's parameters were systolic blood pressure less than 100 or heart rate less than 60. The DON stated on 6/13/24, Resident #24's Blood Pressure was 98/61. The DON confirmed Resident #24 received the medication and he should not have. Review of Resident #69's Admission Record dated 6/27/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hypertension. Review of Resident #69's Quarterly MDS Assessment, dated 3/25/24, revealed: She scored a 12 of 15 on her mental status exam (indicating she was moderately cognitively impaired). Active diagnoses included hypertension. Review of Resident #69's Care Plan, revised 3/28/24, revealed: Resident #69 has hypertension related to [blank]. The goal was Resident #69 would remain free of complication related to hypertension through review date. Identified interventions included: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (blood pressure dropping when standing) and increased heart rate (tachycardia) and effectiveness. Obtain blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently. Review of Resident #69's Order Summary Report, reviewed 6/27/24, revealed orders for Metoprolol Tartrate Tablet 50mg, give 1 tablet by mouth two times daily for hypertension hold if systolic blood pressure is less than 110 or pulse less than 60. Start date 5/6/24. Review of Resident #69's June 2024 MAR (6/1/24 through the morning of 6/27/24) revealed: 6/10/24 evening blood pressure 106/67. The medication was initialed as given by MA G. 6/17/24 evening blood pressure 105/60. The medication was initialed as given by MA G. In an interview on 6/27/24 at 11:24 p.m. the DON stated Resident #69's blood pressure parameters were to hold her Metoprolol if her systolic blood pressure was less than 110 or pulse less than 60. The DON said on the evening on 6/10/24 Resident #69's blood pressure was 106/67. The DON said the blood pressure medication was given and it should not have been. The DON said on the evening of 6/17/24 Resident #69's blood pressure was 105/60. The DON stated the medication was given and it should not have been. Review of the facility's policy and procedure on Medication Administrator Procedures, revised 10/25/17, revealed: When ordered or indicated, included specific item(s) to monitor (e.g. blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g. before or after administering the medication), and parameters for notifying the prescriber. Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence. Review of Resident #43's Admission Record dated 6/27/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (condition that affects how the body uses sugar as a fuel). Review of Resident #43's Annual MDS Assessment, dated 5/30/24, revealed: She scored a 12 of 15 on her mental status exam indicating she was cognitively intact. She needed substantial/maximum assistance with all ADLs except eating. Active diagnoses included diabetes. She received insulin injections 7 of 7 days prior to the assessment. Review of Resident #43's care plan, revised 3/26/24, revealed: Resident #43 had Diabetes Mellitus. The goal was Resident #43 would have no complications related to diabetes through the review date. Identified interventions included: Diabetes medications as ordered by the doctor. Monitor/Document for side effects and effectiveness. Fasting Serum Blood Sugar as ordered by doctor . (blood sugar taken before food was ingested). Review of Resident #43's Order Summary Report, dated 6/27/24, revealed orders: Insulin Gargine Solution (long- acting insulin) 45 units subcutaneously two times a day for diabetes beginning 5/25/24. Novolog Solution (short acting insulin) 12 units subcutaneously before meals for diabetes beginning 6/19/23. Review of Resident #43's Treatment Administration Record for 6/1/24 - 6/27/24 revealed she received Novolog 12 units with her blood sugar below 90 on the following dates: 6/2/24 at 11:30 a.m. blood sugar of 74 by the DON (next blood sugar at 4:30 p.m. was 107) 6/20/24 at 7:30 a.m. blood sugar of 87 by LVN E (11:30 a.m. blood sugar was 113) In an interview on 06/27/24 at 12:20 PM the DON stated Novolog was short acting insulin. She stated the standing parameters on when to hold insulin was to hold when a resident's blood sugar was under 60 and notify the doctor. The DON stated the facility held insulin when the doctor's order specified or when it was discussed with the doctor. The DON said there were no parameters on when to hold Novolog. The DON stated if a resident's blood sugar was 87 and they were given short-acting insulin it would depend on what the resident ate. She stated if the resident was given food within the normal range there should not be any reaction. The DON said she would be comfortable giving insulin to a resident with a blood sugar of 74. The DON said the residents should not be waiting more than 30 minutes between when given insulin and food. The DON stated the nurses knew the residents and they knew who to bring snacks to. The DON said the outcome to the resident to getting insulin if they did not get food within that 30-minute window was their insulin level would drop. The Regional Consultant, who was present, stated the facility always had to notify the physician if they held insulin, but they could wait for the food to arrive, check the blood glucose level, and administer the insulin then. In an interview on 6/27/24 at 5:50 pm when LVN B was asked if she would give a resident with a blood sugar of 74 their scheduled dose of 12 units of fast acting insulin without consulting the physician, she said it would depend on the resident and what they had eaten that day, what their appetite was like, what other diabetic medications they were taking; but generally speaking, no she would not ever feel safe giving that much insulin to a resident with that low of a blood sugar, especially first thing in the morning. She stated that she would hold the dose and call the physician for clarification of the order. She stated that to her knowledge that facility did not have any standing parameters regarding insulin administration and that most of the orders she had seen from the physicians did not have parameters as to when to hold doses and notify the ordering physician. In a follow up interview on 06/27/24 at 06:02 PM the Regional Consultant stated he reviewed Resident #43's record and stated there was no way to say if it was her mental status or her blood sugar that crashed. He said there was no hold parameter on the Novolog. The Regional Consultant stated insulin was given right before meals. He said blood sugars were checked 30 - 60 minutes before breakfast. The Regional Consultant said the resident did not say her blood sugar crashed, he did not have a nurses note saying she crashed, he did not have a doctor saying she crashed, and he did not have a hospital saying her blood sugar crashed. He said he called Resident #43's doctor and got a hold parameter for the Novolog for 90 and to notify the physician if the blood sugar was less than 60. In an interview on 06/27/24 at 06:31 PM, the Administrator was informed of the lack of parameters on holding fast acting insulin for diabetic residents. The Administrator concern was that an outcome for the resident was missed. Review of the facility's policy and procedure on Nursing Care of the Resident with Diabetes Mellitus, dated 5/7/13, revealed Diabetes is a disorder in which there is relative or absolute lack of insulin. Among other things, glucose (sugar) from food cannot be taken up by the cells. Conditions Associated with Diabetes. The following conditions are associated with diabetes: 3. Hypoglycemia (blood sugar below reference ranges). Signs and symptoms of hypoglycemia usually have a sudden onset and may include the following: a. weakness, dizziness, or faintness; b. restlessness and/or muscle twitching; c. tachycardia (increased heart hate); d. pale, cool moist skin; e. excessive perspiration; f. irritability or bizarre changes in behavior; g. blurred or impaired vision; h. headaches; i. numbness of the tongue and lips/ thick speech; j. (more severe) stupor, unconsciousness and/or convulsions; and k. (more severe) coma. If these, or other abnormal conditions exist, notify the physician. 5. Approximate reference range for hypoglycemia are: a. Mild hypoglycemia 55 - 70 mg/dl. Review of the facility's policy and procedure on Notifying the Physician of Change in Status, revised 3/11/13, revealed: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. 11. Abnormal lab, x-ray and other diagnostic reports require physician notification. Record review from; NovoLog Flexpen off the internet 6/27/24: Usage, Side Effects, Warnings (drugs.com) NovoLog is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood. NovoLog is used to improve blood sugar control in adults and children with diabetes mellitus. Low blood sugar (hypoglycemia) can happen to anyone who has diabetes. Symptoms include headache, hunger, sweating, irritability, dizziness, nausea, and feeling anxious or shaky. To quickly treat low blood sugar, always keep a fast-acting source of sugar with you such as fruit juice, hard candy, crackers, raisins, or non-diet soda.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #79) of 3 residents reviewed for infection control. CNA A failed to wash his hands and change his gloves after they became contaminated during incontinent care while assisting Resident #79. This failure could place residents at risk for cross contamination and the spread of infection. Finding included: Record review of Resident #79's admission record dated 06/25/24 indicated she was admitted to the facility on [DATE] with diagnoses of muscle weakness and reduced mobility. She was [AGE] years of age. Record review of Resident #79's care plan dated 05/24/24 indicated in part: Focus: The resident has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: INCONTINENT care at least every 2 hours and apply moisture barrier after each episode. Record review of Resident #79's MDS dated [DATE] indicated in part: BIMS = 11 indicating resident was moderately impaired. Urinary continence = Always incontinent. Bowel continence = Frequently incontinent. During an interview and observation on 06/25/24 at 09:04 AM, CNA A performed incontinent care for Resident # 79. CNA A entered the resident's room, washed his hands, and put some gloves on. The CNA A then undid the resident's brief, took some wet wipes, and wiped the residents' vaginal area. The resident's brief was noted to be soaked with urine. The resident said that whenever she drank some soda, she would urinate a lot. CNA A then turned the resident on her side, while wearing the same gloves he used to wipe the vaginal area, he took the new brief and placed it on the bed by the resident. CNA A noticed the bed sheets were wet with urine, so he undid the sheets, removed his gloves, and left the room to get some clean sheets. CNA A re-entered the room and put on a pair of clean gloves and did not sanitize or wash his hands first. CNA A then proceeded with the incontinent care as he had not yet performed peri-care to the resident's bottom and rectal area. CNA A next applied some skin protection ointment to the resident's buttocks and while still wearing the same gloves, he assisted Resident #79 with getting dressed then fastened a gait belt around the resident and assisted her up into her wheelchair. During an interview on 06/27/24 at 11:46 AM, CNA A said he should have washed or sanitized his hands and changed his gloves before he touched the clean brief. CNA A said he also should have washed or sanitized his hands when he returned back to the room with the clean linen. CNA A said he should have changed his gloves before he fastened the new brief on Resident #79 and helped dress her and transfer her to the wheelchair. CNA A said if he did not wash or sanitize his hands it could lead to cross contamination and spread of infections. During an interview on 06/27/24 at 03:55 PM, the DON said it was expected for the staff to change their gloves once they became contaminated. The DON said the CNA should have washed his hands prior to putting clean gloves on after he returned to the resident's room with the clean linen. The DON said the CNA should have changed his gloves before he assisted Resident #79 with the new brief, dressing, and assisted her out of bed. The DON said the CNA perhaps got nervous and forgot his steps during incontinent care. The DON said the CNA not changing his gloves or washing his hands could lead to cross contamination. The DON said they conducted proficiency checks upon hire and annually. During an interview on 06/27/24 at 04:42 PM the Administrator said it was expected for CNAs to change their gloves once they became contaminated to prevent cross contamination. The Administrator believed the failure occurred because the CNA got nervous and forgot his steps. The Administrator said they conducted proficiency checks to monitor and train staff. Record review of the facility's policy titled Perineal care dated 05/11/2022 indicated in part: It is essential that residents using various devices, absorbent products, external collection devices etc, be checked (and changed as needed) on a scheduled based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations. Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infection and skin irritation, and observing the resident's skin condition. Perform hand hygiene, DON gloves and all other PPE per standard precautions. Gently perform perineal care, wiping from clean, urethral area to dirty rectal area to avoid contaminating the urethral area - clean to dirty. Female resident: Working from front to back, wipe one side of the labia majora, the outside folds or perineal skin that protect the urinary meatus and the vaginal opening. Gently perform care to the buttocks and anal area working from front to back without contaminating the perineal area. Record review of the facility's policy titled Infection control policy & procedure manual 2019 dated 03/2024 indicated in part: Wearing gloves does not replace the need for handwashing because gloves may have small inapparent defects or be torn during use and hands can become contaminated during removal of gloves. Failure to change gloves between resident contacts is an infection control hazard. Recommended techniques for performing hand hygiene with an ABHR - include applying product to the palm of one hand and rubbing hands together covering all surfaces of hands and fingers until the hands are dry. In addition, gloves or the use of baby wipes are not a substitute for hand hygiene. Record review of the facility's undated policy titled Hand Hygiene indicated in part: You may use alcohol-based hand cleaner or soap/water for the following: Before and after assisting a resident with personal care, upon and after coming in contact with a resident's intact skin. After removing gloves or aprons. Record review of the facility's policy titled Infection control plan: overview dated 03/2024 indicated in part: The facility will establish and maintain an infection control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will establish an infection control program under which it investigates, controls, and prevents infections in the facility. Decides what procedures such as isolation should be applied to an individual resident and maintains a record of incidents and corrective actions related to infections.

Based on observations, interviews, and record review the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #19) of two residents reviewed for accidents hazards and supervision. The facility failed to ensure that Resident #19's wheelchair was properly padded to prevent injury to the resident's legs while she used it to move around the facility. This failure could lead to injury and possible infection to the resident. The findings included: Review of Resident #19's Admission Record dated 6/26/24 revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admitted [DATE]. She had diagnoses which included dementia, major depressive disorder, anxiety disorder, malnutrition, hypothyroidism, and gastro-esophageal reflux disease. Review of Resident #19's Annual MDS assessment dated [DATE] revealed she had a BIMS score of 2 (indicating severe cognitive impairment), she had limited range of motion to one or both lower extremities requiring the use of a wheelchair, she required substantial to maximum assistance for all ADLs, and she was at risk for developing pressure ulcers. Review of Resident #19's Weekly Skin assessment dated [DATE] completed by the Treatment Nurse revealed no documented wounds. Review of Resident #19's Weekly Skin assessment dated [DATE] completed by the Treatment Nurse revealed small skin tear to back of right calf with no measurements documented. Review of Resident #19's Historical Incident Report List on 6/26/24 revealed a fall incident on 6/20/24 with no injuries noted. No other reports were documented in the past four months. Review of Resident #19's Care Plan, most recent revision date 6/26/24, revealed no care plan specifically addressing her risk for injury due to her wheelchair. The care plan did address her risk for skin breakdown/pressure ulcer development and her need for assistance with ADL performance. Observation on 6/26/24 at 9:40 am revealed Resident #19 resting in bed. When this state surveyor spoke to her, she began pulling at the blankets covering her legs. This state surveyor assisted her in revealing her legs and noted an open area on her left calf with 2 steri-strips covering it that were saturated in old, bloody drainage, and a second scabbed over area just below dressed wound with no dressing in place. Resident #19 attempted to communicate in Spanish, so this state surveyor asked the DON to come to the room to translate. Resident #19 was confused in her explanation of how she got the wounds on her left leg. The DON stated that she believed the wounds on Resident 19's legs were from a transfer to her wheelchair which was kept wrapped with sheepskin to prevent further wounds from occurring. The DON stated that the resident had been sent to the ER the previous night for elevated blood pressure, but she (the DON) had not been made aware of any new skin issues and she had not seen the calf wounds before. In an interview on 6/27/24 at 11:40 am the Treatment Nurse stated the wounds on Resident #19's left calf were not present when she completed her weekly skin assessment on 6/17/24. She stated was off work from 6/20/24 until 6/23/24, and she was not sure how the wounds on Resident #19's left leg happened or who dressed them. The Treatment Nurse stated she believed that they happened during a transfer to or from her wheelchair. She stated the staff have wrapped the area of the wheelchair where the footrests hook on in sheepskin to prevent these injuries. She stated that the skin assessment from 6/24/24 said right calf, but due to the way the resident laid in bed with her legs tucked up she (Treatment Nurse) could have mistakenly documented the wrong site. She stated that the shower aides documented skin issues on shower sheets. She stated that the shower sheets [NAME] kept in a book in her office, and she reviewed them resident by resident when she returned from being off (on weekends), and it could take her a while to catch up with all the skin issues identified by the shower aides if she was not told about them directly. In an interview on 6/27/24 at 6:27 pm, when informed that there was no investigation into the cause of the wounds or when they had occurred, the DON stated that she started an investigation. This state surveyor stated that the DON was not aware of the wounds until this state surveyor showed them to her (the DON) on 6/26/24 and that was when she started her investigation. The DON stated that was true. The DON stated that the treatment nurse followed up on newly reported wounds by using the shower sheets that the shower aides documented on. The Administrator and the DON were informed that the wounds had not been documented on Resident #19's shower sheets, nurse's notes, and no incident/accident report had been completed in the past week. The Administrator stated that both the treatment nurse and the shower aide for Resident #19's hall were out of the facility at the end of last week which she (Administrator) felt accounted for the lack of documentation of the wounds. The Administrator and the DON were informed that when this surveyor discovered the wounds, there was a dressing in place on one of the wounds. The DON stated that Resident #19 had not left the facility in the past week and she could not explain where the dressing came from. The DON stated the most likely cause of the wound was the resident's wheelchair, but no one had been able to tell her exactly what happened or when. The DON stated that while she had started an incident/accident report, her investigation was ongoing. The DON stated that the staff had wrapped the section of the resident's wheelchair that the footrests hook on with sheepskin to pad the area and protect the resident's legs, but it slips down, and she planned to work with the therapy department on a better option for protecting the resident's legs. Review of facility policy titled Skin Assessment revision date 8/15/16 revealed, in part: 1. All new admits and residents returning from a hospital stay will have a head-to-toe skin assessment completed by the Treatment Nurse/designee within four (4) hours of the resident's arrival at the facility. a. If the Treatment Nurse/designee is not available, then the charge nurse should complete the skin assessment within four (4) hours of the resident's arrival at the facility. i. The charge nurse will then notify the Treatment Nurse/designee of any skin concerns and complete the appropriate attachments/assessments. ii. The DON or designee, along with the Treatment Nurse/designee and other team members will review for the follow-up assessment and recommendations. Any pressure ulcer should also be care planned. Any alterations in skin integrity will be treated according to physician orders.

Based on the observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. A bag of rolls was past the expiration date. The lids and handles of two food storage bins were covered with an accumulation of brown-tinged grime. This failure could place residents at risk of food borne illness. Findings included: Observation on [DATE] at 7:52 AM in the dry storage room of the facility kitchen revealed a large plastic bag of about three dozen wheat rolls with a preparation date of [DATE] and a use by date of [DATE]. In an interview on [DATE] at 7:58 Cook D said that foods are labeled with date opened/prepared and expiration date which is seven days after preparation or opening. She said that the wheat rolls were prepared in the facility and had expired and so had to be thrown out. She said she saw the dietary manager check food expiration dates daily but that the dietary manager was out of town because of a death in the family. She did not know who was to take over this duty when the dietary manager was out of town. Observation on [DATE] at 8:14 AM in the dry storage room of the facility kitchen revealed two large storage bins that were marked Sugar and Flour. The lids and handles for opening the bins both had accumulations of brown-tinged grime. The sugar bin had sugar crystals adhered to the lid and handle. In an interview on [DATE] at 8:16 AM Cook D said that the tops of the flour and sugar bins were not clean. She said that the dietary manager was responsible for making sure the kitchen was clean, but the dietary manager was out of town for a family emergency. She said the kitchen staff did get training on infection control and the dirty food bins posed a risk for cross-contamination which could cause residents to get sick. In an interview on [DATE] at 8:24 AM Cook E said that every kitchen worker was given responsibilities for keeping the kitchen clean. She said that the Dietary Aides were supposed to keep the floor of the dry storage room but did not know who was responsible for cleaning the food storage bins clean. In an interview on [DATE] at 8:00 AM the Administrator said that the day before the cook had disposed of the rolls because they were outside the seven-day window for safe food storage. She said that no one had primary responsibility for making sure foods were not beyond the expiration date or that food storage bins were clean but that ultimately the responsibility fell to the kitchen supervisor. The kitchen supervisor was out of town due to a family emergency. The Administrator said that the expired rolls were thrown out because they might not be edible and could put residents at risk of illness. Record review of the facility policy Food Storage and Supplies dated 2012 reflected in part that facility storage areas will be maintained in an orderly manner that preserves the condition of food. Dry bulk foods (e.g., flour, sugar) are stored in containers that are cleaned regularly. The policy did not address expiration time frames for in-house prepared foods such as the rolls.

Based on observation, interview and record review the facility failed to ensure that residents had the right to be free from any physical restraints not required to treat the resident's medical symptoms for two (Residents #11 & #55) of three residents reviewed for physical restraints. 1. Residents #11 & #55 had bolsters (scoop mattresses) on their beds without physician's orders that the bolsters were to treat a medical condition and no assessments used to determine they were the least restrictive measure. There was no restraint-focused assessment completed for Residents #11 & #55 regarding whether the bolsters constituted restraints for them. 2. There was no consent documentation from Resident #11 or Resident #55 or their resident representatives for bolsters to be placed on their beds. This failure put residents at risk of being restrained without consent and an assessment for the need of restraints. Findings included: Resident #11 Record review of Resident #11 ' s face sheet dated 05/30/2023 reflected that she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #11 ' s History and Physical dated 04/13/2022 reflected that she had diagnoses including Cerebral Palsy, intellectual disability, seizure disorder, and aphasia. Resident #11 also had a feeding tube in place. Record review of Resident #11 ' s care plan dated 08/05/2019 reflected in part that she had a self-care deficit, required total assistance with ADLs, and a lift for transfers. She had contractures to her upper and lower extremities. Her care plan for seizure disorder had as a goal that she would be free from injury from seizure activity. Interventions in case of seizures did not include bolsters on her bed. Her care plan for fall risk (revised 05/14/2020) reflected in part may have mattress with raised parameters for safety. Record review of Resident #11 ' s Annual MDS dated [DATE] reflected in part that her BIMS was 0 (severe cognitive impairment). She was dependent on two staff members to move around in bed, transfer between surfaces, use the toilet, and for personal hygiene. The resident had not had any falls since the prior assessment. Record review of Resident #11 ' s physician ' s order dated 08/08/2021 documented that she could have a mattress with raised parameters (bolsters) for resident safety. Record review of Resident #11 ' s electronic Fall Assessment records accessed 05/11/2023 revealed four fall assessments over 2022 with no fall events, and one fall assessment in 2023 with no fall events. Observation of Resident #11 on 05/29/23 at 09:15 AM revealed that she was lying in bed and had contractures to her arms and hands, and to her legs. Her eyes were open, but she did not respond to attempts to greet her or ask for her name. Bolsters extending from hip-level to the foot of the bed covered by fitted sheets were observed on both sides of her bed. The fitted sheet was taut over the bolster and mattress. Her bed was lowered, and a fall mat was beside her bed. In an interview on 05/29/23 at 09:20 AM LVN B said Resident #11 sometimes wiggled in bed and that the bolsters on the bed were so that she did not fall out of bed. In an interview 05/30/23 at 01:20 PM NA A stated that when assisting Resident #11 with personal care she did not reach out to hold onto the assist bars or anything else to assist with personal care. Record review 05/23/2023 of Resident #11 ' s electronic chart in the consents ' area of her electronic chart reflected no consents documented for bolsters on her bed. Resident 55 Record review of Resident 55 ' s face sheet dated 05/30/2023 reflected in part that she was [AGE] years old, was first admitted to the facility on [DATE] and again on 02/14/2023. Record review of Resident 55 ' s History and Physical dated 02/15/2023 reflected that she had diagnoses including Parkinson disease with stiffness and diminished mobility. She had contractures in the hands and parkinsonian tremors. Record review of Resident 55 ' s quarterly MDS dated [DATE] reflected that her BIMS was 8 (moderate cognitive impairment). She was totally dependent on staff to move around in bed, transfer between surfaces, dress and use the toilet. She had functional limitation in range of motion of both her upper and lower extremities. She had no history of falls. Record review on 05/23/2023 of Resident 55 ' s electronic assessment log reflected that she had been assessed on 02/14/2023 as being at high risk for falls. Record review of Resident 55 ' s care plan for a diagnosis of fall risk revised 10/14/2020 reflected in part that she had a mattress with raised perimeters as an intervention. Record review of Resident 55 ' s physician's order dated 04/16/2020 stated the resident could have a mattress with raised perimeters for safety. In observation and interview on 05/29/23 beginning at 09:37 AM Resident #55 was observed in bed. Bolsters extending from hip-level to the foot of the bed and from the top of the bed to one foot from the lower bolster were evident under the fitted sheets on one side of her bed. The other side of the bed was against the wall. The fitted sheet covering the bolsters was taut over the bolsters and mattress. Her bed was lowered, and a fall mat was beside her bed. She was observed to straighten out her legs during the interview. She responded to questions in a very low voice, and she was difficult to understand. She stated that she had Parkinson disease. In an interview and observation on 05/30/23 beginning at 02:45 PM with Resident #55 and CNA C, the resident said sometimes she was able to turn herself by holding onto the sides of the mattress. CNA C said that she had not seen the resident use the mattress or any other device to help with turning because of the contractures of her hands. The resident was observed to have contractures of both hands. In an interview on 05/30/23 at 01:42 PM the Rehabilitation Director said that no assessment was completed by therapy for use of bolsters by Residents #11 or Resident #55. The Rehabilitation Director said that decisions to use bolsters for residents was usually initiated by nursing in response to resident falls or decreased mobility, and the DON usually interacted with the Rehabilitation director in relation to decisions about placing bolsters. In an interview on 05/30/23 at 02:10 PM with the DON the placement of bolsters for Residents #11 and #55 were discussed. She said that Resident #55 may have rolled off the bed because she had a lot of movement at night. She said that Resident #11 tended to squirm a lot which placed her at increased risk for falls. The DON said the decision to place bolsters for a resident depended on the resident's capacity to get out of bed, and the cause and frequency of falls. She said that if a resident was rolling out of bed at night bolsters might be considered, but they would not be used if it restricted the resident ' s ability to get out of bed on their own. She said that if a resident can ' t get out of bed on their own bolsters would not be a restraint. When a policy regarding restraints was requested from the DON she stated that restraints were not used or necessary in the facility setting. In an interview on 05/31/23 at 02:53 PM the Administrator said she was not aware of concerns about restraints for Residents #11 and #55. When the use of bolsters (scoop mattresses) for Residents #11 and #55 was raised, the Administrator stated that the residents were not able to get out bed by themselves so the bolsters could not be considered restraints. In an interview on 05/31/23 at 03:04 PM the Regional Compliance Nurse pointed out that the facility was not using scoop mattresses but was using bolsters, also known as mattresses with perimeters (mattress with bolsters) which did not constitute restraints. He said the bolsters were used for residents who were at risk of falling with the goal of increasing resident safety and minimizing injury. Record review of the facility policy titled Restraints dated 02/01/2007 reflected in part that a physical restraint was any physical \mechanical device, material or equipment adjacent to the resident's body that the resident cannot remove easily which restrict freedom of movement. A physician's order shall be necessary to begin a restraint assessment. Assessment shall include a physical therapy consultation as needed. The resident and/or family member shall be contacted to obtain informed consent if needed.

46998 Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #22 & #46) of 12 residents observed for oxygen management. Residents #22 & #46, who used on oxygen, did not have oxygen sign posted outside their bedrooms. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Record review of Resident #22's Face Sheet dated 05/29/2023 revealed admission on 03/29/2023 to the facility. Record review of Resident #22's History and Physical dated 04/06/2023 revealed a [AGE] year-old female diagnosed with morbid (sever) obesity due to excess calories, dementia, neuroleptic induced parkinsonism. Record review of Resident #22's care plan dated 03/30/2023 indicated resident was on oxygen therapy but did not indicate nasal cannulas/mask had to be changed out week. Record review of Resident #22's admission MDS dated [DATE] revealed resident was diagnosed with epilepsy. Resident #22 was receiving oxygen therapy. Observation on 05/29/2023 at 8:01 AM revealed Resident #22 who had her cannula on. Outside of Resident #22's room there was no oxygen sign posted. Record review of Resident #46's Face Sheet dated 05/31/2023 admission on 11/25/2022 and readmission on 04/18/2023 to the facility. Record review of Resident #46's History and Physical dated 05/30/2023 revealed a [AGE] year-old female who was a former smoker for years. Record review of Resident #46's quarterly MDS dated [DATE] revealed she was on oxygen therapy before coming to the facility. Record review of Resident #46's Order Recap dated 05/11/2023 changing oxygen tubing and nasal cannula/mask every night shifts every Sunday for shortness of breath . Record review of Resident #46's Care Plan dated 11/28/2022 revealed altered respiratory, difficulty breathing and shortness of breath. Observation on 05/29/2023 at 9:31 AM Resident #46 had a concentrator with a nasal cannula on Observation on 05/29/2023 at 9:02 AM revealed oxygen was in use in Resident #46's room with no oxygen sign posted outside of the room. Interview on 05/29/2023 at 10:28 AM with LVN F stated an oxygen sign meant that there was a concentrator or tank in use in the resident's room. LVN F stated an oxygen sign lets people know not to smoke or have flammables because the oxygen might blow up. LVN F stated the room needed an oxygen sign because oxygen was in use in the room. LVN F stated the nasal cannula needed to be dated so that nursing staff knows when it was changed. LVN F stated not changing the nasal cannula could have bacteria or could be dirty if not changed as ordered. Interview on 05/29/2023 at 10:35 AM DON stated oxygen signs lets people know there was oxygen use in a resident room who was using oxygen. DON stated the oxygen sign also lets smokers, visitors, and staff know not to smoke. DON stated the risk of not having an oxygen sign posted could be combustion or a blow up. DON stated rooms [ROOM NUMBERS] needed to have an oxygen sign posted as oxygen was in use in the room. DON stated nasal cannulas needed to be dated to prevent infection and to let nursing staff know the expiration of the oxygen tubing. Record review of the facility oxygen administration policy dated 2003 indicated Place no smoking signs in area when oxygen was administered and stored.

Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program by referring all residents with newly evident or possible serious mental disorder for level II resident review upon a significant change in status assessment for 1 (Resident #23) of 3 resident's reviewed for PASARR coordination. The facility failed to refer Resident #23 to the local authority for Level 1 PASARR screening after he was given a new diagnosis of schizoaffective disorder. This failure could place residents at risk of not receiving specialized and/or habilitation services as needed to meet their needs. Findings included: Record review of Resident #23 ' s face sheet dated 05/31/2023 reflected he was [AGE] years old, was first admitted to the facility on [DATE] and again on 04/17/2023. Record review of Resident #23 ' s PASRR Level 1 Screening dated 11/18/2021 documented that there was no evidence or indicator that he had a mental illness. Record review of Resident #23 ' s History and Physical dated 11/23/2021 reflected he had diagnoses including dementia, chronic renal insufficiency (kidney failure), and Acute Anxiety. He was being given quetiapine (an antipsychotic) for dementia. Record review of Resident #23 ' s History and Physical dated 04/22/2023 reflected diagnoses of Dementia without behavioral disturbance, unspecified dementia type, and acute anxiety. Record review of Resident #23 ' s quarterly MDS dated [DATE] reflected he had a BIMS of 0 (severe cognitive impairment). He had diagnoses including dementia and Alzheimer ' s Disease, manic depression (bipolar disease), a psychotic disorder and Schizophrenia. Record review of Resident #23 ' s care plan dated 03/16/2023 reflected he required anti-psychotics for behavior management. Record review of Resident #23 ' s electronic diagnosis listing accessed on 05/29/2023 reflected that he had been identified as having a diagnosis of schizophrenia, unspecified on 09/06/2022. Additional diagnoses listed included of mood disorder due to known physiological condition with depressive features; psychotic disorder with delusions due to known physiological condition; anxiety disorder due to known physiological condition; vascular dementia, unspecified severity, without behavioral disturbance; Psychotic disturbance; mood disturbance; anxiety. Record review of Resident #23 ' s physician ' s letter dated 01/17/2023 from a consulting physiatrist reflected that the resident was taking Seroquel (quetiapine) for schizoaffective disorder. In an interview on 05/31/23 at 02:08 PM the MDS LVN Z accessed the Simple LTC portal (software used for reporting PASRR related information) and confirmed that Resident #23 had a PASRR Level 1 screen completed on 11/18/2021 showing no evidence of mental illness, and that no other PASRR related activity had been completed in relation to the resident ' s PASRR status since then (11/18/2021). The MDS LVN Z confirmed that she saw a diagnosis of schizophrenia in Resident #23 ' s electronic record from 09/06/2022 and said it should have triggered a new PASRR Level 1 screen. She said that she did not usually deal with PASRR-related changes for long term residents such as Resident #23, and that the person who handled this had been out of the office for some time. She said that the risk to Resident #23 from not having a new PASRR Level 1 screen was that he might have missed some specialized psychiatric services for which he was eligible. In an interview on 05/31/23 at 02:37 PM the DON said she was not very familiar with the PASRR program but that it pertained to people with disabilities such as mental illness. She said the PASRR program might have provided Resident #23 some extra benefits like psychiatric services and extra health care services, and that the risk to him of not having been screened for the PASRR program was that he would not get those extra benefits. In an interview on 05/31/23 at 02:51 PM the Administrator said that the PASSR program was to provide necessary services to people with qualifying diagnoses such as mental illness or other disabilities. She said that not contacting the local authority to conduct the PASSR Level 1 screening for Resident #23 in response to his new diagnosis could put him at risk of not receiving services which could have been of benefit to him. Record review of the facility policy PASRR Nursing Facility Specialized Services Policy and Procedure revised 03/06/2019 reflected in part that it was the corporate policy to ensure required forms were submitted timely and accurately. The policy did not address how facilities were to respond to new diagnoses for existing facility residents.

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer and discharge from the facility provided in a form and manner that the resident could understand for 2 (Resident #4 and Resident #1) of 3 residents reviewed for discharge. The facility did not provide or document adequate and sufficient preparation and orientation to ensure a safe and orderly discharge for Resident #4 and Resident #1 into the community. This failure could place resident at risks of being discharged and not allowed to return to the facility, causing a disruption in their care and/or services and denying them a voice regarding their treatment plan. Findings include: Record review of Resident #4's Face Sheet, dated 03/17/20223, revealed she was an [AGE] year-old-female was an admitted [DATE] and a discharge date of [DATE]. Diagnoses included Sepsis (body's extreme response to an infection) Unspecified Organism, Essential (Primary) Hypertension (abnormally high blood pressure that is not the result of a medical condition), Heart Failure, Muscle Weakness, and Chronic Kidney Disease, Stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood). Record review of Resident #4's Admission MDS, dated [DATE], revealed a BIMS of 15, which indicted intact cognitive response. Review of the Functional Status section revealed Resident #4 required extensive assistance with one-person physical assist in the areas of transfers, dressing, toilet use, and personal hygiene. Section Q of the MDS revealed Resident #4 was not actively participating in discharging planning and was uncertain if she would return to the community. Record review of Resident #4's Care Plan, dated 01/18/2023, revealed there was no focus or goal to return to the community. Record review of Resident #4's Care Plan, dated 02/21/2023, revealed there was no focus or goal to return to the community and showed a cancellation date of all goals and interventions on 02/21/2023. Record review of Resident #4 Doctor's Order for Discharge, dated 02/16/2023, revealed the physician discharged Resident #1 to home with home health and wheelchair. During an interview on 03/19/2023 at 3:54 p.m., Resident #4's family member said Resident #4 was discharged from the facility on 2/17/2023. Resident #4's family member said he was contacted by the Social Worker by email on 02/15/2023, who informed him Resident #4 had been determined ready for discharge on 2/15/2023. Resident #4's family member said he questioned Resident #4's ability to take care of herself and requested a sitter. Resident #4's family member said when he picked Resident #4 up on 02/17/2023, he was told by staff that a box on the Medicaid application was not checked for long-term-care to ensure Resident #4 had insurance and Resident #4's Medicare was no longer covering Resident #4's nursing home services effective 02/01/2023. Resident #4's family member said the facility did not help Resident #4 find assistance while she was at home. Resident #4's family member said a home health agency was sent a referral packet for Resident #4 on 02/18/2023, the day after Resident #4 was discharged when she needed services in place prior to leaving the nursing home. Resident #4's family member said the nursing facility did not explain to him or to Resident #4 that the referred agency could not provide a sitter and Resident #4's family member said he had been staying with Resident #4 in her home due to her need for 24-hour care and Resident #4 could not be left alone. Resident #4's family member said he did not attend a care plan meeting or receive a discharge plan with written instructions on how to care for Resident #4. Resident #4's family member said he was not provided information on what options he had when Medicare was stopped covering services. He said he called the state and filled out a Medicaid application two day ago because Resident #4 required assistance. Resident #4's family member said Resident #4 was going to stay in the nursing facility long-term due to her health issues and the family living situation. During an interview on 3/20/2023 at 10:15 a.m., the Social Worker said she was notified by the Business Office Manager and the Administrator that Resident #4 was being discharged . The Social Worker said Resident #4 was being discharged due financial issues and she had informed Resident #4's family member to let him know Resident #4 would be discharged on that day, 02/17/2023. The Social Worker said Resident #4's family member voiced concern that Resident #4 would not be able to care for herself at home and would need 24-hour care. The Social Worker said she explained information about an agency that could be used that would provide a sitter but he would have to pay out of pocket for the service. The Social Worker said she sent a packet to the agency she recommended on 02/18/2023 at the request of Resident #4's family member and the agency would schedule a visit to meet with Resident #4. The Social Worker said the IDT was not involved with the discharge process and no discharge plan was developed. The Social Worker said was not familiar with discharge planning or developing a discharge plan. During an interview on 03/20/2023 at 12:42 p.m., the DON said Resident #4 was discharged because she was medically ready to be discharged as determined by the OT and PT evaluations and Resident #4 had never had the intention to stay long-term. The DON said she had no concerns about Resident #4 being discharged and the physician had provided discharge orders. The DON said based on Resident #4's BIM score and the doctor's orders, she felt Resident #4 could discharge safely. Record review of Resident #4's Occupational Therapy OT Evaluation & Plan of Treatment, dated 1/11/2023, revealed Resident #4's clinical impressions were moderate to maximum assistance for self-cares and mobility, had decreased cognition, and was hard of hearing. Resident #4 presented with impairments of balance, dexterity, fine motor coordination, gross motor coordination, mobility and strength resulting in limitations and/or participation restrictions in the areas of mobility and self-care. Record review of Resident #4's Physical Therapy PT Evaluation & Plan of Treatment, dated 1/13//2023, revealed Resident #4 was as a fall risk, hard of hearing, limited safety awareness, physical impairments and associated functional deficits. Record revealed Resident #4 was at for further decline in function, falls, and increased dependency upon caregivers. Record review of email correspondence, dated 02/15/2023, revealed the Social Worker contacted Resident #4's family member by email on 02/15/2023 to notify Resident #4 was being discharged . Resident #4's family member responded that Resident #4 would on be able to go home if she had heavy home health care and Resident #4 had fallen four times prior to going into the hospital because of no sitter in the past. Closed record review of Resident #1's Face Sheet, dated 3/16/2023, revealed she was a [AGE] year-old-female with an admitted [DATE] and a discharge date of [DATE]. Diagnoses included Chronic Kidney Disease, Stage 5 (end-stage kidney disease means kidneys are about to or have failed), Type II Diabetes Mellitus (abnormal high blood sugars) with Unspecified Complications, Dependence on Renal Dialysis, and Myopathy (general term referring to any disease that affects the muscles that control voluntary movement in the body). Record review of the Face Sheet did not include Resident #1's family member as the power of attorney or emergency contact person and listed no contact information. Closed record review of Resident #1's Admission MDS, dated [DATE], revealed a BIMS of 15, which indicated intact cognitive response. Review of the Functional Status section revealed Resident #1 required extensive assistance with 2-person physical assist in the areas of bed mobility, transfers, and dressing. Section Q of the MDS indicated Resident #1 wanted to be asked about returning to community on all assessments. During an interview on 03/16/2023 at 6:15 p.m., Resident #1's family member said she had received a call on or about 03/08/2023, from the Business Office Manager of the nursing facility telling her Resident #1 was going to be discharged due to non-payment. She said this was the first time she was aware that Resident #1 had an issue with payment. Resident #1's family member said the Business Office Manager told her Resident #1's Medicaid had been denied. Resident #1's family member said the call or correspondence she received was a call on Friday, 3/10/2023, at approximately 6:09 p.m. from the facility Van Driver who informed her he was dropping Resident #1 off at Resident #1's apartment. Resident #1's family member said when she arrived at the apartment approximately 45 minutes later, Resident #1 was at the apartment by herself, sitting in her wheelchair. Resident #1's family member said she was not notified that Resident #1 was going to be discharged on [DATE]. Resident #1's family said she had not heard from the facility since the first phone call on 3/08/2023 and had expected the facility to notify her prior to Resident #1 being discharged or at least provide her time to make arrangements. Resident #1's family member said she had financial Power of Attorney for Resident #1. Resident #1's family member said on 03/11/2023, she met with the Administrator at the facility and asked to see the paperwork that Resident #1 signed to discharge herself. Resident #1's family member said she was told by the Administrator that Resident #1 could verbally say she wanted to move out. Resident #1's family member said she asked the Administrator why there was no paperwork provided with Resident #1 on how to manage her medication and Resident #1's family member said the Administrator informed her the instructions on the medications were provided verbally to Resident #1. Resident #1's family member said she did not receive a care plan or any written instructions on the discharge of Residents #1. During an interview on 03/17/2023 at 9:15 a.m., Resident #1 said she remembered being dropped off at her apartment but said no one at the facility had told her she was leaving on that day. Resident #1 said she had a conversation with the Administrator about Medicaid and the need to pay the nursing home, but she was not aware she was going home on that day. Resident #1 said the Van Driver picked her up from dialysis and took her to her apartment. Resident #1 said she was told by the Administrator and Business Office Manager that she was going to lose her VA benefits and would have to pay out of Resident #1's savings because the nursing facility had heard she had received $21,000 from the VA. Resident #1 said she did not want to pay the money but did not know she was being discharged from the nursing facility on that day. Resident #1 said no one at the facility had discussed services with her or her family. Resident #1 said she did not receive a written care plan. During an interview on 03/17/2023 at 12:08 p.m., the Van Driver said he had been at the facility for approximately two years. The Van Driver said on 03/10/2023 at approximately 6:00 p.m., he had picked Resident #1 up from dialysis and drove Resident #1 to her apartment. The Van Driver said he was instructed to pick up Resident #4 and take her to her apartment from dialysis. The Van Driver said he was informed by the Social Worker and Business Office Manager approximately a week before that Resident #1 was going to be discharged . The Van Driver said the discharge was due to money issues and that was all he was aware of, and Resident #1 wanted to go home. The Van Driver said he did not leave paperwork with Resident #1 because he had not received paperwork from the Administrator or Social Worker. The Van Driver said there was no care plan that he was aware of. The Van Driver said he left a bag of medication and Resident #1's dialysis book. During an interview on 03/17/2023 at 12:58 p.m., LVN A said she had been at the facility for three years. LVN A said Resident #1 was discharged after dialysis on Friday, 03/10/2023. LVN A said she was given Resident #1's medication and filled out the Medication Release/Receipt Form. LVN A said the form was the count of Resident #1's medication and LVN A said she went over the form with Resident #1 and Resident #1 signed the form. During an interview on 03/17/2023 at 1:25 p.m., the Business Office Manager said she had been at the facility for four years. The Business Office Manager said Resident #1 was admitted to the facility on [DATE] pending Medicaid. The Business Office Manager said she had received a phone call from Medicaid on 03/08/2023 that Resident #1's Medicaid would be denied unless Resident #1 spent down money withdrawn from a savings account. The Business Office Manager said Resident #1 was not denied at this time, but her Medicaid was pending explanation of Resident #1's savings account asset of $21,000. The Business Office Manager said Medicaid had reported Resident #1 had withdrawn a large amount of money from a checking account prior to admission into the facility and Medicaid wanted Resident #1 to explain the asset. The Business Office Manager said she informed Resident #1 and Resident #1's family member on 03/08/2023 concerning the issue. The Business Office Manager said Resident #1 stated she wanted to go home. The Business Office Manager said Resident #1 was discharged on [DATE]. The Business Office Manager said she was not aware Resident #1's family member was Resident #1's financial Power of Attorney. The Business Office Manager said the only time she spoke with Resident #1's family member was on 03/08/2023 when the Medicaid was discussed. During an interview on 03/17/2023 at 1:45 p.m., the Social Worker said she had been at the facility for approximately one year. The Social Worker said she was informed by the Business Office Manager and Administrator that Resident #1 was going to be discharged . The Social Worker said she had a final conversation with Resident #1 on 03/08/2023 and attempted to contact Resident #1's family member but did not have the phone number. The Social Worker said the phone number was not in Resident #1's records and Resident #1 would not provide her the number. The Social Worker said she did not complete a discharge plan because she was not aware she was assigned to complete the document. The Social Worker said she wanted to provide services such as transportation to dialysis but Resident #1 refused. The Social Worker said she did not complete discharge planning because Resident #1 refused. The Social Worker said the information and details of the conversations were not written or documented in Resident 1#'s records. During an interview on 03/18/2023 at 12:20 p.m., the Administrator said she had been at the facility for 2 1/2 years. The Administrator said Resident #1 was discharged because she wanted to go home and the discharge was a resident-initiated discharge. The Administrator said when Resident #1 was given the option to either private pay or discharge, Resident #1 said she would go home. The Administrator said she spoke with Resident #1 and confirmed Resident #1 did not want to private pay for her services and wanted to go home and her family member would take care of her. The Administrator said she did not contact Resident #1's family member because the Administrator did not have Resident #1's family member's phone number. The Administrator said Resident #1 told her she had called her family member and the phone number was in her phone. The Administrator said discharge planning would have been completed by social services. The Administrator said Resident #1 refused to discuss her options concerning moving back into her apartment and could have refused discharge planning with the Social Worker. The Administrator said it was her expectation that discharge planning be completed and a discharge plan developed prior to discharge. The Administrator said even though a resident refused discharge planning, the facility was responsible for discharge planning and completing the discharge summary. The Administrator said Resident #1 did not sign any forms prior to leaving the facility and her expectation was for Resident #1 to ride the bus to dialysis. During an interview on 03/18/2023 at 1:29 p.m., the DON said she had been at the facility for six years. The DON said Resident #1 was discharged due to issues with her finances and would have had to spend down her money in order to qualify for Medicaid. The DON said Resident #1 was not denied at this time, but her Medicaid was pending explanation of Resident #1's savings account asset. The DON said Resident #1 chose to move back home. The DON said she did not have any concerns about Resident #1 leaving the facility because Resident #1 had told her a family member would take care of her. The DON said she had concerns of Resident #1 taking her blood pressure prior to taking her medication and said if she did not have a family member with her, Resident #1 was unsafe transferring from her wheelchair. The DON said the doctor had written discharge orders to include home health, but Resident #1 refused home health services because Resident #1 would have to pay for the services out her money. The DON said the Social Worker would assist Resident #1 if outside community services were needed, which would be part of the discharge planning. Record review of Resident #1's Progress Note, dated 03/08/2023, revealed the Social Worker documented that the Business Office Manager and she spoke with Resident #1 regarding discharge and her options to pay private in the facility due to having money to cover to the end of the month until her Medicare started back on 4/1/2023. The note further documented the Social Worker documented the Resident #1 declined and wanted to go home and the Social Worker said Resident #1 understood she would not be eligible for home health unless she paid out of her pocket until Medicare became available to Resident #1. Record review of Resident #1's Progress Note, dated 03/10/2023, revealed Resident #1 was discharged on [DATE] with no documentation on the specific details of the discharge. Closed record review: Record review of the document Statutory Durable Power of Attorney, dated 10/20/2022, revealed a family member of Resident #1 was appointed as Resident #1's General Power of Attorney for financial powers and rights. The document was signed and dated by Resident #1 and notarized on 10/20/2022. Resident #1's family member provided a copy of the document. Surveyor found Resident #1's family member's phone number in the admission paperwork sent with Resident #1 when she was transferred from a different nursing facility on 1/27/2023. Record review of Medication and Release/Receipt, dated 3/10/2023, revealed Med Aide A completed the form, which the name, dosage, prescription number, and the total amount of medication. The form was signed by Resident #1 and LVN A. There was no evidence Resident #1 was provided a copy of this form. Record review of Resident #1's Care Plan, dated 02/28/2023, revealed there was no focus or goal to return to the community and discharge focus, interventions, or goals. Record review of Resident #1 Doctor's Order for Discharge, dated 03/07/2023, revealed the physician discharged Resident #1 to home with home health and wheelchair. Record review of Discharge Planning Process Policy, dated 11/28/2016, revealed the nursing facility must complete discharge planning when they anticipate discharging a resident to private resident, or another type of residential facility. Discharge Planning included: Developing an interdisciplinary team discharge plan designed to ensure the resident's needs will be met after discharge from the facility, including resident and family/caregiver education needs; Assisting the resident and family/caregivers in locating and coordinating post-discharge services. Review revealed the Post Discharge Plan must indicate where the resident will reside, any arrangements that have been for the resident's follow up care, and any post discharge medical or non-medical services.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Residents #3, #33, #43, and #53) of 16 residents reviewed for care plan accuracy. Resident #3 did not have a care plan for the use of a mechanical lift. Resident #33 did not have a care plan for [CONDITION(S)] care. Resident #43 and #53 did not have care plans for their anti-coagulant use (due to [CONDITION(S)]). This failure could affect residents whose care plans were reviewed and place them at risk of not receiving needed care. The findings included: Review of Resident #3's Admission Record dated 3/10/22 documented Resident #3 was a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Admission assessment dated [DATE] documented: He scored a 15 of 15 on his mental status exam (indicated he was cognitively intact) He needed assistance of two people for transfers. He had range of motion impairment of the upper and lower extremities on one side. Review of Resident #3's Care Plan dated 12/15/21 documented Resident has [CONDITION(S)]/[CONDITION(S)]. The identified goal was the resident will remain free of complications or discomfort related to [CONDITION(S)]/ [CONDITION(S)]. The interventions did not address use of the mechanical lift. Surveyor observed a mechanical lift transfer for Resident #3 on 3/9/22 at 2:04 p.m. Review of Resident #33's face sheet revealed the resident to be a [AGE] year-old Hispanic male admitted to the facility on [DATE]. Resident #33 had admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's MDS dated [DATE] revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's order summary on 3/10/22 revealed the following orders: [CONDITION(S)] every Tuesday, Saturday 1200 at a local provider (order date 10/14/21); No needle sticks, blood pressure or blood draws in right arm (order date 10/14/21); assess [CONDITION(S)] device right subclavical positive bruit and thrill every shift (order date 11/25/21) Review of Resident #33's care plan dated 01/19/2022 revealed no care plan area for [CONDITION(S)]. In an interview with LVN A on 03/11/22 at 8:59 AM she stated that she was not aware what was on Resident #33's care plan regarding [CONDITION(S)]. She stated the facility had a book that the nurses used for [CONDITION(S)] information. She stated that Resident #33 was scheduled for [CONDITION(S)] every Tuesday, Thursday, and Saturday, and that had been his schedule for as long as he had been a resident in the facility. She stated that the [CONDITION(S)] center was responsible for dressing changes to Resident #33's access sites and that the nurses in the facility only inspected the dressing and site for signs and symptoms of infection, bleeding, or other issues. She stated that Resident #33 has an AV fistula in his right arm that was not being used and that he was currently receiving [CONDITION(S)] through the right [MEDICATION(S)] site. Review of Resident #43's Admission Record dated 3/10/22 documented he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's Annual MDS assessment dated [DATE] documented: He scored a 3 of 15 on his mental status exam (indicated severe cognitive impairment) Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Triggering medication did not include the use of anti-coagulant medication. Review of Resident #43's Order Summary Report dated 3/10/22 documented the anti-platelet medication [MEDICATION(S)] 75 mg once a day for blood clot prevention related to [CONDITION(S)] beginning 4/13/21. Review of Resident #43's Care Plan on 3/10/22 documented care plans related to stroke needs included: Risk for falls and communication problems related to stroke (initiated 8/5/19); but did not find a care plan for the [MEDICATION(S)] medication. Review of Resident #53's face sheet revealed the resident to be a [AGE] year-old female admitted to the facility on [DATE]. Resident #53 had admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's MDS dated [DATE] revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's order summary on 03/11/2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's care plan dated 02/16/2022 revealed no care plan for [CONDITION(S)] /anticoagulant use. In an interview with the Administrator on 03/11/22 at 8:29 AM , she stated that the care plan team consisted of the MDS Coordinator, the DON, the Social Worker, the Dietary Manager, and the Activities Director. She stated that the care plan process was a collaborative effort with the entire team. She stated the process for care plan meetings was in place to make sure nothing was missed for each resident. In an interview with the DON on 03/11/22 at 11:21 AM, he stated that the care plan process was that upon admission, the MDS nurse completed an initial note and generated a baseline care plan. He stated that the facility then conducted a 7 day look back at which point the care plan would be adjusted and that care plan would be adjusted periodically. He stated that care plans were completed on admission, quarterly, and with any significant change in the resident's situation. He stated that areas he expected to see in a resident's care plan would have been code status, therapeutic diet, potential side effect from medications, vaccines, potential for bleeding with anti-coagulant use, a little bit of everything regarding the resident. The DON stated that to ensure care plans were accurate and relevant, the care planning team discussed the care plan itself during meetings and to make sure it was current. The DON stated that the care plan team consisted of the MDS Coordinator, Activities Director, Dietary Manager, DON, Social Worker and that the team invited CNAs or nurses as needed. The DON said Resident #3's mechanical lift absolutely should have been included in the care plan. He stated that Resident #3 had been a mechanical lift transfer the whole time he had resided in the facility. He stated the care plans were supposed to be fill in the blank and the mechanical lift should have been there, but it did not sound like it was care planned. The DON stated that the MDS nurse must have missed Resident #43's and #53's anticoagulant use care plan. The DON agreed that there had been 7 opportunities to catch the missing anticoagulant care plan for Resident #43 and that Resident #53's care plan had just been completed one month ago and it was missed. The DON stated that he expected Resident #33's care plan to include potential for wounds, altered nutrition due to PEG tube, [CONDITION(S)], ADL deficit, communication problems, catheter, and [CONDITION(S)]. He explained Resident #33 was going to [CONDITION(S)] every Tuesday and Saturday when he was admitted to the facility, but the frequency had increased to 3 times a week recently. The DON said he was unsure of when the change occurred but that it had been within the last 30 days. He stated that Resident #33's care plan for [CONDITION(S)] mostly focused on dehydration not [CONDITION(S)]. He stated that Resident #33's care plan for IV access was not appropriate because a [CONDITION(S)] port was not an IV. Regarding the lack of [CONDITION(S)] care plan, he stated the staff had a check list of what to look out for and that the nurses could educate the CNAs, but if it was not care planned the staff were not aware of it. He stated nurses were not as accurate as needed when creating care plans. He stated that the policy was that care plan audits were done by MDS nurses. He stated that the facility had 2 MDS nurses, one did skilled, and one did long term care and that if one missed something on a care plan, the other should have caught it. He stated that MDS nurses auditing themselves was not very effective. He stated that he, as DON had also done audits, but he missed it too. He stated that the care plan team filled out the care plan during the care plan meeting. The DON said the care plan team did go over the care plan and process with each resident's family, but most families did not understand the purpose of a care plan. He stated that the care plan was important because it gave insight into resident care, flagged what was important, and told the resident's story. In an interview with MDS Nurse on 03/11/22 at 11:58 AM, she stated that a care plan was supposed to have things like diagnoses, treatments that nurses was responsible for such as wound care, ADL assessment, allergies, code status, medication such as antipsychotics and antibiotics. She stated the ADON was responsible for psychiatric medication care planning. The MDS Nurse said anticoagulant use should be care planned and would have included the risk for bleeding, labs, and falls. She stated [CONDITION(S)] should definitely have been care planned to include how often they go, assessing shunt and stuff like that. She stated that she had not had a [CONDITION(S)] resident in a long time. The MDS nurse said an ADL care plan should include transfers, toileting, mobility, dressing, bathing, and oral care. She stated that the DON and ADON were responsible for checking the care plans for residents. She stated the corporate MDS nurse checks weekly for Medicare, and monthly for all the rest. She stated that she could not say how these care areas were missed. She stated that she had not seen a check list or set procedure for creating care plans from corporate. She stated the software that the facility used was supposed to trigger care plan areas based on the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she and the other MDS nurse did not check each other's care plans. Review of undated facility policy titled Comprehensive Care Planning on 03/11/2022, revealed, in part, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The policy also stated The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented and When developing the comprehensive care plan, facility staff will, at minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition and functional status, and use of services. The policy stated There may be times when a resident risk, weakness or need is identified within the context of the MDS assessment but does not cause a CAA (Care Area Assessment) to trigger. The facility will address these areas and will document the assessment of these risks, weaknesses or needs in the medical record and determine whether or not to develop a care plan and interventions in the area.

Based on observation, interview and record review, the facility failed to provide personal respect, and privacy, during personal care for 2 of 2 residents (Resident # 8 and # 58) observed for personal care in that: 1. The facility failed to pull privacy curtain for Resident # 8 and # 58 putting their privacy at risk. 2. The facility failed to provide privacy for Residents #8 and #58 during incontinent care. This failure could place incontinent residents at risk for embarrassment poor self-esteem and unmet needs. Findings: Record review on 3/9/22 of Resident # 8 she is [AGE] year-old white female with admitted [DATE], her BIMS score was a 9 which indicated moderate cognitive impairment. Her admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 3/9/33/at/1:23 PM of CNA B and CNA C pushed resident# 8, in her wheelchair, next to bed, door was closed, privacy curtains open CNA B put gait belt around resident #8, both CNAs lifted resident by gait belt assisting her to bed. Once resident # 8 was in bed CNAs performed incontinent care without closing privacy curtains, someone knocked on the door, CNAs said patient care the door opened slightly and a woman said laundry, at this time the resident could have been observed from the hallway by individuals walking by the CNAs repeated patient care and the woman said sorry she would come back. Interview on 3/10/22 at 10:10 AM resident #8 revealed she did want the door closed and curtain pulled when being changed for her personal privacy. Record review on 3/10/22 at 3:50 PM revealed Resident # 58 she was a [AGE] year-old female with a BIMS of 5 indicated cognition was moderately impaired. She had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 3/10/22 at 1:30 PM of incontinent care on resident #58 CNA E and CNA D closed door to room, resident did have roommate, she was in the room. They set up equipment for incontinent care washed hands donned gloves, never pulled either curtain during any of peri care. Resident roommate yelled throughout the process, someone knocked at the door CNAs responded patient care, Nurse opened the door and stuck head in, again CNAs said patient care he replied sorry and shut the door. CNAs completed cleaning, turning, and repositioning resident. Record review on 3/10/22 at 4:30 PM revealed Resident #58 care plan had the problems of bladder incontinence. Care plan dated 8-25-21 revealed problem- The resident has bladder incontinence. Goal- The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions- Apply barrier cream after each incontinent episode. Incontinent care at least q 2h and apply moisture barrier after each episode. Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Report to charge nurse any foul-smelling urine or if the urine is any color than yellow. Record review on 3/10/22 at 4:30 PM revealed Resident #8 care plan had the problems of bladder incontinence. Care plan dated 09/03/21 revealed problem- The resident has bladder incontinence. Goal- The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions- Apply barrier cream after each incontinent episode. Incontinent care at least q 2h and apply moisture barrier after each episode. Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Report to charge nurse any foul-smelling urine or if the urine is any color than yellow. Monitor/document. Report to MD PRN possible medical causes of incontinence: bladder infection, constipation, loss of bladder ton, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Interview on 3/11/22 at 9:30 AM resident #58, due to cognition, was not able to say if she wanted curtain pulled or door closed. Interview on 3/11/22 at 10:35 AM CNA B revealed she was not aware that the privacy curtain needed to be pulled if the door was closed. Interview at 3/11/22 at 10:45 AM with CNA C she revealed that the curtain should have been pulled, but thought it was ok since there was not a resident in the room. Interview at 3/11/22 at 1:10 PM CNA E revealed that she was supposed to pull the privacy curtain even if there is only one resident in the room. She revealed she was nervous and forgot to pull the curtain for resident privacy. Interview at 3/22/22 at 1:20 PM CNA D revealed she thought the curtain was pulled and it was not, she revealed that was her fault she didn't look. She revealed we always provide privacy no matter what, this is their home. Interview on 3/11/22 at 2:30 PM with Administrator she revealed the staff know better they are supposed to pull the curtains during resident care this is not anything new. Administrator revealed they have all been in-service and educated on this. Interview on 3/11/22 at 4:15 PM with DON he revealed it was one of the steps in proving resident care, to pull the privacy curtain, they are expected to do this. Record review on 3/11/22 4:30 PM Policy on Resident Rights: Privacy and confidentiality - The resident has a right to personal privacy and confidentiality of his or her personal and medical records: Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

Based on observation, interview, and record review the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 7 residents (Resident #3) reviewed for dignity and 5 of 9 residents in the confidential group interview. Staff used cell phones in the presence of Residents while providing care (Resident Council Meeting and Resident #3). Staff told residents to use the bathroom in their brief rather than taking them to a bathroom. This failure resulted in a diminished quality of life for the identified residents and could affect additional residents by causing a loss of self-esteem and increased isolation. The findings included: During a confidential interview on [DATE] between 10:30 a.m. and noon an alert, lucid residents stated the staff were on the phone rather than take care of residents and it made them feel mad. The resident stated staff did not answer the call light timely because they were on the phone. The resident stated they went to dinner and heard a resident ask an aide to go to the bathroom and the aide said to a coworker 'it's ok, she's got the diaper on'. The resident stated they were upset for the other resident. During the confidential on [DATE] at 10:05 a.m. 4 of the 9 residents present (not the confidential interview above) stated they heard staff tell residents to go to the bathroom in their brief. One resident stated it happened to her last week at dinner, she said if she wanted to use the bathroom in her brief she would have. Another resident stated it was degrading. The resident stated there were four staff members present and no one said anything about it or took her to the toilet. All 9 of the residents agreed the staff were on their phone instead of working. The residents stated the staff were on the phone at the nurse's station texting, playing games, or watching things. The residents stated they felt like cattle and ignored. The residents stated they gave up on saying anything because the staff knew, and nothing was done. Review of Resident #3's Admission Record dated [DATE] documented Resident #3 was a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Admission assessment dated [DATE] documented: He scored a 15 of 15 on his mental status exam (indicating he was cognitively intact) He needed assistance of two people for transfers. He had range of motion impairment of the upper and lower extremities on one side. Observation on [DATE] at 2:04 PM CNA B and CNA C stated they were going to use a mechanical lift on Resident #3. Resident #3 gave his permission. CNA B and CNA C both hooked Resident #3's sling to the hooks. CNA B's smart phone/watch went off and CNA B slapped the phone off. Immediately after the phone rang, and CNA B answered the phone by telling the caller she would call back and immediately hung up the phone. Resident #3 rolled his eyes. CNA C operated the lift boom up and down. CNA B let go of Resident #3 and CNA C moved Resident #3 with the lift while CNA B stood by. When CNA C got Resident #3 over the bed, CNA B held Resident #3 steady while the boom was lowered onto the bed. Both CNAs adjusted the Resident's clothing per his request. CNA C again operated the boom up while CNA B held Resident #3 steady. CNA B stood by while CNA C swung Resident #3 over to his wheelchair. CNA B's smart watch went off with a text notification, and CNA B stepped back to check the text while Resident #3 was in the air. CNA C moved Resident #3 over his wheelchair but had too much momentum and Resident #3 tapped the wall while CNA B answered her text. CNA B re-engaged with the transfer and steadied Resident #3 as he was lowered into the wheelchair. Interview on [DATE] at 2:21 PM Resident #3 stated he did not remember hitting the wall. He said it did not bother him when the staff answered the phone and hung up like CNA B just did. He stated it did bother him when they talk all through the transfer which happens sometimes. Resident #3 stated the last time it happened was last week and it made him feel ignored. Interview on [DATE] at 12:35 PM The DON stated the expectation of cell phones was they were to be kept up and if the staff needed to use it, they needed to go to a non-resident-use area. The DON said the nurses were allowed to use them if they needed to contact the doctor or the management staff. He said nothing was allowed in resident room. He stated smart watches would have the same expectation as a regular cell phone. The DON said the facility tried to educate the staff as best they could, but cell phone use was everywhere. He stated the management monitored for cell phone use when they did rounds and addressed it when they found it. He said if there was a specific complaint it would be addressed. The DON shared the staff were informed of the facility's policy upon hire, during orientation, and it was discussed individually as it came it. He admitted cell phone use was an ongoing, continuous thing. He said the staff knew what was supposed to be done, they just were not doing. He shook his head when asked why not. Interview on [DATE] at 1:05 PM the Administrator said she hated cell phones in the facility. She stated the facility in-serviced and when she saw them, she addressed them. She stated she heard about the aide on the cell phone during the transfer from another aide. The Administrator said it had been addressed, they have had residents complain in resident complain . She said they asked who, but the residents did not say who because they did not want to get a specific aide in trouble. The administrator stated aides were taught in Nurse Aide class to take residents to the bathroom. She said the facility had received complaints about it prior an on investigation, the aide thought that resident was incontinent. She said it should not matter, if the resident asked, they should be taken to the bathroom. Review of the Resident Council Minutes documented: [DATE]: six residents attended. Residents had concerns including night staff chat too much at the nurse's station or come sit in the dining room instead of making rounds, and staff were taking personal calls on cell phones, [DATE] - nine residents attended. Residents had concerns including nursing care concerns: phones. still an issue; one resident reported the staff came into her room to use the phone because that resident would not tell on them. Review of the facility's undated policy and procedure on Personal Communication Devices documented: Use of personal communication devices during scheduled work hours is not permitted at the facility. The devices include, but are not limited to, cell phones and laptop computers. You may only use you're your personal communication devices during scheduled break/lunch times. Inservice dated [DATE] to Charge Nurse Responsibility documented: keep aides off the phones in hallways and residents' rooms. didn't vote this year, didn't get to vote for president - they used to help by mail. Review of the facility's Statement of Resident Rights, undated, documented: The resident has a right to a dignified existence. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance of his or her quality of life, recognizing each resident's individuality.

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 5 residents reviewed for pressure injuries. (Residents #82) Facility failed to prevent the development of the unstageable pressure sore on Resident #82's coccyx by failing to reposition the resident while in bed. This failure could place residents at risk for new development or worsening of existing pressure injuries. The findings included: Record review of Resident #82's detailed summary report/face sheet dated 09/25/19 indicated he was admitted to facility on 05/17/19 with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #82's weekly ulcer assessment dated [DATE] indicated in part: - Ulcer information: Location of ulcer- sacral/coccyx. Type of ulcer - pressure. Pressure ulcer stage - Unstageable. - Interventions: Current wound treatment - wash with wound cleanser, apply [MEDICATION NAME] (wound healing gel) to wound bed, calcium alginate, padded dressing daily until resolved. Frequency of turning and repositioning - q2h (every 2 hours). - Notification: Is this a new wound - Yes. - Other: Is resident compliant with treatment - Yes. - Presence on admission: If pressure injury, was it present on admission ? - No. Record review of Resident #82's care plan dated 09/24/19 indicated in part: The resident has a pressure ulcer or potential for pressure ulcer development. The resident's pressure ulcer will show signs of healing and remain free from infection. Avoid positioning the resident on the location of the pressure ulcer. Record review of Resident #82's Minimum Data Set ((MDS) dated [DATE] indicated in part: Brief Interview Mental Status (BIMS) score = 03 indicating resident had severe impairment. Functional status - Bed mobility = 3 indicating extensive assistance. Functional limitation in range of motion - no impairment to upper and lower extremity. Record review of Resident #82's Braden scale dated 08/20/19 indicated in part: Degree of physical activity - bedfast confined to bed. Mobility - ability to change and control body position, very limited, makes occasional light changes in body or extremity position but unable to make frequent or significant changes independently. Friction and shear - problem: requires moderate to maximum assistance in moving. Requiring frequent repositioning with maximum assistance. Record review of Resident #82's order summary report dated 09/25/19 indicated part: unstageable to sacral area wash with wound cleanser, apply [MEDICATION NAME] and calcium alginate to wound bed, cover with padded dressing daily until resolved. During an observation on 09/23/19 at 9:25 a.m. Resident # 82 was in bed in a supine position. During an observation on 09/23/19 at 11:42 a.m. Resident # 82 was in bed in a supine position. During an observation on 09/23/19 at 3:09 p.m. Resident # 82 was in bed in a supine position. During an observation on 09/23/19 at 3:57 p.m. Resident # 82 was in bed in a supine position. During an observation on 09/24/19 at 9:00 a.m. Resident #82 in bed supine, heel protectors on. During an observation on 09/24/19 at 12:02 p.m. Resident # 82 was in bed in a supine position. During an observation on 09/24/19 at 3:45 p.m. Resident #82 was in bed in a supine position. During an observation on 09/24/19 at 9:08 a.m. Resident #82 was in bed in a supine position. Record review of Resident #82's task: turn/reposition as indicated on the resident's electronic record indicated in part: Did you turn and reposition ? 09/22/2019. Yes at 7:15am and 2:35pm. (According to document resident was repositioned only twice on this day). 09/23/2019. Yes at 1:58am, 10:21am and 9:07pm. (3 times on this day). 09/24/2019. Yes at 7:40pm. (once on this day). 09/25/2019. Yes at 1:43am, 9:04am and 8:17pm. (3 times on this day). 09/26/2019. Yes at 12:37am and 6:55am. (twice on this day). During an interview on 09/23/19 at 12:18 p.m. CNA D Resident #82 was always in bed and would not get on a wheelchair due to probably complaining of pain. CNA D said they would turn Resident #82 every 2 hours and place a pillow on his side to keep him in that position. CNA D was made aware of multiple observations of the Resident #82 being on a supine position and not being turned on his side. CNA D said she would try to reposition the resident more often. During a telephone interview on 09/23/19 at 11:22 a.m. Resident #82's daughter said that when she came to the facility to visit her dad, he was always in bed laying on his back. She said she would come almost every day at lunchtime to feed him and he was always on his back and the staff would not turn him on his side. She said she had told staff about it, but the resident would continue to be on his back. During an interview on 09/24/19 at 3:45 p.m. Certified Nurse Aide (CNA) C said Resident #82 was pretty much in bed always now. CNA C said she was the shower aide and would even give Resident #82 bed baths. During an interview on 09/25/19 at 10:02 a.m. the Director of Nurses (DON) said their policy for the prevention of pressure sores was to reposition and change the residents every 2 hours. The DON said the aides applied [MEDICATION NAME] creams to their skin and encourage the residents to get out of bed. The DON said the staff were supposed to report any skin problems. The DON said the residents were supposed to be repositioned every 2 hours or as needed. The DON said that even if a resident was on air mattress the staff still had to reposition the residents. The DON was made aware of the multiple observations of Resident #82 being on the same spot (supine) and not being repositioned. The DON said they could put him on a turning schedule and that they would train the staff. During an interview on 09/25/19 at 2:50 p.m. the treatment nurse said during Resident #82's skin assessment on 09/23/19 she noticed a pressure ulcer to his coccyx. The treatment nurse said she had told staff to turn the resident on his side and keep pressure off his coccyx. During an interview on 09/26/19 at 8:56 a.m. Resident #82's doctor said his expectation for the prevention of pressure sores was for staff to turn and reposition the resident on their side and place cushions on their bottom to prevent pressure. The doctor said especially Resident #82 since he was in poor health and required more monitoring to prevent skin breakdown. During an interview on 09/26/19 at 10:08 a.m. the Administrator was made aware of observations of Resident #82 not being repositioned in bed and it probably led to the resident developing a pressure ulcer to his coccyx. The Administrator said staff would be in serviced on making sure they were repositioning the residents. Record review of the facility's policy Pressure injury: Prevention, assessment and treatment dated 08/12/16 indicated in part: - Procedure: Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. - Causes of pressure injuries - Unrelieved pressure over bony prominence resulting in ischemia at the area of pressure. - Nursing action/rationale - Prevention: The nurse assists in the prevention of pressure injuries by performing the following nursing interventions: Determine resident's skin tolerance to pressure and develop a turning schedule; resident should be turned every two (2) hours.

Based on interview and record review, the facility failed to ensure that a resident received CPR in accordance with professional standards of practice for one (Resident #141) of four residents reviewed for CPR. Resident #141, who was a full code, was found unresponsive by staff. LVN I and LVN J failed to call 911. Resuscitative measures were initiated and stopped by LVN I and LVN J. Resident #141 expired in the facility. This was determined to be past non-compliance due to the facility having implemented action that corrected the con-compliance prior to the beginning of the inspection. These failures could affect all 42 residents who could need CPR by placing them at risk of death. Findings Included: Review of Resident #141's Face Sheet indicated he was [AGE] years old and admitted to the facility [DATE]. [DIAGNOSES REDACTED]. Review of Resident #141's (MONTH) (YEAR) Physician order [REDACTED].>Review of the MDS assessment dated [DATE] indicated Resident #141 had moderate cognitive impairment. He required extensive assistance with ADLs. Review of Resident #141's Care Plan dated [DATE] included: Advance Care Planning resident/responsible party request full code status. Resident wishes will be honored on an ongoing basis X 90 days. *Inform staff of code status *Monitor for decline in change of condition - report to MD and responsible party *If resident's heart stops - initiate CPR and call 911 for transfer to the hospital *Review code status with resident quarterly to verify wishes are honored. In an interview on [DATE] at 9:00 AM with the administrator and DON they said no one had expired in facility that was Full Code except for Resident #141 within the past six months. Review of the Provider Investigation Report dated [DATE] at 1:30 AM indicated that Resident #141 was found unresponsive and CPR procedures were not followed to ensure best practices were met in regards to the Resident's full code status. Charge Nurse, LVN I, called the DON and informed her of a death in the facility. No respirations were noted. No blood pressure was audible. No pulse was palpable. There was no response to painful stimuli. The physician had been informed of the resident's death by LVN I at 2:15 AM. An order was given by the physician for the DON to pronounce death. Death was pronounced by the DON at 2:55 AM. The Investigation Summary read as follows: During the investigation the facility learned that when the nurses found Resident (#141) unresponsive the proper CPR procedures were not taken. The first sign of improper procedure was that 911 was not called on a Full Code and CPR was stopped by an LVN at the facility. Upon further investigation there were numerous issues with the code procedure by the two nurses on duty. AED was not applied. 911 was not called. Code stopped by LVN. There were also some questions of whether CPR was actually even initiated to begin with. Statement from CNA on duty said it was not started. Further investigation into this accusation brought about more concern whether it (CPR) was ever actually started or not, but we did not have definitive evidence one way or the other. The outcome of the investigation was that these two nurses did not perform correct Policy and Procedure for a full code. Review of Nursing Notes by LVN J, dated [DATE] at 3:10 AM, included the following, in part: (no time listed) CNA assisted Res. to B/R (bathroom). Res. had a large BM (bowel movement) then Res. assisted back to bed. 0100: LVN I was down hallway, checked on Res., Res. was in bed, Res. was OK. 0100 this nurse went into room, noted that Res. was unresponsive. Other nurse to room, Res. remains unresponsive. Non-rebreather mask applied. Started CPR. CPR unsuccessive (sic). Noted bodily fluids coming from Res. mouth. Reddish in color. DON/DR. notified that Res. had expired. Wife notified that Res. had expired. 0150 - Family here. Wife very upset. 0250 - DON here to pronounce.Funeral Home notified . Review of a statement signed by LVN J dated [DATE], included the following in part: 11:30 - 12:15: CNA L in resident's room. Took vital signs and took Res. to B/R (bathroom). Res. had BM (bowel movement). 24:45 Res. assisted back to bed. O2 on. 0100 - LVN I down hallway, noted Res. in bed, resting quietly, no distress noted .0115 - This nurse went into room .to give (Res. #141) his meds. Res. with eyes closed, slow to respond. This nurse went down to Hall 2 to get other nurse. Took crash cart down to (Res. #141's room). Non-rebreather mask placed on Res., board in place, CPR started. After a few minutes, noted some red mucosy (sic) secretions coming from resident's mouth. No pulse, no B/P (blood pressure) noted. Cont (Continued) CPR. CPR unsuccessful. Resident had another BM while we were performing CPR. LVN I to nurse's station. MD notified that CPR was unsuccessful. This nurse remained in room with res. DON/Family notified. Numerous attempts to contact LVN J between ,[DATE] and [DATE] were unsuccessful. Review of a statement signed by the DON dated [DATE] included the following, in part: I was called by LVN I on [DATE] at 1:30 AM, He informed me that Resident #141 had passed .He stated that Resident #141 was taken to the bathroom by CNA L at around 12:00 AM. He said Resident #141 was in his usual state of confusion at the time. He stated that he walked down the hall at about 1:00 AM and peeked in on the resident and he was resting comfortably .LVN I gathered some equipment and went into a resident's room on his assigned hall. He was then summoned by LVN J and she informed him that Resident #141 was unresponsive. LVN I said he took the crash cart to the resident's room and initiated CPR. He stated that they were unable to resuscitate Resident #141. He stated he then called the Medical Director and informed him that Resident #141 had expired. LVN I then called me to inform me of Resident #141's death. I asked LVN I to inform the wife and that I would arrive at the facility as soon as possible. I then notified the administrator of Resident #141's death. I arrived at the facility at 2:50 AM. Resident #141's wife, family and friends were surrounding his bedside. The wife cried and stated that she had wanted to take him home. Resident #141 was lying in bed with no signs of life . Review of an email from LVN I to the facility administrator, dated [DATE] at 11:14 PM included the following, in part: This is the time line regarding (Resident #141). At 11:15 p.m. (CNA L) hear the bed alarm and goes to (Resident #141's) room and assists resident to the bathroom, aide stated he voided and put him to bed. At 00:00, resident is checked .by aide (CNA L) and resting in bed. At 01:00, I go .and past resident room and noticed door wide open and check on resident see respirations and oxygen via n/c (nasal cannula) on him and with eyes closed. I go to back door and through (sic) wastes containers and bags. I also clean the break room and go back to (Resident #141's) room and walk into the room and checked on resident a second time but this time entering room and not just passing by room. I enter room halfway from the doorway and see respirations and close the door because he likes the door almost closed. I go to my hallway duties on hall 200. I am with (another resident) . and I see (LVN J) .and I see something is wrong. She says (Resident #141) is unresponsive. I grab the crash cart and she double checks the chart. He is full code. I am with crash cart and see resident is nonresponsive. I grab the non-rebreather mask to quickly try to get some oxygen to him and tell (LVN J) to take over the non-rebreather mask and then I start chest compressions. I am doing chest compressions while (LVN J) is giving him oxygen. Also, checking responsiveness and pulse. I then tell (LVN J) to take over respirations while I am grapping (sic) the bag valve mask and parts. In the meantime she is doing chest compressions. I have bag valve mask together and I tell (LVN J) I will take over compressions and (LVN J) take over the bag valve mask giving oxygen. We continue giving chest compressions and using the bag valve mask. Checking for pulse and responsive (sic) and no response from (Resident #141). We temporarily stop because he has emesis coming from his mouth. The color of the emesis is light pinkish color. The amount of emesis covers the left side of his face. (LVN J) and I check for pulse and resident not responsive. We did CPR and resident was non-responsive with life saving measures. (LVN J) was more in shock because I was not the main nurse but we help each other. She got report that he was supposed to go home. I made phone calls for (LVN J) and called (the doctor) and (Resident #141's) wife and .DON. Also, resident had a bowel movement and more pinkish slimy emesis and brown colored stool come out of his mouth when aides .cleaned him up. This is the circumstances the (sic) occurred [DATE] thought (sic) [DATE] regarding (Resident #141). Review of a statement signed by CNA K dated [DATE] included the following: was charting in the dining room, saw (LVN J) walking fast and grab the crash cart. Followed her to (Resident #141's) room. Saw no response. I started to shake him and check for a pulse. I told (LVN I) who took charge and told him we needed to start CPR, (LVN I) froze and I asked (LVN J) for the board to put underneath him. She handed me the board, as I rolled him over I noticed bodily fluids. I reported it to (LVN I) and told him we still need to start CPR. (LVN I) looked at me panicked and said I'm calling the family. In an in-person interview with CNA K on [DATE] at 10:15 AM she said she was in the dining room at about 1:30 AM, and saw LVN J run by and come back pushing the crash cart. She said the other two CNAs were busy with other residents. Both nurses (LVN I and LVN J) were in Resident #141's room. CNA K said she did a sternal rub with no response, checked for a pulse and found none. She said she asked the nurses if he was DNR and got no response. Then LVN J told her to go get Resident #141's chart. She said she got the chart and returned to the resident's room and told the LVNs that he was not DNR and they needed to start CPR. CNA K asked if 911 had been called and nurses did not respond. LVN I had the ambu bag in his hand. She said one of the nurses handed her an oxygen mask and she put it on him and connected it to his oxygen concentrator. She said she told the nurses they need to get the board under him. They did nothing so she asked for the board. She said one of them handed it to her and she turned the resident to get it under him. When she turned him she said that body fluids started coming from his mouth and nose. She said that when she told the nurses that, LVN I said he was calling the family and left the room. LVN J was at the end of bed, and shrugged her shoulders, and told her to clean the body. CNA K said that the family got there at about 2:00 AM. CNA K said that no CPR was done on Resident #141. Review of a statement signed by the DON dated [DATE] included the following: This RN, the administrator and Cooperate (sic) nurse interviewed (LVN I) in regards to the events that occurred with (Resident #141) on (MONTH) 7, (YEAR). His sequence of the events and what actually occurred changed several times during the conversation. When asked why he didn't call 911 during the CPR procedure, he had no explanation. However, he did voice understanding that 911 should have been called and that CPR should have been performed by the facility's nursing staff until the paramedics arrived. Review of statement signed by CNA L dated [DATE] included the following: I arrived to (Resident #141's) room where I witnessed (LVN J) holding ambu bag, was told to get (Resident #141) cleaned up before the family came. (CNA K) and I cleaned up resident, family arrived shortly after. In a telephone interview with CNA L on [DATE] at 9:40 AM she said she took Resident #141 to the bathroom on her first rounds of the 10:00 PM to 6:00 AM shift, ,[DATE] -[DATE]. She said she later checked his vital signs at about 12:15 AM, [DATE]. She said that at about 1:00 AM CNA K came and got her to go to Resident #141's room to clean up his body. She said she had been on Hall 400 taking care of other residents and did not know what had occurred with Resident #141. She said that when she got to the resident's room LVN J had an ambu bag in her hand, the backboard was under Resident #141, and the crash cart was outside the room. Review of the Vital Sign Sheet dated [DATE] listed Resident #141's vital signs as: temperature - 98.2; blood pressure - ,[DATE]; pulse - 75; respirations - 18. Review of a second (undated) statement signed by LVN I included the following, in part: On 7th (MONTH) onto 8th of (MONTH) .I grab the crash cart and ask her what code status he is. She checks the chart. She says full code .I lie resident flat and tilt neck a little back. I get non-rebreather mask and put it on. I tell (LVN J) that (sic) 1:25 to take over mask . At 1:25 I do 30 compressions and she give two. I tell her I need to get the bag valve mask. I tell her do compressions while I get the mask. We are continuing CPR. I/we .did not put board for CPR .We were doing CPR checking for pulse and respirations. I check cart for A.E. (sic) but found it locked. I go back at 1:30 and continue helping (LVN J) while I am giving compressions while she it (sic) bagging him with oxygen. Checking for response and no response .He has slimy light pink emesis come out of his mouth on his left side. We temporarily stop compressions to clean his mouth. We do compressions once cleaned up .We have done about 10 - 30 x2 compression sets by 1:45. No response .LVN J .in shock when we get no respirations. I tell (LVN J) I will leave room and call Dr., DON, and family. (LVN J) is giving CPR when I leave the room. Review of a third statement dated [DATE] by LVN I included the following, in part: On the night of (MONTH) 7 through (MONTH) 8, (YEAR). Re; (Resident #141) .I go do my duties on hall 200 .I see (LVN J) at my resident's room. I said what's wrong. She says He's gone. I leave room and .follow (LVN J). As we pass nurse's station, I ask her if he is full code. We go check on resident check him and no pulse, no respirations. I go back and get crash cart. I grab oxygen, non-rebreathing mask and no regulator. So I go get regulator off (another resident's) w/c. I put regulator on first time not put on right and hisses, readjust and second time hisses. Third time finally on resident. I put non-rebreather on. Aides see us in room. I do chest compressions and Aides put back board on. I then get bag valve mask while (LVN J) is watching. I get parts and give him air through the bag valve mask .I attempted CPR, giving him O2 via non-breather (sic) and bag valve mask. I did not call 911 but I attempted CPR and did do compressions. I have changed my story several times but never been in this predicament. I am willing to take a lie detector test. I attempted CPR, gave bag valve mask, and non breather (sic) and chest compressions. But more than the main nurse (LVN J). The main nurse never called all while I was doing the above. Yes we worked together. She got report that he was going home. As a nurse, I did more interventions while main nurse watched. Rember (sic) I check resident twice and he was not my resident but I still checked on resident when going down hallways. I called MD, DON, and family .I did attempt CPR and also interventions. I check (sic) tried getting the AED machine bit (sic) it was locked while the main nurse watched and not telling the truth. Numerous attempts to contact LVN I between ,[DATE] and [DATE] were unsuccessful. In a telephone interview on [DATE] at 12:11 PM the facility Medical Director said he was called by the male nurse (LVN I) and told that Resident #141 had expired. He said he had a QA meeting with the administrator and DON regarding the issue. He said the nurses should have called 911 when they found Resident #141 unresponsive and should have performed CPR. During an observation and interview with the administrator and DON on [DATE] at 3:45 PM in the room with crash cart, the AED was attached to the side of the crash cart. The AED is not locked. The administrator and DON said the key was kept in a filing cabinet in BOM's (business office manager's) office and the AED was never locked. The ambu bag was attached to a pole on top of the crash cart. The DON and administrator said LVN I told them the non-rebreather mask was used because they wanted to get oxygen to the resident as quickly as possible. Review of LVN I's personnel file included a CPR certification issued on [DATE] with a renewal date of [DATE]. Review of LVN J's personnel file included a CPR certification issued on [DATE] with a renewal date of [DATE]. Review of CPR Standard of Practice with revision date of ,[DATE] included the following, in part: 2. If a resident experiences a [MEDICAL CONDITION], facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order . 9. Continue CPR until you see signs of life, another rescuer takes over for you, or help arrives. It was determined these failures placed Residents in an Immediate Jeopardy situation which continued from [DATE] to [DATE]. The facility took the following action to correct the non-compliance: Review of the Provider Investigation Report dated [DATE] at 1:30 AM indicated the facility suspended the two nurses upon knowledge of improper code being conducted. After investigation, the two nurses were terminated. The facility referred the licenses to the Texas Board of Nursing. All staff was in-serviced by the DON for proper CPR/Full Code procedures and educated if any lack of knowledge existed. The facility developed a code review form to have nursing staff verbally walk through steps of an emergency code. An emergency QA meeting was held with the Medical Director, DON, Administrator was set up to discuss the root causes and best practices to ensure the event does not recur. Review of In-Service Training Report dated [DATE] with the nursing department with the topic of CPR Procedures, included the following attachment: Attention Staff: Many residents maintain a full code status. Therefore, CPR must be initiated if they are found unresponsive. 911 must be called when CPR is started. The CPR process (chest compressions and rescue breaths) must continue until the resident becomes responsive or the paramedics arrive and assumes responsibility. The AED must also be used in the case of [MEDICAL CONDITION]. Code Reviews including a code scenario, and CPR AED Checklists were additional activities included in the ongoing inservice training. On [DATE] separate interviews were conducted with RN M at 11:45 AM; RN N at 11:50 AM; and LVN B at 11:55 AM. Each nurse responded correctly to the following questions: 1. How do you determine code status? Answer: chart, computer 2. Who is responsible for initiating CPR? Answer: Nurse 3. Use of non-rebreather mask? Answer: For resident with low O2 sats that is breathing 4. Use of AED? Answer: As soon as it gets to coding resident's room According to a list provided by the DON on [DATE] there were 42 residents in the facility that had requested a code status of Full Code.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, consistent with the resident's comprehensive assessment and plan of care for two (Resident #86 and Resident #87) of two resident reviewed for pain management. a) The facility failed to assess Resident #86's pain and address continuous pain relayed to staff by Resident #86. b) The facility failed to assess Resident #87's pain or address pain during wound care. This failure could affect 36 residents on pain management program to treat pain and placed the residents at risk for further decline in their mental or physical functioning. Findings include: Resident #86 initial MDS assessment on 11/15/17 revealed he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. BIMS (Brief Interview Memory Score) of 11 reveals Resident #86 could cognitively make his needs known. MDS section J Health Condition (pain interview) revealed on 11/15/17 the pain assessment interview: J0300 (1) answer yes pain presence J0400 Pain Frequency (3) occasionally J0500 Pain Effect on function (ask resident): Over the past 5 days, has pain made it hard for you to sleep at night? yes J0600 Pain intensity (number pain scale) 0-10 Ask resident: Please rate your worst pain over the last 5 days on a zero to ten scale zero no pain and ten as the worst pain you can imagine Pain scale rated by Resident #86 revealed his pain scale was a 9. Resident #86's Care Plan dated 11/08/17 revealed: Problem onset: At risk for alteration in comfort due to pain Goal: Resident #86 will have relief of pain within one hour of pain intervention. Approaches: Assess Resident #86 using standardized pain scale appropriate for his cognition. Administer pain medications as ordered Observe effect/non effect of pain medication Monitor/reassess pain frequency and intensity Report documented findings to physician. Record review of physician orders [REDACTED].#86 was ordered Tylenol with [MEDICATION NAME] #3 one tablet scheduled every 6 hours around the clock. Review of Therapy Notes on 11/08/17 revealed: Pain at rest: Intensity = 9/10 Frequency/Duration = Constant; Location back and abdomen; Pain Description/type: Discomforting. Pain With Movement: Intensity = 9/10 Frequency/Duration = Constant; Location back and abdomen; Pain Description/type: Discomforting Pain Assessment: Pain Assessment Method = Patient verbalized pain level.; Does pain limit patient's functional activities? = Yes Review of nurses' notes on 11/25/17 at 3:40 p.m. revealed Resident up on wheelchair complains of pain 10/10 in lower hip area given Tylenol #3 resident stated It's unbearable and I don't want to talk about it but I hope you believe me when I say it's over a pain level of 10. It hurts more in my testicles but I hurt from my head to my toes. Will continue to monitor pain levels. During initial tour on 12/18/17 at 2:10 p.m. Resident #86 was observed grimacing while he was sitting in his wheel chair. Resident #86 also was having difficulty moving his extremities for comfort due to his paralysis. He said he was in pain and discomfort at the time the reason for facial expression. Resident #86 said he was in pain and rated it at a 9 with zero meaning no pain to a pain scale of nine meaning a great deal of pain. Resident #86 said he has been in constant pain ever since his admission the first week of (MONTH) (YEAR). He also said the pain medication he was given was a joke and did not relieve his pain. Resident #86 said he presently at a pain scale of nine. During an observation on 12/19/17 at 8:50 a.m., Resident was moaning and crying out in pain while he was in bed trying to adjust his position for comfort. He said all he is getting is Tylenol #3 and it is not helping. During an interview with LVN A on 12/19/17 at 9:45 a.m. she said Resident #86 always says he was in pain but all he wants was Marijuana. She said since he was on scheduled pain medication she said we do not do pain assessments. During an interview with Resident #86's Physician on 12/20/17 at 9:30 a.m. he said he had not been notified by the facility regarding Resident #86's pain and did not remember anyone calling him about Resident #86's pain not being relieved. He said he will adjust his pain medication today. During an interview with Resident #86 on 12/21/17 at 8:50 a.m., he said he has been in constant pain and he was given pain medication this morning at 8:30 a.m. but it only been half an hour and could not decide if the new pain medication is effective. He said it was at a pain scale of 8 on a scale of 0-10. He said it has never dropped below an 8 on the pain scale of 0-10 since his admission. During an interview with CMA C (Certified Medication Aide) on 12/21/17 at 9:15 a.m. she said Resident #86 has been telling me he is in pain and it has not been resolved. She said she has told the nurses' Resident #86 was in pain and he has even told them (nurses) he was in pain and they said all he wants was Marijuana. CMA C said she does a pain assessment scale of 0-10 to rate his pain and he always says it was a 9 meaning he is in significant pain. She said ever since he was admitted he complained of pain. She said they scheduled Resident #86 Tylenol #3 and he still complained of pain. She said Resident #86 said it does not do[***]for him. She said she told the charge nurses Resident #86 was complaining of pain. She said Resident #86 was scheduled Tylenol #3 and he still complained of pain and it was not relieving his pain. CMA C said she asks him what is pain scale was but since he was on scheduled pain medication assessments are not done. During an interview with LVN B on 12/21/17 at 9:30 a.m. she said when Resident #86 complained of pain he was getting Tylenol #3 PRN (as needed) and was changed to a schedule of Tylenol #3 every 6 hours around the clock. She said since the medication was scheduled we do not do pain assessments. She said she has never been told Resident #86 was in constant pain. During an interview with DON on 12/21/17 at 9:50 a.m. she said she was not aware Resident #86 was in pain, she said the Physician does not write orders for narcotics in this facility and they have to get a pain management physician to give Resident #86 narcotics for his pain. She said she will make arrangements for Resident #86 to see a pain management physician today. During an interview with Physician's nurse on 12/21/17 at 10:00 a.m. she said there was no documentation on the Physician's progress notes saying the facility contacted him in regards to Resident #86's continuous pain or if he had pain relief. During an interview with CNA D (Certified Nurse Aide) on 12/22/17 at 9:50 a.m. he said he would tell the nurses if a resident told him they were in pain. He said the nurses would be the main person to tell. He said he has worked with Resident #86 and he is always saying he is in pain and I let the nurses know. During an interview with OT (Occupational Therapist) on 12/22/17 at 10:00 a.m. she said if a resident complains of pain we let the nurses know. She said Resident #86 has chronic pain and he was on scheduled medication and it is not always meeting his pain needs. She said, poor man he was always in pain During an interview with CNA E on 12/22/17 at 10:15 a.m. said if a resident is in pain we tell the nurses. She said Resident #86 was always complaining about muscle cramps and the nurses were aware of his pain. Record review of MAR (medication administration record) from (MONTH) 1, (YEAR) to (MONTH) 21, (YEAR) revealed Resident #86 received Tylenol #3 every 6 hours around the clock. No pain assessment was documented for the scheduled pain medicatio Tylenol #3. Record review of Physician orders [REDACTED].#86 had a new order for Tylenol #4. Review of nurses' notes on 12/20/17 at 2:56 p.m. revealed they received new orders for Tylenol #4 every 6 hours around the clock. Review of nurses' notes on 12/21/17 at 1:36 a.m., 12/21/17 at 2:19 p.m.12/22/17 and at 12:31a.m. reveal Resident #86 was receiving Tylenol #4 and did not voice pain. Resident #87 MDS assessment on 12/14/17 revealed his was a [AGE] year old male admitted on [DATE] for wound care for a diabetic wound on his left heel. [DIAGNOSES REDACTED]. Resident #87's BIMS was 13 indicating he was cognitively able to make his needs known. Resident #87's care plan was not generated due to short term admission for wound care. discharged [DATE] Review of physician's orders [REDACTED].#87 received [MEDICATION NAME] 50 mg one tablet every four hours and Tylenol 325 mg two tablets every four hours as needed for pain. During initial tour on 12/18/17 at 2:10 p.m. Resident #87 was observed with a wound vac (a negative pressure wound therapy used to promote healing) on his left foot. The drain was removing brown colored body fluids in the collection port. Resident #87 was alert and oriented to person, place and time. Resident #87 did not complain of pain and was optimistic to go home in a few days He said he was there for therapy and wound care. He said he was not in pain at this time. During observation of wound care on 12/19/17 at 9:30 a.m. revealed Treatment Nurse F began to remove the wound vac and dressing from Resident #87's left foot. During removal of wound dressing resident #87 was asked if he was in pain he said he was in pain. Treatment Nurse F continued to remove Resident #87's dressing without asking nursing staff for pain medication. During an interview with Treatment Nurse F on 12/19/17 at 9:35 a.m. she was asked if it was acceptable to continue with wound care when the resident was complaining of pain, she said no I should have stopped and ask for pain medication. Treatment Nurse F called for the charge nurse to bring Resident #87 pain medication, she then continued with removing dressing and resident was grimacing during wound care. CMA C arrived at 9:50 a.m. with Tylenol 325 mg (milligram) two tablets. Treatment Nurse F did not wait for pain medication to take effect during wound care. During an interview with Resident #87 on 12/19/17 at 10:15 a.m. revealed he was in pain and the two Tylenol 325 mg given at 9:50 a.m. had not taken effect and was in pain during wound care dressing removal. During an interview with Resident #87's nurse LVN B on 12/20/17 at 10:30 a.m. said Resident #87 did not have a care plan because he was there for a short time and only there for wound care. During an interview with DON on 12/21/17 at 9:50 a.m. she said the Physician does not write orders for narcotics in the facility. During an interview with Treatment Nurse F on 12/21/17 at 2:20 p.m. she said she gave Resident #87 pain medication this time before she did his dressing change. During an interview with DON on 12/21/17 at 4:00 p.m. she said she would expect nurses to assess and provide pain medication during wound care if the resident is in pain. Review of Resident #87's medications on 11/16/17 at the acute care facility (prior to admission to this facility) revealed the following pain medications. [MEDICATION NAME] 2 mg, 0.4ml (milliliter) every 4 hours as needed [MEDICATION NAME] 5mg-325 mg oral tablets, 1 tablet every 6 hours as needed. Review of Physician orders [REDACTED].#3 prior to wound care for 14 days. Un-dated Policy and procedure titled Pain Management Process revealed the following: Purpose: The facility will react to the residents pain control needs based on the resident's goals for pain relief and the resident's goals for functional ability. The facility's goal is to ensure all residents receive appropriate pain relief measures to assure that resident's pain does not affect their ability to function within their designated goals for functional ability. Process: Upon admission and re-admission the facility will complete a pain assessment/evaluation. The facility will complete pain interviews or reviews based on MDS RAI(Resident Assessment Instrument) guidelines. If pain is triggered the facility will complete a comprehensive pain assessment/evaluation to include. 1. Current presence of pain (acute/chronic or both) 2. Type of pain scale to utilize 3. Predisposing cause of the pain 4. Location and etiology of the pain 5. Quality, intensity and duration of pain 6. Accompanying symptoms associated with the pain 7. Current management 8. Pharmacological and non-pharmacological treatments 9. History of resolved or unresolved pain 10. Resident's pain management goals Documentation of pain intensity will be recorded along with intervention for pain reduction using appropriate facility form and no less than the Pain Assessment, Pain Flow Sheet, and SBAR (Situation, Background, Assessment, Recommendation) for notification and 24 hour report for any pending re-evaluation or pending interventions .upon follow-up, if the intervention is ineffective, process should be repeated until resident indicates adequate relieve and/or functional goals are met. .residents who have received PRN (as needed) pain medications more than three times in the last week or having pain scale greater than (7) will be reviewed weekly by Pain Management Committee. Review of CMS-672 provided by the DON on 12/18/17 revealed 36 residents were on pain management program.

Based on interview and record review, the facility failed to consult with the physician regarding a need to alter treatment for 2 of 2 residents reviewed for pain (Resident #86, and Resident #87) The facility did not consult with Resident #86's and Resident #87 physician (same physician) about their unrelieved pain. This failure could affect 36 residents on pain management program to treat pain and placed the residents at risk for further decline in their mental or physical functioning. Findings include: Resident #86 initial MDS assessment on 11/15/17 revealed he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. BIMS (Brief Interview Memory Score) of 11 reveals Resident #86 could cognitively make his needs known. MDS section J Health Condition (pain interview) revealed on 11/15/17 the pain assessment interview: J0300 (1) answer yes pain presence J0400 Pain Frequency (3) occasionally J0500 Pain Effect on function (ask resident): Over the past 5 days, has pain made it hard for you to sleep at night? yes J0600 Pain intensity (number pain scale) 0-10 Ask resident: Please rate your worst pain over the last 5 days on a zero to ten scale zero no pain and ten as the worst pain you can imagine Pain scale rated by Resident #86 revealed his pain scale was a 9. Resident #86's Care Plan dated 11/08/17 revealed: Problem onset: At risk for alteration in comfort due to pain Goal: Resident #86 will have relief of pain within one hour of pain intervention. Approaches: Assess Resident #86 using standardized pain scale appropriate for his cognition. Administer pain medications as ordered Observe effect/non effect of pain medication Monitor/reassess pain frequency and intensity Report documented findings to physician. Record review of physician orders [REDACTED].#86 was ordered Tylenol with [MEDICATION NAME] #3 one tablet scheduled every 6 hours around the clock. Review of Therapy Notes on 11/08/17 revealed: Pain at rest: Intensity = 9/10 Frequency/Duration = Constant; Location back and abdomen; Pain Description/type: Discomforting. Pain With Movement: Intensity = 9/10 Frequency/Duration = Constant; Location back and abdomen; Pain Description/type: Discomforting Pain Assessment: Pain Assessment Method = Patient verbalized pain level.; Does pain limit patient's functional activities? = Yes Review of nurses' notes only record of Resident #86's continued pain on 11/25/17 at 3:40 p.m. revealed Resident up on wheelchair complains of pain 10/10 in lower hip area given Tylenol #3 resident stated It's unbearable and I don't want to talk about it but I hope you believe me when I say it's over a pain level of 10. It hurts more in my testicles but I hurt from my head to my toes. Will continue to monitor pain levels During initial tour on 12/18/17 at 2:10 p.m. Resident #86 was observed grimacing while he was sitting in his wheel chair. Resident #86 also was having difficulty moving his extremities for comfort due to his paralysis. He said he was in pain and discomfort at the time the reason for facial expression. Resident #86 said he was in pain and rated it at a 9 with zero meaning no pain to a pain scale of nine meaning a great deal of pain. Resident #86 said he has been in constant pain ever since his admission the first week of (MONTH) (YEAR). He also said the pain medication he was given was a joke and did not relieve his pain. Resident #86 said he presently at a pain scale of nine. During an observation on 12/19/17 at 8:50 a.m., Resident was moaning and crying out in pain while he was in bed trying to adjust his position for comfort. He said all he is getting is Tylenol #3 and it is not helping. During an interview with LVN A on 12/19/17 at 9:45 a.m. she said Resident #86 always says he was in pain but all he wants was Marijuana. She said since he was on scheduled pain medication she said we do not do pain assessments. During an interview with Resident #86's Physician on 12/20/17 at 9:30 a.m. he said he had not been notified by the facility regarding Resident #86's pain and did not remember anyone calling him about Resident #86's pain not being relieved. He said he will adjust his pain medication today. During an interview with Resident #86 on 12/21/17 at 8:50 a.m., he said he has been in constant pain and he was given pain medication this morning at 8:30 a.m. but it only been half an hour and could not decide if the new pain medication is effective. He said it was at a pain scale of 8 on a scale of 0-10. He said it has never dropped below an 8 on the pain scale of 0-10 since his admission. During an interview with CMA C (Certified Medication Aide) on 12/21/17 at 9:15 a.m. she said Resident #86 has been telling me he is in pain and it has not been resolved. She said she has told the nurses' Resident #86 was in pain and he has even told them (nurses) he was in pain and they said all he wants was Marijuana. CMA C said she does a pain assessment scale of 0-10 to rate his pain and he always says it was a 9 meaning he is in significant pain. She said ever since he was admitted he complained of pain. She said they scheduled Resident #86 Tylenol #3 and he still complained of pain. She said Resident #86 said it does not do[***]for him. She said she told the charge nurses Resident #86 was complaining of pain. She said Resident #86 was scheduled Tylenol #3 and he still complained of pain and it was not relieving his pain. CMA C said she asks him what his pain scale is but since he is on scheduled pain medication assessments are not done. During an interview with LVN B on 12/21/17 at 9:30 a.m. she said when Resident #86 complained of pain he was getting Tylenol #3 PRN (as needed) and was changed to a schedule of Tylenol #3 every 6 hours around the clock. She said since the medication was scheduled we do not do pain assessments. She said she has never been told Resident #86 was in constant pain. During an interview with DON on 12/21/17 at 9:50 a.m. she said she was not aware Resident #86 was in pain, she said the Physician does not write orders for narcotics in this facility and they have to get a pain management physician to give Resident #86 narcotics for his pain. She said she will make arrangements for Resident #86 to see a pain management physician today. During an interview with Physician's nurse on 12/21/17 at 10:00 a.m. she said there was no documentation on the Physician's progress notes saying the facility contacted him in regards to Resident #86's continuous pain or if he had pain relief. During an interview with CNA D (Certified Nurse Aide) on 12/22/17 at 9:50 a.m. he said he would tell the nurses if a resident told him they were in pain. He said the nurses would be the main person to tell. He said he has worked with Resident #86 and he is always saying he is in pain and I let the nurses know. During an interview with OT (Occupational Therapist) on 12/22/17 at 10:00 a.m. she said if a resident complains of pain we let the nurses know. She said Resident #86 has chronic pain and he was on scheduled medication and it is not always meeting his pain needs. She said, poor man he was always in pain. During an interview with CNA E on 12/22/17 at 10:15 a.m. she said if a resident is in pain we tell the nurses. She said Resident #86 was always complaining about muscle cramps and the nurses were aware of his pain. Record review of MAR (medication administration record) from (MONTH) 1, (YEAR) to (MONTH) 21, (YEAR) revealed Resident #86 received Tylenol #3 every 6 hours around the clock. No pain assessment was documented for the scheduled pain medication Tylenol #3. Review of nurses' only notes on 11/25/17 at 3:40 p.m. regarding Resident #86's pain revealed Resident up on wheelchair complains of pain 10/10 in lower hip area given Tylenol #3 resident stated It's unbearable and I don't want to talk about it but I hope you believe me when I say it's over a pain level of 10. It hurts more in my testicles but I hurt from my head to my toes. Will continue to monitor pain levels. Record review of Physician orders [REDACTED].#86 had a new order for Tylenol #4. Review of nurses' notes on 12/20/17 at 2:56 p.m. revealed they received new orders for Tylenol #4 every 6 hours around the clock. Review of nurses' notes on 12/21/17 at 1:36 a.m., 12/21/17 at 2:19 p.m.12/22/17 and at 12:31a.m. reveal Resident #86 was receiving Tylenol #4 and did not voice pain. Resident #87 MDS assessment on 12/14/17 revealed his was a [AGE] year old male admitted on [DATE] for wound care for a diabetic wound on his left heel. [DIAGNOSES REDACTED]. Resident #87's BIMS was 13 indicating he was cognitively able to make his needs known. Review of physician's orders [REDACTED].#87 received [MEDICATION NAME] 50 mg one tablet every four hours and Tylenol 325 mg two tablets every four hours as needed for pain. During initial tour on 12/18/17 at 2:10 p.m. Resident #87 was observed with a wound vac (a negative pressure wound therapy used to promote healing) on his left foot. The drain was removing brown colored body fluids in the collection port. Resident #87 was alert and oriented to person, place and time. Resident #87 did not complain of pain and was optimistic to go home in a few days He said he was there for therapy and wound care. He said he was not in pain at this time. During observation of wound care on 12/19/17 at 9:30 a.m. revealed Treatment Nurse F began to remove the wound vac and dressing from Resident #87's left foot. During removal of wound dressing resident #87 was asked if he was in pain he said he was in pain (treatment nurse did not access pain with scale of 0-10 or asked Resident #87 his pain scale). Treatment Nurse F continued to remove Resident #87's dressing without asking nursing staff for pain medication. During an interview with Treatment Nurse F on 12/19/17 at 9:35 a.m. she was asked if it was acceptable to continue with wound care when the resident was complaining of pain, she said no I should have stopped and ask for pain medication. Treatment Nurse F called for the charge nurse to bring Resident #87 pain medication, she then continued with removing dressing and resident was grimacing during wound care. CMA C arrived at 9:50 a.m. with Tylenol 325 mg (milligram) two tablets. Treatment Nurse F did not wait for pain medication to take effect during wound care. During an interview with Resident #87 on 12/19/17 at 10:15 a.m. revealed he was in pain and the two Tylenol 325 mg given at 9:50 a.m. had not taken effect and was in pain during wound care dressing removal. During an interview with DON on 12/21/17 at 9:50 a.m. she said the Physician does not write orders for narcotics in this facility. During an interview with Treatment Nurse F on 12/21/17 at 2:20 p.m. she said she gave Resident #87 pain medication this time before she did his dressing change. During an interview with DON on 12/21/17 at 4:00 p.m. she said she would expect nurses to assess and provide pain medication during wound care if the resident is in pain. Review of Resident #87's medications on 11/16/17 at the acute care facility (prior to admission to this facility) revealed the following pain medications. [MEDICATION NAME] 2 mg, 0.4ml (milliliter) every 4 hours as needed [MEDICATION NAME] 5mg-325 mg oral tablets, 1 tablet every 6 hours as needed. Review of Physician orders [REDACTED].#3 prior to wound care for 14 days. Un-dated Policy and procedure titled Pain Management Process revealed the following: Purpose: The facility will react to the residents pain control needs based on the resident's goals for pain relief and the resident's goals for functional ability. The facility's goal is to ensure all residents receive appropriate pain relief measures to assure that resident's pain does not affect their ability to function within their designated goals for functional ability. Process: Upon admission and re-admission the facility will complete a pain assessment/evaluation. The facility will complete pain interviews or reviews based on MDS RAI(Resident Assessment Instrument) guidelines. If pain is triggered the facility will complete a comprehensive pain assessment/evaluation to include. 1. Current presence of pain (acute/chronic or both) 2. Type of pain scale to utilize 3. Predisposing cause of the pain 4. Location and etiology of the pain 5. Quality, intensity and duration of pain 6. Accompanying symptoms associated with the pain 7. Current management 8. Pharmacological and non-pharmacological treatments 9. History of resolved or unresolved pain 10. Resident's pain management goals Documentation of pain intensity will be recorded along with intervention for pain reduction using appropriate facility form and no less than the Pain Assessment, Pain Flow Sheet, and SBAR (Situation, Background, Assessment, Recommendation) for notification and 24 hour report for any pending re-evaluation or pending interventions .upon follow-up, if the intervention is ineffective, process should be repeated until resident indicates adequate relieve and/or functional goals are met. .residents who have received PRN (as needed) pain medications more than three times in the last week or having pain scale greater than (7) will be reviewed weekly by Pain Management Committee. Review of CMS-672 provided by the DON on 12/18/17 revealed 36 residents were on pain management program.

Based on observations, interviews and record review the facility failed to ensure that 1 of 6 residents reviewed for accidents. (Resident #1) The facility failed to ensure: a) Resident #1's wheelchair was securely strapped down in the facility's transport van to prevent the wheelchair from tipping over and causing Resident #1 to sustain a cervical neck fracture. Failure to securely strap resident's wheelchairs in the facility's transport van could affect any of the 26 wheelchair bound residents identified as residents that are transported in the facility's van by placing them at risk for harm or injury. The findings: Record review of the Face Sheet dated 11/16/10 Resident #1's date of birth was 04/08/1932 and was a [AGE] year old male who was admitted on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Record review of the Resident Incident Report dated 1/20/12 documented in part that Resident #1 fell in the van. The corresponding "Conclusion and Interventions of Incident, Clinical Assessment of Occurrence" documented, in part: "fall: res's (resident's) wc (wheelchair) turned over while being transported; driver reported that res. had been 'squirming'". The facility documented that Resident #1 hit his head and skin tears were visible. The facility documented they called 911and had Resident #1 taken to the hospital. Record review of the Provider Investigation Report dated 1/21/12 completed by the Administrator documented in the Investigation Summary, in part: "it is proposed that if certain dynamics were aligned at the same time (i.e. loosened tie downs, movement of resident & traveling over a man hole cover) that such would result in the wheel chair tipping over." Record review of the hospital Discharge Instructions dated 1/20/12 documented in part: "the muscles and ligaments in your neck have been stretched and a bone in your neck appears to be broken. This is known as a cervical fracture." Record review of the statement by the Maintenance Supervisor documented in part: "In my opinion, the tie downs may have ratcheted loose due to the resident rustling around. During my inspection of the tie downs, none gave me reason to believe they did not hold as all were in working order." Record review of the Texas Department of Aging and Disability Services Regulatory Services Incident Investigation Worksheet dated 01/21/12 revealed, in part, on 01/20/12 Resident #1 was being transported from the wound care center back to the facility. Resident #1 tipped over in his wheelchair. 911 was called and Resident #1 was transported to the local hospital. Resident #1 sustained a neck fracture, was evaluated a soft collar was placed on Resident #1 and he was returned to the facility. The van driver reported that Resident #1 was secured in his wheelchair even when EMS staff arrived. In an interview on 02/01/12 at 2:10 p.m. with CNA "A" said "I was driving the van and (Resident #1) was in the back of the van and was squirming and complaining that he had diarrhea and it was running down his legs. I started singing to him to try and calm him. All the sudden I heard (Resident #1) call my name so I looked into the rearview mirror and saw (Resident #1) had tipped over and was laying on his right side on the van floor. As soon as I could, I pulled over and stopped the van and went back to check on (Resident #1). (Resident #1's) wheelchair had tipped all the way over on it's right side. The shoulder strap was around (Resident #1's) neck and the lap strap was up around his chest. I didn't hear anything. I don't know how he fell over. The lap strap that goes around the residents hip slips a little bit. (Resident #1) said he didn't know how he fell over but the side of his head hurt." CNA "A" said she unfastened the seat belts after the accident. She said they were stretched down to the side of the wheelchair and she had to push the pink buttons to release the straps. She said the two guys that stopped to help her take Resident #1 out of his wheelchair and they placed him on the van floor. In an interview on 02/01/12 with at 2:20 p.m. the Maintenance Man said everything just malfunctioned at the same time. He said the straps were not long enough to let the wheel chair go to all the way down on its side. Observation on 02/01/12 at 2:20 p.m. the Maintenance Man was securely strapped in a wheelchair and tried to rock the chair over and was unable to knock the wheelchair over. In an interview on 02/01/12 at 3:05 p.m. the Administrator said "we have never had an issue like this before. I can't explain how the accident happened" with Resident #1. She said "the straps must have stretched. It is a puzzlement." In an interview on 02/02/12 at 9:15 a.m. the Administrator said "I made sure a check list of the van is in place. The staff that drive the facility van have to take the time to fill it out. It causes them to stop and think. We only transport one resident at a time so they can focus on that. We ordered the manual lock device for the straps. We had a walk through and we did training." In an interview 02/02/12 at 11:00 a.m. the DON (Director of Nurses) said she received a call from CNA "A" that Resident #1 had fallen; he was lying on the floor of the van; and he had bumped his head. The DON said she told CNA "A" to call 911 so he could be assessed. The DON said the staff called Resident #1's physician and his family and informed them of the accident and that the CNA "A" was with him. The DON said since the incident, the staff had not noticed any changes in Resident #1's mental status or change in his activities of daily living (ADL's). The DON said on Sunday after the incident (incident occurred on 01/20/12 Thursday) he was sent back to the emergency room due his being lethargic. She said Resident #1 was admitted and stayed for five days. He started therapy on Friday after the accident. In an interview/observation on 02/02/12 at 11:45 a.m. the Maintenance Man was strapped in an empty wheelchair in the facility's van and was rocking the wheelchair hard from side to side. The Maintenance Man said there was no way the wheelchair was tipping over. He said "I don't know how it happened with (Resident #1.) I was at a loss of words when (CNA "A") told me that (Resident #1) had tipped over all the way to the right side." In an interview on 02/02/12 at 2:20 p.m. Resident #5 said that the staff put him in the van all the way to the left side of the van and then they put the shoulder and lap strap on. Resident #5 said one time they did not strap him in, "I guess they forgot." In an interview on 02/03/12 at 3:55 p.m. Resident #1's physician said he was told Resident #1 was injured and he thought it was in a motor vehicle accident. The physician said the neuro- surgeon informed the physician that Resident #1 had no difference in head injury from the accident. The Physician said he "just assumed" Resident #1 was injured in a vehicle accident and that he needed to ask more questions. He said the staff did notify him that Resident #1 was injured and sent to the emergency room . He also revealed there had been no changes in Resident #1's mental status or his ADL's. Record review of an unnamed, unsigned and undated document revealed in part: "Resident safety during transport is of vital importance. Therefore, a diagram of proper strapping and a check off list is included in this in-service. The check off list should be completed by the transport driver for each resident with each transport. These completed forms should be handed into the DON for review." Record review of the CT Cervical Spine X-ray report dated 1/20/12 documented "there is a non-displaced fracture of C2 through the base of the odontoid. There is also fracture of the lateral mass of C2 on the left also non-displaced." Record review of the Physical Therapy, PT (Physical Therapy) Evaluation and Plan of treatment dated 01/23/12 documented, in part: "resident referred to PT due to new onset of decrease in strength, decrease I functional mobility, decrease in transfers, reduced balance, reduced functional activity tolerance, decreased coordination, decreased judgment, cognitive deficits, increased need for assistance from others and reduced ADL's participation placing patient at risk for compromised general health, decrease in level of mobility, decreased participation with functional tasks, falls, further decline in function and increase dependency upon caregivers." Record review of an undated statement from the physical therapy department documented, in part: "At the time of discharge from Rehab services in April of 2011, resident demonstrated good dynamic sitting balance with the ability to right self (readjust self in balance challenges) when needed in order to reduce the risk for falls, facilitate upright posture, facilitate weight distribution, and decrease loss of balance during functional mobility." And, "since time of discharge from Rehab services, no changes have been observed to indicate decline in trunk control or strength." Record review of a statement written by the restorative aide documented in part that Resident #1 was capable of balancing and repositioning himself in his wheelchair independently. The Restorative Aide documented Resident #1 was independent or needed one person assistance. Record review of the 1/17/08 "Q'Straint" (the manufacturer) instruction manual documented, in part: " - Inspect your QRT MAX (product name) system regularly " "- Always keep belts clean and off the floor by using Qstraint well pouch (optional) or your own method." "- The QRT MAX system must be replaced if suspected to have been in use during impact or show any sign of damage or excessive wear and tear." "- Occasionally lubricate tie down belt buckles at the hinges being careful not to contaminate the webbing." Record review of the QRT Series User Instructions revised 8/10 documented, in part: "Secure Wheelchair: 1. Place wheelchair facing forward in securement area, apply wheel locks or turn power off. 2. Attach tie-downs into floor anchorage and ensure they are locked in. 3. Attach the four tie-downs hooks to solid frame members of __ILLEGIBLE__ near seat level. Ensure tie downs are fixed at approximately 45 degrees and are within angles shown. Do not attach hooks to wheels, plastic, or parts of wheelchair. 4. Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knots (if present) to take up additional webbing slack." "Secure Passenger: 1. Attach Lap Belt - use integrated stiffeners to feed belts through openings between seat backs and bottom, and/or armrests to ensure proper belt fit around occupant. A. On the aisle side, attach belt with female buckle to rear tie-downs pin connector ensuring buckle rests on passenger ' s hip. B. on the window-side attach belt with tale tongue to rear tie-down pin connector and insert into female buckle 2. Attach Shoulder Belt - extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt. Note: combination lap/shoulder belts serve as both window-side lap belt and shoulder belt. 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort." The facility was given the opportunity to provide any additional information during the exit conference on 02/03/12 and was unable to do so. Record review of the Hall Roster dated 02/01/12 and written by the Administrator documented 26 were identified as residents that are transported in the facility's transport van.

Based on observation record review and interviews, the facility failed to ensure one (Resident #2) of 20 sampled residents received adequate supervision and/or assistive devices to prevent avoidable accidents. 1) Resident #2, who was morbidly obese, with [DIAGNOSES REDACTED]. Resident # 2 sustained a fracture of the left femur (upper leg bone) on 01/05/11. This could affect 66 residents that are dependent and/or required one or two staff assistance for transfers. The findings include: A review of Resident #2's Face Sheet documented Resident #2 was admitted to the facility on [DATE] and had been readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was an [AGE] year old male. A review of Resident #2's Physician order [REDACTED]. A review of Resident #2's Quarterly (MDS) data set [DATE] documented in part Resident #2 had poor short term memory, was incontinent, was on a scheduled pain management program, and scored a 12 (moderate risk for falls) on the Fall Risk Assessment. The Fall Risk Assessment documented in part that a score of 7-14 indicates a moderate risk resident and a care plan is indicated. A review of Resident #2's MDS dated [DATE] documented in part Resident #2 required two person assistance with transfers, one person assistance with grooming, bathing and dressing, and one person assist with setting up meals for Resident #2. A review of Resident #2's Care Plan dated 12/28/10 documented under Problem. Need: Potential for injury from falls R/T (related to) history of falls. Under Approaches: Report all falls to DON (Director of Nurses) and inform family/physician. Check on Resident #2 Q2HRS and PRN. Provide safe environment. Remove environmental hazards: Spill, etc. Keep call light in reach when in room and answer promptly. (Care plan had no direct interventions to implement to prevent falls). A review of Resident #2's Care Plans dated 12/28/10 documented in part Resident #2 required limited to total assistance with ADL's. The care plan did not specify the number of staff to assist Resident #2 with transfers, grooming/dressing, or assistance with meal setup. A review of Resident #2's Care Plans dated 12/28/10 documented in part Resident #2 had poor decision making capabilities related to short term and long term memory loss. A review of Resident #2's Incident Report dated 1/05/11 at 8:45 a.m. documented in part Resident #2 was being transported by CNA "C" to the hall shower room in a shower chair when Resident #2 leaned forward and fell on the shower room floor. Resident #2's left leg was turned outward and Resident #2 complaining of left leg pain. Resident #2 was transported and admitted to a local hospital with a left hip fracture. A review of hospital X-ray results dated 1/05/11 documented in part Resident #2 sustained an impacted left femoral neck fracture with greater trochanter overriding the acetabulum. A review of Incident Witness Statement form dated 1/05/11 documented in part CNA "C" was transporting Resident #2 down the hall to the shower room. CNA "C" documented Resident #2 kept leaning forward and was advised numerous times to lean back. CNA "C" documented once in the shower room Resident #2 again leaned forward and complained the shower chair back rest was hurting his back. CNA "C" advised Resident #2 to lean back in the shower chair. Resident #2 leaned forward again and started to fall. CNA "C" grabbed Resident #2 trying to prevent the fall but Resident #2 fell out of the shower chair onto his back. A review of Resident #2's Nurses Notes documented Resident #2 returned to the facility on [DATE] after having left total hip replacement surgery. A review of Resident #2's Physician order [REDACTED]. Can be full weight bearing on the right, only toe touch weight bearing on the left. (Prior to the fall on 1/05/11 Resident #2 was able to have full weight bearing status). In an interview on 1/25/11 at 8:20 a.m. CNA "C revealed Resident #2 had complained the shower chair was hurting his back and started leaning forward in the shower chair. CNA "C" stated he grabbed Resident #2's shoulders and tried to turn him as he was falling to keep Resident #2 from falling too hard but Resident #2 was "real heavy" and he twisted and hit the floor hard. CNA "C" further stated Resident #2 had a history of [REDACTED]. In an interview on 1/25/11 at 2:30 p.m. CNA "D" and CNA "E" revealed Resident #2 had a history of [REDACTED].#2 complained of back pain and staff had to put pillows behind him while he was up in a wheelchair. CNA "E"stated since the incident Resident #2 now requires total assistance with all ADL's including having to feed Resident #2 and that he was in more pain since the fall. Observations of Resident #2 during wound treatments (surgical wound treatments and pressure sore treatments) on 1/25/11 at 9:50 a.m. revealed Resident #2 with two surgical wound sites with staples to the left hip area. Resident #2 yelled out in pain as nursing staff turned and repositioned Resident #2's legs during the treatment procedures. LVN "F"stated they had given Resident #2 pain medications 45 minutes prior to doing the treatment procedures but it did not control Resident #2's pain. LVN "F" stated she would have wait and re-medicate with pain medications before completing the remaining treatments on Resident #2. Resident #2 was able to answer simple questions but was not able to recall the incident of 1/05/11. In an interview on 1/27/11 at 10:30 a.m. the DON stated prior to Resident #2's fall the facility had implemented therapy and restorative to strengthen Resident #2 while in wheelchair and during transfers but acknowledged Resident #2 was assessed with [REDACTED]. The DON acknowledged Resident #2's care plan did not have any direct interventions implemented to prevent falls and Resident #2's care plan was not updated after the fall. In an interview on 1/27/11 at 10:45 a.m. the manager of the physical/occupational therapy department acknowledged reminding Resident #2 not to lean forward was not an effective intervention due to Resident #2 being assessed with [REDACTED].#2 from leaning forward. The therapy manager also stated the use of two person assist with showers could also be an option to prevent falls. Record Review of the form CMS 672 Resident Census and Conditions of Residents completed by the DON on 1/24/11 revealed there were 66 residents that were dependent and/or required one or two staff for assistance of transfers.