Every finding on record at Capstone Healthcare of Perryton

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #33) of 12 residents reviewed for resident rights.The facility failed to ensure Resident #33's naked bottom was not visible to other residents in the common area as he was wheeled into the facility on [DATE].This failure could place residents at risk of embarrassment, feelings of insecurity, and/or diminished self-esteem.Findings Included:Record review of Resident #33's admission record dated 06/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder (inability to control constant worrying) and acquired absence of right leg above knee.Record review of Resident #33's EHR under the assessments tab revealed he had a BIMS score of 15 which indicated intact cognition.During an observation on 06/24/26 at 03:03 PM AD wheeled Resident #33 into the front door of the facility from the facility van, by the nurses' station, and between four residents seated around the nurses' station. Resident #33 was wearing only a hospital gown and approximately five inches of his naked bottom was visible between the back and seat of his wheelchair. Resident #24 and Resident #28 began laughing loudly and poking each other as AD wheeled Resident #33 past where they were seated. Resident #24 gestured AD over and whispered into AD's ear. AD wheeled Resident #33 to his room and told him she would let the nurse know he had arrived at the facility.During an interview on 06/25/26 at 08:50 AM Resident #24 stated yesterday when she and Resident #28 were laughing and she whispered in AD's ear they were laughing at Resident #33's naked bottom and she was telling AD Resident #33's naked bottom was visible.During an interview on 06/25/26 at 09:01 AM AD stated she was not aware Resident #33's naked bottom was visible as she wheeled him into the facility and past several other residents. She stated she picked Resident #33 up at the hospital and secured his wheelchair in the facility transport van. AD stated, We cannot change him on the van. She stated Resident #24 did not whisper in her ear and tell her Resident #33's bottom was visible from behind his wheelchair.During an interview on 06/25/26 at 09:12 AM HSK stated it was never okay to push a resident in their wheelchair through common areas of the facility when the resident's naked bottom was exposed. She stated it was not treating the resident with dignity and respect. HSK stated, I wouldn't want it done to me.During an interview on 06/25/26 at 09:14 AM Resident #33 stated he was unaware his bottom was visible to other residents when AD wheeled him into the facility for admission. He stated he did not care that other residents saw his naked bottom.During an interview on 06/25/26 at 09:22 AM Resident #28 stated he was laughing with Resident #24 at Resident #33's naked bottom being exposed in the back of his wheelchair.During an interview on 06/25/26 at 09:24 AM CNA A stated it was not okay to wheel a resident through common areas of the facility with the resident's naked bottom exposed. She stated, Not only is that a privacy thing I feel it is more like an identity thing. They wouldn't want to be exposed in front of others.During an interview on 06/25/26 at 09:26 PM CNA B stated it was not okay to wheel a resident through common areas of the facility with the resident's naked bottom exposed. She stated, It . could make them feel insecure, vulnerable, and mentally not well.During an interview on 06/25/26 at 09:28 AM DON stated wheeling a resident through common areas with their naked bottom exposed was a dignity thing.During an interview on 06/25/26 at 09:30 AM CNA C stated wheeling a resident through common areas with their naked bottom exposed was a dignity issue.During an interview on 06/26/26 at 08:34 AM AD stated a new resident admitting to the facility would feel exposed if wheeled through the common areas with their naked bottom showing out the back of their wheelchair.During an interview on 06/26/26 at 08:49 AM ADM stated it was a resident's right to be treated with dignity and not have their naked bottom exposed.Record review of page 21 of the facility's admission packet titled Resident's Rights Nursing Facilities revealed the following: . Dignity and respect You have the right to . Be treated with dignity, courtesy, consideration and respect.Record review of facility policy titled Promoting/Maintaining Resident Dignity and dated 03/01/26 revealed the following, . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 12. Maintain resident privacy.

Based on interview and record review the facility failed to complete a significant change assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for 1 (Resident #5) of 12 residents reviewed for assessments.The facility failed to complete Resident #5's significant change MDS within 14 days of her admission to hospice care on 06/10/26.This failure could place residents at risk of not receiving necessary care/coordination of care.Findings Included:Record review of Resident #5's admission record dated 06/24/26 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her Primary Payer was noted to be Hospice.Record review of Resident #5's EHR under the MDS tab revealed no significant change MDS assessment in the last year.Record review of Resident #5's modification of quarterly assessment revealed it was completed on 06/02/26. Section O Special Treatments, Procedures, and Programs revealed Resident #5 was not receiving hospice services.Record review of Resident #5's care plan completed on 06/07/26 revealed no mention of hospice.Record review of Resident #5's active orders revealed an order for Resident #5 to be admitted to hospice services dated 06/10/26.During an interview on 06/26/26 at 08:40 AM DON stated she was responsible for completing MDS assessments and she used the RAI as the policy she followed when completing MDS assessments. She stated significant change MDS assessments were to be completed within 14 days of the change taking place. DON stated she did not realize she needed to do a significant change MDS for Resident #5 entering hospice care. She stated a possible negative outcome to Resident #5 was her care plan would not accurately reflect her status and the care plan was what helped staff know how to care for the resident.During an interview on 06/26/26 at 08:49 AM ADM stated DON was responsible for completing MDS assessments. She stated if a significant change MDS was not completed within the allotted 14 days the resident's care could be negatively affected.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 revealed a chart on page 38 with the following: Assessment Type.Significant Change.MDS Completion Date.no later than 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Significant Change in Status Assessment . Must be completed (item Z0500B) within 14 days after the determination that the criteria are met for a Significant Change in Status assessment.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #28) of 12 residents reviewed for accuracy of assessment.The facility failed to ensure Resident #28's admission MDS indicated his use of tobacco.This failure could place residents at risk of not receiving necessary care/supervision.Findings Included:Record review of Resident #28's admission record dated 06/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE].Record review of Resident #28's quarterly MDS completed on 03/19/26 revealed a BIMS score of 14 which indicated intact cognition.Record review of Resident #28's admission MDS with an ARD of 07/29/25 revealed it was completed on 07/30/25. Section J Health Conditions revealed Resident #28 did not use tobacco.Record review of Resident #28's care plan completed on 05/09/26 revealed the following problem area initiated on 07/30/25 [Resident #28] is a smoker.Record review of Resident #28's Smoking and Safety evaluation dated 07/22/25 revealed he used tobacco and the evaluation was to be used for his smoking care plan on admission.During an observation and interview on 06/24/26 at 02:28 PM Resident #28 was lying on his back in bed. He stated he was a smoker.During an interview on 06/26/26 at 08:40 AM DON stated she was responsible for completing MDS Assessments and she used the RAI as her policy. She stated an inaccurate MDS assessment could negatively impact resident care. DON stated the reason Resident #28 was not coded as using tobacco on his admission MDS was probably just human mistake.During an interview on 06/26/26 at 08:49 ADM stated DON was responsible for completing MDS assessments. She stated an inaccurate MDS assessment could lead to staff providing inaccurate care to the resident.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 revealed the following: SECTION J: HEALTH CONDITIONS . The intent of the items in this section is to document a number of health conditions that impact the resident's functional status and quality of life. Other items in the section assess. tobacco use . J1300: Current Tobacco Use Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If they resident states they used tobacco in some form during the 7-day look-back period, code 1, yes. 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period.

Based on interview and record review, the facility failed to report an alleged violation of misappropriation immediately, but not later than 24 hours after the allegation is made, if the events that cause the allegation did not involve abuse or result in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for 1 of 1 facilities reviewed for misappropriation. The facility failed to report to the State Survey Agency when money went missing from a Resident's room. This could place at risk of missing property being reported to the State Agency.Findings included: During an interview on 02/19/26 at 1:04 p.m., the ADM stated that she was on vacation when the resident money went missing. She stated she was notified of the incident when she returned on 1/5/26. She said the resident and DON told her about the missing money, and she then reported the incident on 1/5/26 and thoroughly investigated it at that time. She stated the incident was reported late, but she was not in the facility when the incident occurred, and the DON was responsible for reporting to the State Agency during her absence. The ADM stated the DON knew how to report incidents to the State Agency and it was her responsibility to report incidents to the State Agency when the administrator was not available. During an interview on 02/19/26 at 1:10 p.m., the DON stated that it was the ADM and her responsibility to report incidents regarding abuse, neglect, or misappropriation of property. She stated she did not report the missing money on 12/29/25, the day it went missing. The DON stated she should have reported the incident but she was hoping the money would be found. Record review of PP call sheet report dated 01/05/26 with call number 26-00062 documented the reporting person was the ADM for a theft on 01/05/26. Record review of the facility provided provider investigation report dated 01/11/26 revealed the following:Incident date: 12/29/25Date Reported to HHSC: 01/05/26 at 8:12 PM Record review of facility provided policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, revealed the following in part.Residents have the right to be free from abuse, neglect misappropriation of resident property and exploitation. 9. Investigate and report any allegations within timeframes required by federal requirements. Record review of facility provided policy titled Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating, revised date of September 2022 revealed the following in part .All reports of resident abuse, neglect, exploitation, ore theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). 3. immediately is defined as: a. within 2 hours of an allegation involving abuse or result in serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

46534 Based on observation, interview, and record review the facility failed to assess the resident for risk of entrapment from bedrails and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 7 (Resident #10, Resident #11, Resident #13, Resident #15, Resident #16, Resident #69, and Resident #119) of 14 residents reviewed for bed rails. The facility failed to assess Resident #10, Resident #11, Resident #13, Resident #15, Resident #16, Resident #69, and Resident #119 for risk of entrapment prior to installing bed rails. The facility failed to obtain informed consent for bed rails from Resident #10, Resident #11, Resident #13, Resident #15, Resident #16, Resident #69, and Resident #119 or their resident representatives prior to installing bed rails. These failures could place residents at risk of injury or death. Findings Included: 1. Record review of Resident #10's admission record dated 04/08/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, epilepsy (disorder that causes abnormal brain function, uncontrolled body movement), syncope and collapse (sudden temporary loss of consciousness due to a drop in blood flow to the brain), mixed incontinence and unspecified dementia (breakdown of thought process). Record review of Resident #10's admission MDS completed on 02/04/25 revealed a BIMS of 3 which indicated severely impaired cognition. Resident #10 was noted to be dependent or require substantial/maximal assistance with transfers, dressing, hygiene, bathing, and toileting. The MDS did not mention use of bed rails. Record review of Resident #10's care plan completed on 03/19/25 revealed she had a diagnosis of epilepsy. The care plan contained no mention of bed rails. Record review of Resident #10's active orders dated 04/07/25 revealed no order for bed rails. Record review of Resident #10's EHR revealed no consent or assessment for bed rails. During an observation on 04/07/25 at 12:01 PM Resident #10 was lying in bed, eyes closed. She had bilateral 1/8 bed rails upright at the top of her bed. During an observation on 04/07/25 at 01:47 PM Resident #10 was lying in bed, eyes closed. She had bilateral 1/8 bed rails upright at the top of her bed. During an observation on 04/08/25 at 08:11 AM Resident #10 was lying in bed with eyes closed. She had bilateral 1/8 bed rails upright at the top of her bed. 2. Record review of Resident #11's admission record dated 04/07/25 revealed a [AGE] year-old female admitted to the facility originally on 07/22/24 and readmitted on [DATE] with diagnoses to include presences of left artificial knee joint, diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), dementia (a group of thinking and social symptoms that interferes with daily functioning),, weakness, overweight, and rheumatoid arthritis rheumatoid arthritis (autoimmune inflammation of the joints). Record review of Resident #11's quarterly MDS completed on 01/29/2025 revealed a BIMS of 15 which indicated intact cognition. Resident #11 required substantial/maximal assistance with most activities of daily living. Record review of Resident #11's care plan completed 03/04/25 revealed she had a history of seizure disorder. The care plan contained no mention of bed rails. Record review of Resident #11's order summary report with print date of 04/08/25 revealed no orders for bedrails. Record review of Resident #11's EHR revealed no consent for the use of bedrails present in the clinical record. During an observation and interview on 04/07/25 at 11:15 AM Resident #11 was noted to have bilateral 1/8 bedrails up and locked in place. Resident #11 reported she used the bed rails to move around in bed and that she knew how to use them. Resident #11 could not remember if she had been trained on the bed rails by the facility. 3. Record review of Resident #13's admission record dated 04/07/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include unspecified fracture of the sacrum (a triangular bone at the base of the vertebral column, formed by the fusion of the five sacral vertebrae), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), unspecified fracture of the pubis (forms the lower and anterior part of each side of the hip bone), unspecified fall, neuromuscular dysfunction (a diverse group of conditions that impact the nerves that control voluntary muscles), and morbid obesity. Record review of Resident #13's quarterly MDS completed on 02/05/2025 revealed a BIMS of 8 which indicated moderate cognitive impairment. Resident #13 required substantial/maximal assistance with most activities of daily living. Record review of Resident #13's care plan completed on 03/04/25 revealed no mention of bed rails. Record review of Resident #13's order summary report with print date of 04/08/25 revealed no orders for bedrails. Record review of Resident #13's EHR revealed no consent for the use of bedrails present in the clinical record. During an observation and interview on 04/07/25 at 10:59 PM Resident #13 was noted to have bilateral 1/8th bedrails up and locked in place. When questioned about the use of the rail and if she had been informed and trained by the facility on the use of the bed rails Resident #13 stated, I don't know. Resident #13 stated, I don't know to all questions asked. 4. Record review of Resident #15's admission record dated 04/07/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, repeated falls, and muscle weakness. Record review of Resident #15's quarterly MDS completed on 04/02/25 revealed a BIMS of 00 which indicated severely impaired cognition. Resident #15 was noted to be dependent or require substantial maximal assistance across most of her activities of daily living. The MDS did not mention use of bed rails. Record review of Resident #15's care plan completed on 04/04/25 revealed Resident #15 requested the use of grab bars as an enabler to aide in bed mobility and transfers. Record review of Resident #15's active orders dated 04/08/25 revealed no order for bed rails. Record review of Resident #15's EHR revealed no consent or assessment for bed rails. During an observation on 04/08/25 at 08:24 AM Resident #15 was lying in bed with bilateral 1/8 bed rails in upright position on the top of her bed. During an observation on 04/08/25 at 09:32 AM Resident #15 was noted to have bilateral 1/8 bed rails in upright position on her bed. 5. Record review of Resident #16's admission record dated 04/07/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, conversion disorder with seizures or convulsions, and muscle weakness. Record review of Resident #16's MDS completed 01/14/25 revealed a BIMS of 00 which indicated severely impaired cognition. Resident #16 needed extensive assistance with bed mobility and supervision across most other activities of daily living. The MDS did not mention bed rail use. Record review of Resident #16's care plan completed on 04/04/25 revealed he had impaired physical mobility and was at risk for seizure activity. Record review of Resident #16's active orders dated 04/08/25 revealed no order for bed rails. Record review of Resident #16's EHR revealed no consent or assessment for bed rails. During an observation on 04/07/25 at 01:43 PM Resident #16 was noted to have bilateral 1/8 bed rails in upright position on the top of his bed. 6. Record review of Resident #69's admission record dated 04/07/25 revealed a [AGE] year-old female admitted to the facility originally on 02/06/25 and readmitted on [DATE] with diagnoses to include malignant neoplasm of the pancreatic duct (caner that begins in the organ lying behind the lower part of the stomach), myocardial infarction (heart attack), and arthritis (swelling and tenderness in one or more joints casing joint pain or stiffness that often gets worse with age). Record review of Resident #69's admission MDS completed on 02/11/2025 revealed a BIMS of 13 which indicated intact cognition. Resident #69 required supervision/touching assistance with most activities of daily living. Record review of Resident #69's care plan completed on 03/19/25 revealed no mention of bed rails. Record review of Resident #69's order summary report with print date of 04/08/25 revealed no orders for bedrails. Record review of Resident #69's EHR revealed no consent for the use of bedrails present in the clinical record. During an observation and interview on 04/07/25 at 11:07 AM Resident #69 had bilateral 1/8 bedrails that she reported she sometimes used to get in and out of bed and for positioning. Resident #69 had been advised by therapy on how to use them. 7. Record review of Resident #119's admission record dated 04/07/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), obesity (complex disease involving having too much body fat), seizures (sudden abnormal electrical activity in the brain affecting muscle control resulting in uncontrolled body movement), and altered mental status. Record review of Resident #119's EHR revealed he did not have an admission MDS completed. Record review of Resident #119's baseline care plan completed by RN C on 03/31/25 revealed a diagnosis of seizures. Resident #119 was noted to require two or more person assist for bed mobility and transfer. He was noted to be always incontinent of bowel and bladder and to be cognitively intact. The care plan contained no mention of bed rails. Record review of Resident #119's active orders dated 04/07/25 revealed no order for bed rails. Record review of Resident #119's progress notes revealed no mention of a BIMS or of bed rails. Record review of Resident #119's EHR revealed no consent or assessment for bed rails. During an observation on 04/07/25 at 12:00 PM Resident #119 was lying in bed with eyes closed. He had full bed rails in upright position along both sides of his bed. During an observation on 04/07/25 at 01:45 PM Resident #119 was lying in bed with eyes closed. He had full bed rails in upright position along both sides of his bed. During an interview on 04/07/25 at 06:06 PM Resident #119's family member stated no one from the facility talked to her about the bed rails or had her sign a consent. She stated, I told them I would sign one (a consent), but they (bed rails) were up when I got here (to facility). But I'll go sign it (consent). During an observation on 04/08/25 at 08:06 AM Resident #119 was lying in bed with eyes closed. He had bilateral 1/2 bed rails in upright position. During an observation and interview on 04/08/25 at 09:05 AM DON was given a list including Resident #10, Resident #11, Resident #13, Resident #15, Resident #16, Resident #69, and Resident #119 and asked for consents and assessments for bed rails. DON took the list, looked at it, and stated, Okaaay . During an interview on 04/08/25 at 09:25 AM DON stated the facility did not have consents and assessments for bed rails for Resident #10, Resident #11, Resident #13, Resident #15, Resident #16 and Resident #69 because they had turn bars only. She stated when the facility was recently purchased by a new company and that company told the facility the 1/8 bed rails were turn bars and did not need consents and assessments. When told 1/8 bed rails qualify as bed rails, DON stated, I can go do them (consents and assessments) all right now, but we don't have them (consents and assessments). DON did provide a consent and assessment for Resident #119's bed rails signed by Resident #119's family member on 03/31/25 and witnessed by DON on 03/31/25. During an interview on 04/08/25 at 10:27 AM DON was asked if she back dated the consent and assessment for Resident #119's bed rails due to Resident #119's family member stating on 04/07/25 that she had not signed a consent for bed rails. DON stated, Yes, I did. During an interview on 04/09/25 at 08:06 AM RN B stated nursing staff was responsible to assess residents for bed rail use when they come for admission. She stated if the RN, DON and doctor all agree the resident may have bed rails. She stated DON was responsible for completing assessments for bed rails and getting consents signed for bed rails. RN B stated if a resident was not assessed for bed rails prior to installation, It can cause a fall or injury. We need to do less restrictions and try to work with the resident. Use that (bed rails) as last resort. She stated a resident with dementia might be more at risk for injury from bed rails because they don't see the danger. During an interview on 04/09/25 at 08:13 AM DON stated she was the one usually responsible for doing bed rail assessments and getting bed rail consents signed. She stated a resident could be negatively impacted if bed rails were installed prior to assessment and consent. DON stated, Because we have to go over benefits and risks of side rails and if they are not aware of those it can be an issue. Also, because we are supposed to use the lowest intervention with them (residents), and the assessment will show if we can get rid of them (bed rails). During an interview on 04/09/25 at 08:20 AM CNA A stated if a resident had bed rails installed prior to being assessed for bed rail safety it could negatively impact the resident. She stated, It would be important to see how they are, if they are combative or a fall risk would need to be discussed with the family. During an interview on 04/09/25 at 08:38 AM ADM stated nursing was responsible for ensuring assessments and consents for bed rails were complete prior to installation. She stated a resident could become entrapped in the bed rails if they were not properly assessed for bed rail safety. Record review of Resident #119's Bed Rail/Assist Bar Evaluation provided on 04/08/25 by DON and dated 03/31/25 revealed the following: 1. Resident #119's family requested bedrails, 2. Resident #119 had fluctuations in levels of consciousness or cognitive deficit 3. Resident #119 had visual deficits 4. Resident #119 was unable to get out of bed 5. Resident #119 was unable to get out of bed safely 6. Resident #119 had a history of falls 7. Resident #119 had problems with balance or poor trunk control 8. Resident #119 did not use the bed rails for positioning or support 9. The bed rails did not help Resident #119 rise from lying to sitting or standing 10. Resident #119 had not history of postural hypotension 11. There was no possibility Resident #119 would climb over the bed rails 12. There was no evidence Resident #119 had or would have the desire or reason to get out of bed 13. Resident #119 received antihypertensive medication which would require safety precautions. 14. There was no risk to Resident #119 if bed rails were used 15. Alternatives to bed rails did not create more risks than bed rails use to Resident #119. For questions 2, 3, and 7 of the Bed Rail/Assist Bar Evaluation no explanation was provided in spite of a request for explanation and lines upon which to write said explanation. The Bed Rail/Assist Bar Evaluation form did not indicate who filled it out. Record review of Resident #119's Resident/Legal Representative Education and Consent for Bedrails provided on 04/08/25 by DON revealed the following: Resident Name: (Resident #119's name was written on the line provided) Date: (3/31/25 was written on the line provided) Bed rails are used by many people to help create a supportive and assistive sleeping environment in nursing home facilities. This type of equipment has many commonly used names, including: side rails, bed side rails, half rails, safety rails, bed handles, assist bars, grab bars, hospital rails, and adult portable bed rails. Residents who are considered frail, agitated, have delirium, confusion, pain, uncontrolled body movement, hypoxia, elimination issues, or sleep disturbances are potentially at risk to receive injury with the use of bed rails. A nursing home shall provide bed rails to a resident only upon receipt of a signed consent form authorizing bed rail use and an order from the resident's attending physician. I am responsible for the medical treatment decisions of the above named resident. I have been advised that I may request that bed rails be installed on the resident's bed. The risk and benefits to using bedrails, as they apply to this resident's particular condition and circumstance, have been clearly explained to me. It is my understanding that the Facility will periodically review and re-evaluate the resident's need for bed rails and that the resident, responsible party and attending physician will be consulted in this matter. With all the above information in mind, I consent to the installation and utilization of bed rails for the care of the above named resident, consistent with the orders of the attending physician. I understand this authorization is revocable, except to the extent of those actions already taken. Signature: (Resident #119's family member's name was written on the line provided) Date: (3/31/25 was written on the line provided) Witness: (DON's name was written on the line provided) Date: (3/31/25 was written on the line provided) Record review of undated paperwork titled Bed Rail Entrapment Risk Notification and provided by DON on 04/08/25 revealed the following: .Failure to comply with the information contained in this Bed Rail Entrapment Risk Notification Guide can result in serious injury or death. The term 'Bed Rail Entrapment' describes an event in which a patient using the bed is caught, trapped, or entangled in the space in or about the bed rail, mattress, or bed frame. Bed Rail Entrapment may result in serious injuries or death by the patient becoming entrapped . Bed Rail Entrapment is a known risk in the use of bed's equipped with bed rails. Only the patient's medical care provider is familiar with the patient's unique medical condition and needs. Only the patient's medical care provider . upon proper assessment of the patient's medical condition and needs can evaluate whether this equipment is appropriate for use by any particular patient and assist the patient, the patient's family . in assessing the Risk of Entrapment. Proper patient assessment, equipment selection, frequent patient monitoring, and compliance with instructions, warnings and this Bed Rail Entrapment Risk Notification Guide is essential to reduce the risk of entrapment. Conditions such as restlessness, mental deterioration and dementia or seizure disorders (uncontrolled body movement), sleeping problems, and incontinence can significantly impact a patient's risk of entrapment. Record review of facility policy titled Proper Use of Side Rails and dated December 2016 revealed the following: .2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 6. Less restrictive interventions that will be incorporated in care planning include: a. Providing restorative care to enhance abilities to stand safely and to walk; b. Providing a trapeze to increase bed mobility; c. Placing the bed lower to the floor and surrounding the bed with a soft mat; d. Equipping the resident with a device that monitors attempts to arise; e. Providing staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom; and/or f. Furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 47159

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen(s) reviewed for food safety. The facility failed to ensure all foods in the freezer were properly sealed, labeled and dated. The facility failed to ensure all foods in the refrigerator were properly sealed, labeled and dated. The facility failed to ensure all foods in the dry pantry were properly sealed, labeled and dated. These failures could place residents at risk of food-borne illness, diminished nutritional value and a reduced quality of life. Findings included: On [DATE] at 10:41AM an initial observation of the kitchen was conducted, and the following was noted: 10:45AM freezer observation: (4) 12-count bags of breaded shrimp with no label and no date., (9) hamburger buns and (3) hoagie rolls, in a plastic bag, open to air, with no label and no date opened. 11:22AM refrigerator observation: One zip-style bag of thawed ground beef with no label and a date of [DATE], One zip-style bag of sliced bologna luncheon meat with no label and a date of [DATE], One zip-style bag of sliced ham with no label and a date of [DATE], One 1-gallon container of cheese sauce with no label and no date opened. 11:42AM dry pantry observation: (4) [NAME] cracker pie crusts with an expiration date of [DATE], (3) 0.13-ounce packages lemon-lime Kool-Aid drink mix with an expiration date of [DATE], One partial 1-gallon container of soy sauce with an opened dated of [DATE], ,d+[DATE] loaf white sandwich bread, open to air, with no date opened, (1) 5-pound package quick white grits with a best by date of [DATE], (1) partial 12-ounce bag of semi-sweet chocolate chips in a zip-style bag labeled [NAME] Sugar, (1) partial 8-ounce bag of sugar-free lemon pudding mix with an expiration date of [DATE], (1) 20-ounce bottle of caramel sundae syrup with an expiration date of [DATE], (1) partial 25-pound bag of seasoned breadcrumbs, open to air, (1) partial 5-gallon bucket of confectioners' sugar with no date received. An interview with the DM on [DATE] at 1:11PM reflected the negative outcome of residents eating foods which were not labeled and dated, open to air or expired was they could become sick if they ate foods which were expired and the quality of foods might deteriorate, if left open to air or if not served by the use by date. The DM stated he conducted in-services regarding food storage and food safety and the last in-service had been earlier this month or at the end of [DATE], although he could not produce the date or material used for the in-services. Record Review of facility policy for Food Receiving and Storage dated [DATE] reflected the following: Refrigerated/Frozen Storage: 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date), 2. Refrigerated foods are labeled, dated, and monitored so they are used by their use by date, frozen or discarded, 3. Other opened containers are dated and sealed or covered during storage. Dry Food Storage: 1. Dry foods and goods are handled and stored in a manner that maintains the integrity of packaging until they are ready to use, 2. Dry foods that are stored in bins are removed from original packaging, labeled, and dated (use by date). Record Review of the posted, undated kitchen charts from FoodSafety.gov reflected the following: Cold Storage Foods: Luncheon meat in an opened package or deli sliced shall be refrigerated for no more than ,d+[DATE] days and then discarded, Hamburger, ground meats, and ground poultry shall be refrigerated for no more than ,d+[DATE] days and then discarded, Ham, fresh, cured, or uncured, and cooked shall be refrigerated for no more than ,d+[DATE] days and then discarded, Shrimp, frozen, shall be used within ,d+[DATE] months and then discarded. There was no chart for refrigerated cheese sauce or frozen bread products. Dry Storage Staples: Bread, once opened, shall be discarded after one day, Breadcrumbs shall be stored in a cool, dry place in an airtight container, used within 6-months, and then discarded, Chocolate, semi-sweet shall be used within 18-months, and then discarded, Confectioners' sugar shall be stored in a cool, dry environment. Once opened, store in an air-tight container, use within 18-months, and then discarded, Graham cracker pie shells shall be kept dry and covered, used within 6-months, and then discarded, Grits shall be used within 12-months and then discarded, Lemonade, fruit punch mix (powdered drink mixes) shall be used within ,d+[DATE] months, and then discarded, Soy sauce, once opened, shall be used within 9-months, and then discarded, Syrups shall be used within 12-months, and then discarded. There was no chart for dry pudding mix.

Based on interviews and record reviews the facility failed to ensure each resident had the right to reasonable access to the use of a telephone, and a place in the facility where calls can be made without being overheard, and the right to promptly receive unopened mail and other letters and the privacy of such communication for 4 of 4 residents (Resident #s 3, 4, 7 and 11) reviewed for resident rights. The facility failed to ensure that Residents #3, #4, #7 and #11 had access to a telephone where personal calls could be made without being overheard. The facility failed to ensure that Residents #3, #4, #7 and #11 promptly received unopened mail and other letters. These failures could place residents at risk of frustration, a reduced confidence in administration and a decrease in resident rights. Findings included: During an interview on 04/08/2025 at 2:30PM, in the Resident Council meeting, Resident #7 stated the facility did not have a place for residents to have a private telephone conversation without being overheard. Resident #7 stated the facility had a corded landline telephone which sat on a folding chair near the entrance of the facility, that could be used by residents. Resident #7 stated the telephone sat outside the office door of one staff member and if the door was open, conversations could be easily overheard. Resident #7 stated community and family members also entered and exited through the front door of the facility where conversations could be easily overheard. Resident #11 stated not all residents had cellular phones to use in their rooms. Resident #11 stated her cell phone was not currently working, so she had no other means of private communication. She stated most residents also had a roommate who could have overheard private conversations. Resident #7 stated residents did not receive mail on the weekend. He stated he had been told by weekend staff they were not allowed to retrieve mail from the mailbox in front of the facility; only core staff were allowed to retrieve mail, so any mail delivered over the weekend, was not distributed until the following Monday when core staff returned to the building. Residents #s 3 and 4 agreed both issues existed within the facility. An observation was made immediately after the adjournment of the Resident Council meeting at 2:32PM, of the corded landline telephone on a folding chair by the facility's front door and the open staff door near the telephone. Both confirmed Resident #7's statements. An interview with the AD on 04/09/2025 at 1:25PM reflected she was unaware there was not a place for residents to conduct a private phone call. She stated she had not asked the Resident Council members about private phone calls in any of their meetings. The AD stated she would ask the Administrator about the purchase of a cordless phone, which could be left at the nurse's station and checked out by residents to privately use in their rooms or another part of the facility. She stated she had never thought about the fact that private communications were not available to all residents and understood not all residents had cellular phones. The AD stated she was unaware residents were not receiving mail on the weekend. She stated she had not asked the Resident Council members about receiving mail on the weekend. She was not aware residents had been told by weekend staff members that only core staff was allowed to retrieve the mail from the mailbox in front of the facility. The AD stated she would ask the Administrator about the residents being told only core staff could retrieve the mail and would ensure weekend staff were aware they were allowed to retrieve and distribute mail to the residents. Record Review of facility policy for Evening, Night, Weekend and Holiday Operations dated February 2021 reflected the following: 1. During the hours that management is absent from the facility (i.e., evening and night shifts, weekends, and holidays), the nurse supervisor or charge nurse shall be responsible for the overall operation of the facility including the supervision and management of nursing services activities. Review of facility policy for Resident Rights dated April 2019 reflected the following: Residents of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the Constitution and laws of this state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal in exercising these rights as citizens of the United States. Privacy and Confidentiality You have the right to: 1. Privacy, including privacy during visits, telephone calls and while attending to personal needs. 2. Send and receive unopened mail and receive help in reading or writing correspondence, at all times.

Based on observations, interviews, and record reviews the facility failed to assess residents in a way that accurately reflected the resident's functional status for 2 of 14 residents (Resident # 5 and Resident #15) reviewed for accuracy of assessment. The facility failed to assess Resident #5 and Resident #15's ability to feed themselves with only set up help provided by facility staff. This failure could place residents at risk of a reduced level of daily caloric intake, a decline in overall health and well-being and an undesired decrease in weight. Findings included: 1. Record review of Resident #15's clinical records reflected a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnoses of Unspecified Protein-Calorie Malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands), Type 2 Diabetes Mellitus without complications, Generalized Muscle Weakness (muscle weakness due to lack of exercise, ageing, muscle injury or pregnancy), Nutritional Anemia (the body's failure to produce enough hemoglobin or enough red blood cells), Unspecified, Depression ( a mental health condition where someone displays depressive symptoms, but there is not enough information for a specific diagnosis), Unspecified, Carrier or Suspected Carrier of Methicillin Resistant Staphylococcus Aureus (staph infection bacteria you still have on your skin and in your nose that is resistant to most antibiotics), and Old Myocardial Infarction (heart attack). Record review of Resident #15's annual MDS dated [DATE] reflected Resident #15 needed only setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, which indicated the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Record review of Resident #15's dietary orders dated 07/16/2024 reflected regular diet, mechanical soft texture, regular consistency related to dysphagia (swallowing difficulty). Review of Resident #15's supplement orders dated 03/14/2025 reflected Glucerna high-protein drink, 3-times per day and Megestrol Acetate oral suspension; 10 milligrams by mouth 1-time daily for appetite stimulation. Record review of Resident #15's care plan dated 04/04/2025 reflected Resident #15 had a self-care deficit related to bathing, dressing, and feeding. The goal was the resident would participate in self-care activities, and the intervention was encourage resident to participate in planning day-to-day activities, evaluate resident's ability to perform ADLs/IADLs (Activities of Daily Living/Instrumental Activities of Daily Living), maintain consistent schedule with daily routine, minimize environmental stimuli, and provide assistance with ADLs/IADLs as needed. An interview with Resident #15's RR on 04/08/2025 at 8:17AM revealed he came to the facility every morning and fed Resident #15 her breakfast. The RR stated CNA E fed Resident #15 lunch and dinner, because she was too weak to sit completely upright in bed to feed herself and did not like to go to the dining room. The RR stated CNA E watched out for Resident #15 in a very special way and he was grateful for her care of Resident #15. An interview with CNA E on 04/08/2025 at 9:04AM, reflected she cared for Resident #15 very much and was glad to perform her lunch and dinner feedings. CNA E stated Resident #15 was not a good eater and had begun to pocket food in her cheeks. She stated Resident #15 had also choked from time-to-time, as her dysphagia progressed. An interview with the DON on 04/08/2025 at 1:43PM revealed Resident #15 had recently started needing assistance with feedings. She was unable to recall how long ago the feeding assistance began. She stated she should have updated Resident #15's MDS and care plan to reflect the changes in her eating abilities. A phone interview with the CN on 04/08/2025 at 5:28PM revealed Resident #15's MDS from 03/19/2025 had not been coded correctly by the DON to reflect Resident #15's functional abilities. She stated she had not spoken with the DON regarding Resident #15. The CN stated Resident #15 had swallowing difficulties and pocketed food in her cheeks. She also choked occasionally related to her diagnosis of Dysphagia. This writer told her I had spoken with Resident #15's RR and CNA E and they both assisted with her feeding, due to her inability to completely sit upright, her lack of desire to go to the dining room and the inability to feed herself, due to weakness. The CN stated the source used for documentation of a resident's abilities was the RAI (Resident Assessment Instrument) and there was no other facility-based assessment tool. 2. Record review of Resident #5's clinical records reflected a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Bipolar Disorder (a mental health condition that causes extreme mood swings), Unspecified, Moderate Intellectual Disabilities (persons having an Intelligence Quotient {IQ} between 35 and 39 and are slow in the understanding and use of language) , Need for Assistance with Personal Care, Generalized Anxiety Disorder (excessive, on-going anxiety and worry that are difficult to control), Intermittent Explosive Disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts), Drug-induced Subacute Dyskinesia (a drug-induced movement disorder in which sudden, uncontrollable, and repeated movements happen in the face and body due to the prolonged use of medication, typically antipsychotics), Impulse Disorder (a group of behavioral conditions that make it difficult to control your actions or reactions), and Personal History of Poliomyelitis (an infectious disease caused by the poliovirus which affects nerves in the spinal cord and/or brain stem and can cause paralysis or death), and Type 2 Diabetes Mellitus without complications. Record review of Resident #5's Quarterly MDS dated [DATE] reflected Resident #5 needed only setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, which indicated the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Record review of Resident #5's care plan dated 01/25/2025 reflected Resident #5 had a self-care deficit related to bathing, dressing, and feeding. The goal was the resident would participate in self-care activities, and the intervention was encourage resident to participate in planning day-to-day activities, evaluate resident's ability to perform ADLs/IADLs (Activities of Daily Living/Instrumental Activities of Daily Living), maintain consistent schedule with daily routine, minimize environmental stimuli, and provide assistance with ADLs/IADLs as needed. Record review of Resident #5's dietary orders dated 04/05/2025 reflected the following: No Added Salt (NAS)/Low Concentrated Sweets (LCS) diet, Puree texture, Nectar consistency related to dysphagia (swallowing difficulty). May use built-up silverware to assist with feeding self. An interview with CNA E on 04/09/2025 at 12:45PM, revealed Resident #5 was unable to feed himself. CNA E stated Resident #5 required a pureed diet due to pocketing food in his cheeks and choking occasionally related to his progressing dysphagia. She stated Resident #5 was unable to eat a pureed diet with built-up utensils due to its consistency and she had not seen built-up utensils on his food trays, for an undetermined amount of time. An interview with the DON on 04/09/2025 at 1:43PM, revealed Resident #5 had recently started needing assistance with feedings. She was unable to recall how long ago the feeding assistance began. The DON stated she thought Resident #5 only had an order for a divided plate, but upon reviewing his physician orders, stated there was not an order for a divided plate, but for built up utensils. She was not aware if Resident #5 was being provided with built up utensils or that Resident #5 was a full-assist with his eating capabilities. She stated she should have updated Resident #5's MDS and care plan to reflect the changes in his eating abilities. A phone interview with the CN on 04/09/2025 at 1:58PM, revealed Resident #5's MDS from 03/19/2025 had not been coded correctly by the DON to reflect Resident #5's functional abilities. She stated she had not spoken with the DON regarding Resident #5. The CN stated Resident #5 had swallowing difficulties and pocketed food in his cheeks related to a diagnosis of dysphagia and ID/DD. The CN stated the source used for documentation of a resident's abilities was the RAI (Resident Assessment Instrument) and there was no other facility-based assessment tool. Record Review of the RAI reflected clinicians are generally taught a problem identification process as part of their professional education. For example, the nursing profession's problem identification model is called the nursing process, which consists of assessment, diagnosis, outcome identification, planning, implementation, and evaluation. All good problem identification models have similar steps to those of the nursing process. The RAI simply provides a structured, standardized approach for applying a problem identification process in nursing homes. The RAI should not be, nor was it ever meant to be, an additional burden for nursing home staff. The completion of the RAI can be conceptualized using the nursing process as follows: a. Assessment-Taking stock of all observations, information, and knowledge about a resident from all available sources (e.g., medical records, the resident, resident's family, and/or guardian or other legally authorized representative). b. Decision Making-Determining with the resident (resident's family and/or guardian or other legally authorized representative), the resident's physician and the interdisciplinary team, the severity, functional impact, and scope of a resident's clinical issues and needs. Decision making should be guided by a review of the assessment information, in-depth understanding of the resident's diagnoses and co-morbidities, and the careful consideration of the triggered areas in the CAA process. Understanding the causes and relationships between a resident's clinical issues and needs and discovering the whats and whys of the resident's clinical issues and needs; finding out who the resident is and consideration for incorporating his or her needs, interests, and lifestyle choices into the delivery of care, is key to this step of the process. c. Identification of Outcomes-Determining the expected outcomes forms the basis for evaluating resident-specific goals and interventions that are designed to help residents achieve those goals. This also assists the interdisciplinary team in determining who needs to be involved to support the expected resident outcomes. Outcomes identification reinforces individualized care tenets by promoting the resident's active participation in the process. d. Care Planning-Establishing a course of action with input from the resident (resident's family and/or guardian or other legally authorized representative), resident's physician and interdisciplinary team that moves a resident toward resident-specific goals utilizing individual resident strengths and interdisciplinary expertise; crafting the how of resident care. e. Implementation-Putting that course of action (specific interventions derived through interdisciplinary individualized care planning) into motion by staff knowledgeable about the resident's care goals and approaches; carrying out the how and when of resident care. f. Evaluation-Critically reviewing individualized care plan goals, interventions, and implementation in terms of achieved resident outcomes as identified and assessing the need to modify the care plan (i.e., change interventions) to adjust to changes in the resident's status, goals, or improvement or decline. The following pathway illustrates a problem identification process flowing from MDS (and other assessments) to the CAA decision-making process, care plan development, care plan implementation, and finally to evaluation. This manual will refer to this process throughout several chapter discussions. If you look at the RAI process as a solution oriented and dynamic process, it becomes a richly practical means of helping nursing home staff gather and analyze information in order to improve a resident's quality of care and quality of life. The RAI offers a clear path toward using all members of the interdisciplinary team in a proactive process. There is absolutely no reason to insert the RAI process as an added task or view it as another layer of labor. The key to successfully using the RAI process is to understand that its structure is designed to enhance resident care, increase a resident's active participation in care, and promote the quality of a resident's life. This occurs not only because it follows an interdisciplinary problem-solving model, but also because staff (across all shifts), residents and families (and/or guardian or other legally authorized representative) and physicians (or other authorized healthcare professionals as allowable under state law) are all involved in its hands on approach. The result is a process that flows smoothly and allows for good communication and tracking of resident care.

Based on observation, record review, and interview the facility failed, in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #119) of 14 residents reviewed for medical records. The facility failed to ensure the DON did not back date a consent for bedrails for Resident #119. This failure could place residents at risk of receiving inaccurate care/treatment due to inaccurate records. Findings Included: Record review of Resident #119's admission record dated 04/07/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), obesity (complex disease involving having too much body fat), seizures (sudden abnormal electrical activity in the brain affecting muscle control), and altered mental status. Record review of Resident #119's EHR revealed he did not have an admission MDS completed. Record review of Resident #119's progress notes from 03/31/25 to 04/08/25 revealed no mention of a BIMS or of bedrails. Record review of Resident #119's active orders dated 04/07/25 revealed no order for bedrails. Record review of Resident #119's baseline care plan completed by RN C on 03/31/25 revealed no mention of bedrails. Record review of Resident #119's EHR under the Assessments tab revealed no consent or assessment for bedrails. Record review of Resident #119's EHR under the Documents tab revealed no consent or assessment for bedrails. During an observation on 04/07/25 at 12:00 PM Resident #119 was lying in bed with eyes closed. He had full bed rails in upright position along both sides of his bed. During an observation on 04/07/25 at 01:45 PM Resident #119 was lying in bed with eyes closed. He had full bed rails in upright position along both sides of his bed. During an interview on 04/07/25 at 06:06 PM Resident #119's family member stated no one from the facility talked to her about the bed rails or had her sign a consent. She stated, I told them I would sign one (a consent), but they (bed rails) were up when I got here (to facility). But I'll go sign it (consent). During an observation on 04/08/25 at 08:06 AM Resident #119 was lying in bed with eyes closed. He had bilateral 1/2 bed rails in upright position. During an observation and interview on 04/08/25 at 09:05 AM DON was given a list including Resident #119 and asked for consents and assessments for bed rails. DON took the list, looked at it, and stated, Okaaay . During an interview on 04/08/25 at 09:25 AM DON provided a consent and assessment for Resident #119's bed rails signed by Resident #119's family member on 03/31/25 and witnessed by DON on 03/31/25. During an interview on 04/08/25 at 10:27 AM DON was asked if she back dated the consent and assessment for Resident #119's bed rails due to Resident #119's family member stating on 04/07/25 that she had not yet signed a consent for bed rails. DON stated, Yes, I did. During an interview on 04/09/25 at 08:06 AM RN B stated it was never okay to back date a form for a resident's medical record. She stated, Everything should be the same day. If that has to happen or something got missed do communication and write down late entry or something. But no back dating. Just late entry. During an interview on 04/09/25 at 08:13 AM DON stated when records were back dated the medical record was inaccurate. She stated inaccurate medical records could negatively impact residents. She stated, regarding Resident #119's back dated consent and assessment for bed rails, It is inaccurate because it wasn't dated when he got here. They (family) obviously didn't know when he got here what the benefits and risks (of bed rails) were. During an interview on 04/09/25 at 08:38 AM ADM stated it was not okay to back date a form for a resident's medical record. Record review of Resident #119's Resident/Legal Representative Education and Consent for Bedrails provided on 04/08/25 by DON revealed the following: Resident Name: (Resident #119's name was written on the line provided) Date: (3/31/25 was written on the line provided) Bed rails are used by many people to help create a supportive and assistive sleeping environment in nursing home facilities. This type of equipment has many commonly used names, including: side rails, bed side rails, half rails, safety rails, bed handles, assist bars, grab bars, hospital rails, and adult portable bed rails. Residents who are considered frail, agitated, have delirium, confusion, pain, uncontrolled body movement, hypoxia, elimination issues, or sleep disturbances are potentially at risk to receive injury with the use of bed rails. A nursing home shall provide bed rails to a resident only upon receipt of a signed consent form authorizing bed rail use and an order from the resident's attending physician. I am responsible for the medical treatment decisions of the above named resident. I have been advised that I may request that bed rails be installed on the resident's bed. The risk and benefits to using bedrails, as they apply to this resident's particular condition and circumstance, have been clearly explained to me. It is my understanding that the Facility will periodically review and re-evaluate the resident's need for bed rails and that the resident, responsible party and attending physician will be consulted in this matter. With all the above information in mind, I consent to the installation and utilization of bed rails for the care of the above named resident, consistent with the orders of the attending physician. I understand this authorization is revocable, except to the extent of those actions already taken. Signature: (Resident #119's family member's name was written on the line provided) Date: (3/31/25 was written on the line provided) Witness: (DON's name was written on the line provided) Date: (3/31/25 was written on the line provided) Recod review of facility policy titled Charting and Documentation and dated July 2017 revealed the following: . All services provided to the resident, progress toward the care plan goals, or any changes in the residents medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (RN B) of 4 staff observed for infection control. -RN B did not wash her hands after changing her gloves when performing wound care for Resident #15. This deficient practice has the potential to affect residents in the facility receiving wound care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: Record review of Resident #15's face sheet revealed she was a [AGE] year-old female resident admitted to the facility originally on 02/08/24 and readmitted on [DATE] with diagnoses to include pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of the left heel (unstageable), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), pressure ulcer of the sacral (a triangular bone in the lo9wer back formed from fused vertebrae and situated between the two hipbones and pelvis) region stage 2 (partial thickness skin loss involving the epidermis (the surface epithelium (the thin tissue layer forming the outer layer of the body surface) of the skin overlaying the dermis) and/or dermis(the thick layer of living tissue below the epidermis which forms the true skin)), pressure ulcer of the right heel (stage 4(full thickness skin loss , exposing underlying structures like muscles, tendons, ligaments, and even bone)), and carrier or suspected carrier or methicillin resistance staphylococcus aureus (a strain of staphylococcus aureus (staph) bacteria that has developed resistance to methicillin, and antibiotic). Record review of Resident #15's quarterly MDS assessment completed on 03/19/25 revealed the resident had a BIMS of 00 indicating she was severely cognitively impaired, and she had a functional status of being dependent on staff for all her activities of daily living. Resident #15 was marked for having 1-Stage 3 (full-thickness skin loss where the subcutaneous fat is visible, but not muscle, tendon, or bone) pressure ulcer 2-Stage 4 pressure ulcers, and 2-Unstageable pressure injuries. Record review of the care plan with admitted [DATE] for Resident #15 revealed the following: Focus: Resident has pressure ulcers to her left heel, right heel and coccyx r/t immobility and malnutrition. Goal: Resident pressure ulcers will shous sings of healing and remain free from infection . Interventions: Administer treatments as ordered by MD. During an observation on 04/08/25 at 09:47 AM revealed RN B used ABHR before entering Resident #15's room to perform wound care on Resident #15's unstageable left foot heel ulcer. RN B touched the door handle to enter the room then removed the residents old dressing with noted purulent (containing or producing pus)/dark liquid drainage dripping from the old dressing on the pad provided below the wound. RN B changed her gloves (no hand hygiene performed) and cleaned the wound with wet gauze 3 times. RN B changed her gloves (no hand hygiene performed) and opened a package of betadine and wiped the wound bed. RN B changed her gloves (no hand hygiene performed) and applied a gauzed and foam dressing. RN B changed her gloved (no hand hygiene performed) wrapped the foot with Kerlex, and secured the dressing with tape. RN B then reached into her shirt pocket for a sharpie and dated the wound dressing. RN B changed her gloves (no hand hygiene performed) then removed all the used supplies. RN B then exited the room and used ABHR to wash her hands. During an interview on 04/08/25 at 10:01 AM RN B stated, I was told as long as you wash your hand before and after you perform wound care then you are fine. That as long as you change your gloves between each step, so you have new gloves on you are fine. RN B reported that she could not remember who gave her those instructions. When asked if she should wash her hands after removing her gloves when completing the dirty portion of the wound care and before placing new gloves on and moving to the clean portion of the wound care RN B again stated that if they had clean gloves then they were fine. During an interview on 04/09/25 at 08:05 AM the DON reported that staff were expected to wash their hands when they change gloves because they were messing with bacteria, fecal matter, and don't know what the resident may have. The DON reported that if staff do not use proper hand hygiene with resident care, then they can spread infection and other things. During an interview on 04/09/25 at 09:02 AM the DON reported that RN B received her last hand hygiene training in October of 2024 when she (RN B) was a part time employee via their computer system, and she (the DON) could not print the material for review because most of it was video training. The DON did report that RN B had been trained on handwashing with glove changes. Record review of the facility provided policy titled Handwashing/Hand Hygiene revised August 2019, revealed the following: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving form a contaminated body sit to a clean body site during resident care. m. After removing gloves.

Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (the treatment cart) of 2 medication carts (1 treatment cart and 1 medication cart) and 1 of 17 resident rooms reviewed for medication safety. The treatment cart contained two insulins that were opened and accessed that were not marked with the expiration date. Resident #69's room contained two medications (Fluticasone Propionate Nasal Suspension and Systane Eyedrops) that should have been stored in locked compartments. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings included: Record review of Resident #69's clinical record revealed a [AGE] year-old female admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include malignant neoplasm of the pancreatic duct (caner that begins in the organ lying behind the lower part of the stomach), myocardial infarction (heart attack), arthritis (swelling and tenderness in one or more joints casing joint pain or stiffness that often gets worse with age), and allergic rhinitis (an allergic reaction to airborne pathogen like pollen, that causes symptoms such as sneezing, runny nose, itchy eyes, and nasal congestion). Record review of Resident #69's clinical record revealed her last MDS was an admission completed [DATE] which indicated her BIMS was 13 indicating she was cognitively intact, and she had a functionality of requiring supervision/touching assistance with most activities of daily living. Record review of Resident #69's order summary report with print date of [DATE] revealed the following orders: -Fluticasone Propionate Nasal Suspension 50mcg - 2 sprays alternating nostril .-Active [DATE]. (Allergy Relief Nasal Spray) -no noted order for the Systane Eyedrops. Record review of Resident #69's care plan with date of admission [DATE] revealed the following: - Problem - Resident has altered respiratory status r/t dx of seasonal allergies. Date initiated: [DATE]. - Intervention - Administer medication/puffers as ordered: Fluticasone Nasal Susp 50mcg 2 sprays in both nostrils. During an observation on [DATE] at 11:07 AM of Resident #69's room a bottle of Allergy Relief Nasal Spray (Fluticasone Propionate Nasal Suspension) with an expiration date of ,d+[DATE] was observed in her room sitting on the table/dresser area on the right side of the resident's recliner. Also noted were two bottles of Systane eyedrop solution on the bedside table on the left side of the resident recliner. The resident was not present in the room. Record review of Resident #9's clinical record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include diabetes (a chronic condition that affects the way the body processes blood sugar (glucose). Record review of Resident #9's clinical record revealed his last MDS was a quarterly completed [DATE] with a BIMS of 15 indicating he was cognitively intact, and he had a functionality of requiring set-up/clean up assistance with most activities of daily living. Record review of Resident #9's medication administration record with active orders as of [DATE] revealed the following orders: - Lantus Subcutaneous Solution 100 Units/ml-inject 46 units subcutaneously two times a day related to diabetes . -administered at 08:00 AM on [DATE] by RN C. -administered at 08:00 AM on [DATE] by RN B. - Novolin R 100 units/ml inject per sliding scale subcutaneously before meals and at bedtime related to diabetes . -administered at 11:30 AM and 4:30 PM on [DATE] by RN C. -administered at 06:30 AM on [DATE] by RN B. Record review of Resident #9's care plan with date of admission [DATE] revealed the following: - Problem - Resident has diabetes mellitus. Date initiated: [DATE]. - Intervention - Novolin R per sliding scale . Monitor for side effects. During an observation on [DATE] at 11:30 AM 4 insulin bottles were noted in the insulin medication cart. Resident #9 had a Novolin R insulin bottle that RN C had just administered a dose from. Also noted was Resident #9's Lantus insulin bottle. The Lantus insulin bottle was observed to be approximately ,d+[DATE] full. Both the Novolin R and the Lantus Insulin bottles did not have a date of when they were opened/accessed or when they would expire. During an observation and interview on [DATE] at 11:34 AM RN C observed the Novolin R insulin bottle and the Lantus insulin bottle for Resident #9 and verified that both bottles had been opened and used, that both bottles had not been dated of when they were opened or used, and that both insulins should have been dated of when they were opened and when they should expire. RN C reported that insulins can expired and that if not marked then staff would not know when that insulin was expired. RN C reported that this was an issued because staff would not know when the insulin expired, and they would not know if they were giving expired medication to a resident. RN C reported that giving an expired insulin to a resident would affect that resident negatively. During an observation and interview on [DATE] at 10:04 AM Resident #9's Novolin R Insulin bottle and Lantus Insulin bottle were still in the insulin medication cart and were still unmarked. Both insulins did not have the date of when they were opened/accessed or when they would expire. RN B observed both insulins and stated that she did not see that either insulin was marked with an open date or expiration date and that both insulins should have been marked/labeled. RN B reported that both the Novolin R Insulin bottle and Lantus Insulin bottle had been used. RN B reported that the Lantus insulin was half full and the Novolin insulin had been opened but still had most of its liquid. RN B reported that the insulins should be marked with the date of when they were opened/accessed and when they expire because they were only good for a certain number of days. RN B reported that if you give and insulin that was not marked then you will not know if it was affective and you will not know if the resident was getting an accurate treatment. During an interview on [DATE] at 07:59 AM the DON reported that she expects meds to be stored in the medication carts or the medication room and secured under a lock. The DON reported that residents were not supposed to have medications in their rooms unless they have had a Self-Medication Assessment and have been found to be safe to have and administer their own medications. The DON reported that the Self-Medication Assessments would be in the resident's electronic chart under the assessment section. The DON reported that insulin should be stored in a refrigerator until it was needed for the resident. When the insulin was pulled and opened for the resident, the insulin should be marked with the date it expires. The DON reported that the medication cart had a form listing when each type of insulin would expire. The DON reported the staff member opening the insulin for the first time was expected to mark the insulin pen or insulin bottled with the expected expiration date. The DON reported that if the insulin was not marked with the expiration date, then staff would not know how long the insulin had been in the medication cart and the insulin may not be effective which will affect the resident's treatment. The DON reported that medication not stored properly could place resident at risk and affect them negatively, especially if the medication is administered improperly such as with expired insulin. During record review on [DATE] at 08:20 AM no Self-Medication Assessment was noted in Resident #69's clinical record. Record review of the facility provided policy titled, Storage of Medication revised [DATE], revealed the following: Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medication have access to the locked medications. Record review of the facility provided Admission Packet had the following information: Medications: -All medications [NAME] be administered by the nurse on duty .unless the interdisciplinary team determines that the resident is capable of self-administration of his/her medication .if the interdisciplinary team has determined that the resident may self-administer his/her medication, medication [NAME] be kept in the secured area . Items allowed in Resident personal possession or room environment while in facility: The following articles are not permitted because they are controlled by codes, regulations, standards, or because the present and/or use of such articles could have a adverse effect on the health and safety of residents. A. Medications 2. Eye, ear, and nose preparations 3. Any preparation or substance bearing a warning statement . Record review of the facility provided policy titled Medication Labeling and Storage revised February 2023, revealed the following: Medication Labeling: 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 5. Multi-dose vials that have been opened or accessed, (e.g. needle punctured) are dated and discarded within 28 days .

Based on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 14 residents reviewed for respiratory care. The facility failed to ensure Resident #1 received O2 via NC at the rate of 4 lpm as ordered by her physician. This failure could place residents who receive oxygen at an increased risk of hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: Record review of Resident #1's admission record dated 04/08/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, secondary pulmonary hypertension(high blood pressure in pulmonary vessels), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), acute systolic congestive heart failure (heart is unable to pump blood efficiently leading to shortness of breath, fatigue, and leg swelling), shortness of breath, and acute respiratory distress (lung condition characterized by rapid onset inflammation in lungs, shortness of breath, rapid breathing, and/or bluish skin coloration leads to low blood oxygen). Record review of Resident #1's annual MDS completed on 01/27/25 revealed a BIMS of 9 which indicated moderately impaired cognition. Section O of the MDS revealed Resident #1 received O2 therapy while a resident. Record review of Resident #1's care plan completed on 03/04/24 revealed she had congestive heart failure and one of the interventions listed was OXYGEN SETTINGS: O2 via nasal cannula @ 4LPM continuous. Record review of Resident #1's active orders dated 04/08/25 revealed the following order with an order date of 12/04/23: Use oxygen continuouslyvia [sic] NC @ 4L/min to keep oxygen saturation above 90%. Record review of Resident #1's oxygen saturation for the last 3 months (01/08/25-04/08/25) revealed her O2 sats were measured 119 times. Of those 119 times, Resident #1's O2 sats were 90% or below 30 times. During an observation on 04/08/25 at 10:56 AM Resident #1 was lying in bed receiving O2 via NC at 2.5 lpm. During an observation on 04/08/25 at 01:26 PM Resident #1 was lying in bed receiving O2 via NC. CNA H was bent over adjusting Resident #1's NC. During an observation on 04/08/25 at 01:34 PM Resident #1 was lying in bed receiving O2 via NC at 2.75 lpm. During an observation on 04/08/25 at 03:09 PM Resident #1 was lying in bed receiving O2 via NC at 2.75 lpm. During an observation on 04/09/25 at 08:21 AM Resident #1 was lying in bed receiving O2 via NC at 3.75 lpm. During an interview on 04/09/24 at 08:06 AM RN B stated nurses were responsible for setting O2 flow rates. She stated they knew what lpm to set the O2 to by referring to the physician's order. She stated a possible negative outcome for a resident receiving O2 at a lower rate than ordered was, They can become short of breath and oxygen not going through the body like it is supposed to. She stated, I check daily, every morning when I'm checking vitals. When asked why Resident #1 was receiving O2 at lower lpm than ordered, RN B stated she did not know. During an interview on 04/09/24 at 08:13 AM DON stated nursing staff were responsible to ensure O2 flow rates were set correctly. She stated nursing staff would know what flow rate to set O2 on by referring to doctor orders. She stated there could be a negative outcome for a resident receiving O2 at lower rates than ordered by the physician. DON stated, I would say if their O2 sats are not staying above 90 (percent), I would say yeah. She stated a resident might have signs of cyanosis (bluish or purplish skin, lips, or nail beds due to lack of O2 in the blood) or trouble breathing. DON stated, I do not know why (Resident #1 was receiving O2 at lower rates than ordered). Actually, I feel like everyone has known she is on 4 liters (of O2). During an interview on 04/09/24 at 08:20 AM CNA A stated nurses were responsible for setting flow rates on O2 concentrators. She stated, I do not. CNA A stated if a resident does not receive O2 at the rate ordered by the physician, They can't fully breath well. Won't get enough O2 to sustain their lungs. During an interview on 04/09/24 at 08:38 AM ADM stated nurses were responsible for setting flow rates for O2. She stated the flow rate was listed on the physician order. ADM stated receiving O2 at a lower rate than ordered by the physician could negatively affect the resident. She stated she did not know why Resident #1 was receiving O2 at a lower rate than ordered. She stated, Honestly, they (nursing staff) should be following the order. It (O2) needs to be set on the flow rate the order says. Record review of facility policy titled Oxygen Administration dated October 2010 revealed the following: .The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders . 2. Review the resident's care plan to assess for any special needs of the resident. Steps in the Procedure 7. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #3, #5 and #10) of 16 residents reviewed for advanced directives. Residents #3, #5, and #10 had DNR's in their records that were missing required information including dates and signatures. These failures placed residents at risk of not having their end of life wishes honored which could result in prolonged pain and suffering and physical harms in the event of CPR being administered against a resident's wishes. Findings include: Resident #3 Record review of the face sheet dated [DATE] in the clinical record for Resident #3 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), abnormalities of gait, muscle weakness, hypertension (a condition in which the force of the blood against the artery walls is too high), major depression(a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), congestive heart failure(a chronic condition in which the heart does not pump blood as well as it should), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and basal cell carcinoma (cancer that begins in the lower part of the epidermis (the outer layer of the skin). Under the section Advanced Directives Resident #3 was listed as a DNR. Record review of the clinical record for Resident #3 revealed the last MDS assessment completed was a quarterly dated [DATE] with a BIMS of 10 indicating she was moderately cognitively impaired, and she required partial to moderate assistance with most of her activities. Record review of the clinical record for Resident #3 revealed a care plan with the following: Problem: Problem start date [DATE]. Resident request of DNR status. Goal: Residents' rights will be maintained. Record review of the clinical record for Resident #3 revealed a Clinical Physician Orders summary printed [DATE] with the following: Code Status DNR - (No active or revision date listed) Record review of the clinical record for Resident #3 revealed a DNR dated [DATE] (by Resident #3) with the following: -Section-Physician Statement-there was no printed physician name, no date for the physician's signature, and no printed license number for the physician. -There was no second signature for Resident #3 in the All person who have signed above must sign below, acknowledging that this document has been properly completed section. Resident #5 Record review of the face sheet dated [DATE] in the clinical record for Resident #5 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include multiple Sclerosis(potentially disabling disease of the brain and spinal cord (central nervous system), borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), muscle weakness, bipolar disorder(disorder associated with episodes of mood swings ranging from depressive lows to manic highs), suicidal ideation, hypertension(a condition in which the force of the blood against the artery walls is too high), and seizures(sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). Under the section Advanced Directives Resident #5 was listed as a DNR. Record review of the clinical record for Resident #5 revealed the last MDS assessment completed was an annual dated [DATE] with a BIMS 0f 14 indicating she was cognitively intact, and she required partial to moderate assistance with most of her activities. Record review of the clinical record for Resident #5 revealed a care plan with the following: Problem: Resident has requested a DNR status. Date initiated: [DATE]. Interventions: Respect residents' rights to make end of life decisions. Record review of the clinical record for Resident #5 revealed a Clinical Physician Orders summary printed [DATE] with the following: Code Status DNR - Revision date [DATE] Record review of the clinical record for Resident #5 revealed a DNR dated [DATE] (by the physician) with the following: -Section A. Declaration of the adult person. -there is no date for the resident's signature and no printed name for the resident. -Section All persons who have signed above must sing below, acknowledging that this document has been properly completed. -there is no second signature for the resident and no second signature for Witness #1 Resident #10 Record review of the face sheet dated [DATE] in the clinical record for Resident #10 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include type 2 diabetes(a chronic condition that affects the way the body processes blood sugar (glucose), acquired absence of right leg, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), chronic pain, major depression(a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), coronary artery disease(damage or disease in the hearts major blood vessels), and hypertension (a condition in which the force of the blood against the artery walls is too high). Under the section Advanced Directives Resident #10 was listed as a DNR. Record review of the clinical record for Resident #10 revealed the last MDS assessment completed was an annual dated [DATE] with a BIMS 0f 15 indicating he was cognitively intact, and he was independent with most of his activities. Record review of the clinical record for Resident #10 revealed a care plan with the following: Problem: Problem start date [DATE]. Resident is a DNR. Goal: Residents' wishes will be followed. Record review of the clinical record for Resident #10 revealed a Clinical Physician Orders summary printed [DATE] with the following: Code Status DNR - Revision date [DATE] Record review of the clinical record for Resident #10 revealed a DNR dated [DATE] (by Resident #10) with the following: -Section All person who have signed above must sign below, acknowledging that this document has been properly completed - Witness #1 signed in the physician's signature section and the physician's signature (that is in the Witness #1 section) in this section does not match the Physicians Statement section signature. During an interview on [DATE] at 08:54 AM the DON reported that when a resident is admitted she or the administrator will interview the resident to determine the resident's wishes for their code status and complete the proper paperwork to include the DNR form. The DON stated that she is the primary person responsible for ensuring that the DNR was completed. The DON reported the DNR status was reviewed with each resident's quarterly assessment. The DON reported that to determine a resident's code status staff are to check the residents printed chart at the nurse's station, that when they completely switch to electronic charting then staff can check the computer, or they have a list printed at the nurse's station that has each resident's code status. The DON reported that once the residents code status was determined the staff member was to address the resident according to the code status. If the resident was a full code, then implement CPR and if the resident was a DNR then hold CPR and notify the physician and family. The DON reviewed Resident #5's DNR and noted the missing resident information, the incorrect Physician's information, and the missing secondary signatures at the bottom of the form. The DON reviewed Resident #3's DNR form and noted the missing Physician information. The DON reviewed Resident #10's DNR form and noted the confusing physician second signature and signatures in the incorrect places. The DON reported that all three DNR's were currently invalid and therefore if any of the three residents coded (were determined to be without a heartbeat or to be breathing), they would currently be treated as a full code and CPR would be initiated. The DON reported that this would affect the residents care due to their wishes would not be followed. During an interview on [DATE] at 09:12 AM LVN A (the nurse responsible for all the residents this shift) reported that if a resident were to code, she would check the resident's chart and then handle the code according to what the chart indicated. If the resident was a full code, she would start CPR and if the resident was a DNR then she would not start CPR. LVN A reviewed Resident #3, #5, and #10's DNR's, verified the missing information, and reported that all three DNR's were currently invalid. When questioned if she would honor each of the three residents DNR's currently if she found any of the residents not breathing and without a heartbeat LVN A stated, Probably not since the DNR is not right. LVN A reported that it might affect resident care since she would have to code the resident and start CPR against their wishes and that would not be following the residents wishes. Record review of facility provided policy titled Advanced Directives, revised [DATE], revealed the following: The resident has the right to formulate to an advanced directive .Advanced directives are honored in accordance with state law and facility policy. 4. Written information includes .polices to implement advanced directives and applicable state law. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

Based on observations, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident receives adequate supervision for 3 of 16 residents (Resident #7, Resident #9 and Resident #10) reviewed for accidents and hazards. Smoking materials were left out unsupervised. Residents #7, #9, and #10 were smoking outside without supervision. This failure could result in physical and mental harm. Findings Include: Record review of Resident #7's face sheet, dated 3/4/24, showed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7's diagnoses include but were not limited to legal blindness (complete loss of all visual light perception), dementia in other diseases classified elsewhere, moderate (group of symptoms that affect memory, thinking, and behavior), anxiety (a physiological and psychological response that occurs when the mind and body encounter stressful, dangerous, or unfamiliar situations), disorder of brain, unspecified (conditions that affect the structure or function of the brain, causing problems with thinking, memory, movement, or emotions), and unspecified hearing loss (partial or total inability to hear). Record review of Resident #7's annual MDS assessment, dated 6/13/23, reflected resident had a BIMS of 15, indicating resident is cognitively intact. Section J reflected resident was not a current tobacco user. Record review of Resident #7's care plan, dated 6/14/23, reflected a goal of, Resident #7 is at risk of injury due to smoking, delay response r/t intellectual disabilities. Record review of Resident #7's smoking assessment, dated 2/26/24, indicated resident smoking and safety: supervision, designated smoking location, and smoking times are determined by facility policy; this evaluation will be utilized for the Resident's smoking care plan on admission as indicated. Resident #7 displayed poor vision or blindness, balance problems while sitting or standing, drops ashes on self , and follows the facility's policy on location and time of smoking. Record review of Resident #9's face sheet, dated 3/4/24, indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #9's diagnoses included but were not limited to chronic obstructive pulmonary disease with acute exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs), acute respiratory failure with hypoxia (lungs cannot provide enough oxygen to the body or remove enough carbon dioxide), unspecified macular degeneration (eye disease that affects central vision), and acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (a group of signs and symptoms, caused by an impairment of the heart's blood pumping function). Record review of Resident #9's annual MDS assessment, dated 9/11/23, reflected a BIMS of 15 indicating Resident #9 is cognitively intact. Section J of the MDS reflected resident is a current tobacco user. Record review of Resident #9's care plan with admitted [DATE] revealed the following: Problem: Resident #9 is a risk of injury r/t smoking. Date initiated 1-24-2024. Interventions: -Encourage her to keep lighter and cigarettes at nurses' station, although resident might refuse. -Encourage Resident #9 to follow nursing facility smoking policy when refusing to comply. Record review of Resident #9's smoking assessment, dated 1/9/24 , reflected: Line 1- supervision, designated smoking location, and smoking times are determined by facility policy; this evaluation will be utilized for the Resident's smoking care plan on admission as indicated. Resident #9 displayed poor vision or blindness and follows the facility's policy on location and time of smoking. Record review of Resident #10's face sheet, dated 3/4/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include but were not limited to type 2 diabetes mellitus, chronic obstructive pulmonary disease with acute exacerbation, other lack of coordination, and tobacco use. Record review of Resident #10's annual MDS assessment, dated 11/17/24 , reflected a BIMS of 15 indicating cognitively intact. Section J reflected Resident #10 is a current tobacco user. Record review of Resident #10's smoking assessment, dated 2/7/24, reflected: Line 1 - supervision, designated smoking location, and smoking times are determined by facility policy; this evaluation will be utilized for the Resident's smoking care plan on admission as indicated. Smoking assessment indicated that resident displays balance problems while sitting or standing and follows the facility's policy on location and time of smoking. Record Review of Resident #10's care plan with last review date of 9-22-2023 revealed the following: Problem: Resident #10 is at risk for injury r/t smoking. Approach: -Resident #10 with abide by the smoking policy. -Resident #10 will keep lighter and cigarettes at nurse station. In an observation on 3/5/24 at 7:28 AM, Resident #9 re-entered the facility from the smoking area independently. In an observation on 3/5/24 at 11:01 AM, Resident #7 and Resident #9 went to the smoking area to smoke unsupervised. In an observation on 3/5/24 at 11:09 AM, a white lighter was identified on the nurse's station with no supervision. In an observation on 3/5/24 at 11:48 AM, a white lighter remained on the corner of the nurse's station. In an observation on 3/5/24 at 12:17 PM, a white lighter remained on the corner of the nurse's station. In an observation on 3/5/24 at 12:49 PM, the white lighter had been removed from the nurse's station. In an observation on 3/5/24 at 3:02 PM, Residents #7, #9, and #10 were outside smoking unsupervised. In an interview on 3/6/24 at 9:20 AM, DON observed Resident #7, #9, and #10's smoking assessments. DON verified all assessments stated residents required supervision. DON stated supervision meant someone is with the residents while residents were outside smoking. DON verified smoking materials, including cigarettes and lighters, were locked up where residents do not have access to them. DON indicated a negative outcome is residents could burn themselves or start a fire if not supervised while smoking. DON stated a negative outcome of not locking up smoking materials could be ingestion of smoking materials as residents with Alzheimer's or Dementia could grab them. Record review of policy Smoking Policy-Residents, revised August 2022, stated (line 11) any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. (Line 12) Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed. Dry goods were not stored in sealed containers. Refrigerated and frozen food were not labeled or stored correctly. This failure can result in cross contamination, bacteria, pests, and harm to residents. Findings include: In an observation on 3/4/24 at 10:27 AM of the pantry: 12 oz box Signature Select Crispy Rice cereal was opened and in original box with resident's name on the top. 12 oz box General Mills Corn Chex Cereal was opened and in the original box. 28 oz Quaker Creamy Wheat was opened and in the original box. [NAME] Cake Mix was opened, in gallon sealed bag with no date Refrigerator 2 22 oz. Budding oven roasted turkey with no date Package of 7 flour corn tortillas was not dated or labeled. Gallon bag with cooked meat, not labeled or dated. 5 lb. de Pasado cheese in cardboard box and not in sealed container. Silver serving pan with tin foil on top was not labeled and not dated. Freezer Gallon bag of frozen rolls was not labeled. Gallon bag of frozen chocolate chip cookies with no label and date on container was faded. Gallon bag of breaded chicken tenders, open to air and not labeled. In an interview on 3/4/24 at 10:43 AM, DM stated an open container is not correct and that it is supposed to be sealed. DM stated a negative outcome is the food is open to getting bacteria or freezer burn. Record review of policy titled Food Receiving and Storage, revised November 2022, under heading Dry Food Storage, line 3- dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Record review of policy titled Food Storage, dated 2013, under heading procedure- line 4 plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled. Line 12- leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Line 14- Refrigerated Food Storage- item f- all foods should be covered, labeled and dated. Line 15- Frozen Foods- item c- all foods should be covered, labeled and dated.

Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 12 residents (Resident #7) reviewed for accuracy of MDS assessments. -The facility did not correctly identify tobacco use for Resident #7 on his annual MDS assessment. This failure to ensure accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Record review of Resident #7's face sheet, dated 3-4-2024, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, (a group of thinking and social symptoms that interferes with daily functioning), major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), hypertension (a condition in which the force of the blood against the artery walls is too high), disorder of the brain (any condition marked by disruption of the normal functioning of the brain), muscle weakness, contact with and exposure to environmental tobacco smoke acute and chronic, family history of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and family history of ischemic heart disease (heart weakening caused by reduced blood flow to the heart). Record review of Resident #7's annual MDS, dated [DATE], revealed that the resident had a BIMS of 15 indicating he was cognitively intact, and he had a functionality of requiring set up assistance with most of his activity except dressing, toilet use, and personal hygiene which he required two-person physical assistance. Section J-Health Conditions: J1300 Current Tobacco Use-Resident #7 was marked 0 for no use of tobacco. Record review of Resident #7's current comprehensive care plan revealed the following: Problem Start Date: 7-08-2022. Resident #7 is a risk of injury d/t smoking, delay response, d/t intellectual deficit. Record Review of Resident #7's Interdisciplinary Care Plan dated 6-14-2023 revealed the following: Activities: talks on phone, smokes Smoker-Yes Eval Done/Safety-Yes During an interview on 03-06-2024 at 08:44 AM the DON reported that Resident #7 has smoked daily for as long as she has known him which has been 7-8 years. The DON verified that she is currently responsible for completing the MDS assessments due to the low census. The DON reviewed Resident #7's last annual MDS, noted that he was not marked for tobacco use, and verified that the MDS had been marked correctly. The DON reported that she did not complete that MDS and that the person responsible no longer worked for the facility. The DON reported that if the facility was audited then the MDS would not be correct, and the facility could lose funding which would affect resident care. The DON reported that she did not feel this would affect Resident #7's care directly because he was still able to smoke and use his tobacco. The DON reported that they follow the RAI (Resident Assessment Instrument) manual for facility policy when addressing the use of the MDS. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: Section J: Health Conditions- J1300: Current Tobacco Use Item Rationale Health-related Quality of Life o The negative effects of smoking can shorten life expectancy and create health problems that interfere with daily activities and adversely affect quality of life. Planning for Care o This item opens the door to negotiation of a plan of care with the resident that includes support for smoking cessation. o If cessation is declined, a care plan that allows safe and environmental accommodation of resident preferences is needed. Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. DEFINITION TOBACCO USE Includes tobacco used in any form.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with the resident rights set forth with goals for admission and desired outcomes for 1 of 16 residents (Resident #5) reviewed for care plans. Resident #5 care plan focus areas of DNR, diagnoses of hypertension, physical mobility, cognitive functioning, antidepressant medication, and psychotropic medication had minimal or no person centered goals or interventions to meet the resident's specific needs. This failure can result in inadequate/incorrect care or harm. Findings include: Record review of Resident #5's face sheet, dated 3/5/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included but are not limited to multiple sclerosis (disease that affects central nervous system), borderline personality disorder (a mental disorder characterized by the instability in mood, behavior, and functioning), need for assistance with personal care, and muscle weakness. Record review of Resident #5's annual MDS assessment, dated 1/12/24, revealed Resident #5 has a BIMS of 14 indicating Resident #5 is cognitively intact. Resident #5's functional abilities indicated Resident #5 needed supervision or touching assistance with eating and oral hygiene, partial/moderate assistance with toileting hygiene, upper body dressing, personal hygiene, and rolling left to right, and substantial/maximal assistance with shower/bathe self, lower body dressing, putting on/taking off footwear, sit to lying, lying to sitting on side of the bed, chair/bed-to-chair transfer, and toilet transfer. Record review of Resident #5's care plan, dated 1/24/24, reflected the following: Resident #5 has requested a DNR status had no goals listed to achieve resident's decision for a DNR. Problem listed as Resident #5 has dx of hypertension with a goal of Resident blood pressure will be within normal limits. There were no interventions to help achieve this goal. Problem was listed as impaired physical mobility had no goals listed and interventions of observing resident's posture and gait and observe ROM in all joints. Problem was listed as the resident has impaired cognitive function or impaired through processes with no goals or interventions listed . Problem was listed as the resident uses antidepressant medication (specify medications) r/t, with no goals or interventions. Problem listed as the resident uses psychotropic medications Abilify, Goal- the resident will be/remain free of psychotropic drug related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date and the resident will reduce the use of psychotropic medication through the review date with no interventions to achieve goal listed. Problem was listed as the resident has depression r/t, goal listed as the resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date and the resident will remain free of s/sx of distress, symptoms of depression, anxiety or sad mood by/through review date with no interventions listed to achieve the goal;. Problem listed as the resident has bladder incontinence with a goal of the resident will decrease frequency of urinary incontinence from (SPECIFY) to (SPECIFY ) times per week through the next review date, no interventions listed and no amount provided to observations of urinary incontinence. In an interview on 3/6/24 at 9:14 AM, DON stated she oversaw the care plans. DON stated care areas for care plans were obtained from the MDS. DON observed Resident #5's care plan and verified missing information from problems of impaired cognitive function, psychotropic medication, resident has depression, and resident has bladder incontinence. DON stated interventions were important because the staff need to know how to care for the resident and it is missing a step of the equation to meet the goal. DON stated a negative outcome could be a lot of things; resident could have an allergy to something and could cause harm to the resident. Record review of policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, stated a comprehensive person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Line 3 stated the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Line 7 stated the comprehensive, person-centered care plan: a- includes measurable objectives and time frames, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c- includes the resident's stated goal upon admission and desired outcomes; d- builds on the resident's strengths; e- reflects currently recognized standards of practice for problem areas and conditions. Line 10 stated care plan interventions are chosen only after data gathering, proper sequencing of events, careful considerations of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observation, interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of a comprehensive assessment for 1 (Resident #15) of 12 residents reviewed for comprehensive care plans. The facility failed to develop Resident #15's comprehensive care plan within 7 days after completing her admission MDS assessment. The deficient practice could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #15's face sheet dated 3-4-2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include fracture of other parts of the pelvis, malnutrition (lack of proper nutrition), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), chronic kidney failure (longstanding disease of the kidneys leading to kidney failure), repeated falls, pain, hypertension (a condition in which the force of the blood against the artery walls is too high), heart failure (a chronic condition in which the heart does not pump blood as well as it should), and old myocardial infarction (heart attack). Record review of Resident #15's admission MDS, dated [DATE] (Completed by the DON on 2-19-2024) revealed that the resident had a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring the use of a walker or wheelchair and partial to moderate assistance with most activities of daily living. Record review of Resident #15's comprehensive care plan printed 3-5-2024 revealed the following: No Data Found. During an observation and interview on 03-04-2024 at 11:01 AM Resident #15 was observed in her room sleeping and did not wake to knocking or introduction. Resident #15 was noted to have a catheter bag hanging from the foot of her bed in a privacy bag and she had bilateral 1/3 bedrails up and locked in place. During an observation and interview on 03-04-2024 at 12:18 PM Resident #15 was observed in the dining room sitting in a wheelchair at a table with another resident. Resident #15's catheter was in a privacy bag, and she was overheard visiting with a staff member about her meal preferences. Resident #15 reported no issues with the facility or staff and immediately returned to conversing with the other resident at the table. Resident #15 did not acknowledge this surveyor's presence any further and did not address any further questions. During an interview on 03-06-2024 at 08:49 AM the DON verified that she was currently responsible for completing the MDS assessments and the care plans to include the comprehensive care plans due to the low census. the DON reported that the only care plan they currently had for Resident #15 was the base line care plan and that it was her understanding that she had 14 days after the completion of the MDS to complete the comprehensive care plan. The DON reported that if there was a different time frame requirement for the comprehensive care plan to be completed, she was not aware of it. The DON reported that if the comprehensive care plan was not completed as is should then resident care can be affected, that staff should be aware of the care listed on the comprehensive care plan. Review of facility presented policy titled Care Plans, Comprehensive Person-Centered, revised 3-2022, revealed the following: Policy Interpretation and Implementation 2. The comprehensive, person-centered care plan is developed within seven (7) days a=of the completion of the required MDS assessment (Admission, Annual, or Significant Change in Status) .

Based on observation, record reviews, and interviews, the facility failed to ensure that residents unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 16 residents (Resident #5) reviewed for choices. Resident #5 was told no when asking staff to shave her legs during her showers. This failure can result in residents not receiving proper care and not attaining their highest level of physical, mental, and psychosocial well-being. Findings Include: Record review of Resident #5's face sheet, dated 3/5/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included but are not limited to multiple sclerosis (disease that affects central nervous system), borderline personality disorder (a mental disorder characterized by the instability in mood, behavior, and functioning), need for assistance with personal care, and muscle weakness. Record review of annual MDS assessment, dated 1/12/24, revealed Resident #5 has a BIMS of 14 indicating Resident #5 is cognitively intact. Resident #5's functional abilities indicated Resident #5 needed supervision or touching assistance with eating and oral hygiene, partial/moderate assistance with toileting hygiene, upper body dressing, personal hygiene, and rolling left to right, and substantial/maximal assistance with shower/bathe self, lower body dressing, putting on/taking off footwear, sit to lying, lying to sitting on side of the bed, chair/bed-to-chair transfer, and toilet transfer. Record review of Resident #5's care plan, dated 1/24/24, showed a problem of Self-Care deficit: Bathing, Dressing, Feeding, with a goal of resident would participate in self-care activities, and interventions of encouraging resident to participate in planning day to day care, evaluate resident's ability to perform ADLs, maintain consistent schedule with daily routine, provide assistance with ADLs as needed. In an observation and interview on 3/4/24 at 1:21 PM, Resident #5 and FM were in resident's room. FM was sitting on the bed, shaving Resident #5's legs while resident was sitting in her wheelchair. FM stated the staff had been asked multiple times to shave Resident #5's legs and they had received different excuses such as staff did not have time, staff was too busy, or staff did not shave residents. In an interview on 3/6/24 at 9:53 AM, CNA A stated she was responsible for showers during her shift. CNA A stated she has shaven legs. CNA A stated she has told Resident #5 she was unable to shave her legs during a shower because of a heavy workload that day. CNA A stated other CNA's have told her no and verified Resident #5 has been told no before. CNA A stated a negative outcome could be mental decline. In an interview on 3/6/24 at 10:01 AM, DON stated CNAs were responsible for showering residents. DON stated residents were encouraged to be as independent as possible and a lot of residents needed lower body help. DON stated CNAs did shave residents when asked and they had a conversation with CNAs recently. DON stated a negative outcome could be the resident feeling disrespected, belittled, and emotional decline. In a policy titled Resident Self-Determination and Participation, revised August 2022, policy statement stated, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life, Line 1: Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or her interests, values, assessments and plans of care, including: Line b- personal care needs such as bathing methods, grooming styles and dress. In a policy titled Resident Rights, revised February 2021, stated employees shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one facility reviewed for infection control, in that: Staff were not masking as required by the facility during a COVID outbreak. Staff were doffing used PPE and placing it on furniture in the rooms of COVID positive residents. These failures could place residents at risk of contracting infectious diseases. Findings Included: Resident #1 Record review of Resident #1's admission record dated 02/12/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, multiple sclerosis (potentially disabling disease of the brain and spinal cord (central nervous system), borderline personality disorder (mental illness that severely impacts a person's ability to manage their emotions), repeated falls, and need for assistance with personal care. Record review of Resident #1's Annual MDS, dated [DATE] revealed a BIMS of 14 which indicated intact cognition. Record review of Resident #1's progress notes revealed the following: A note from 02/05/24 at 01:07 AM written by LVN E which stated Resident #1 was complaining of a headache and feeling cold. Resident #1 was tested for COVID and tested positive. A note from 02/05/24 at 01:19 AM written by LVN E which stated Resident #1 was placed in quarantine. Resident #2 Record review of Resident #2's admission record dated 02/12/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), dementia (a group of thinking and social symptoms that interferes with daily functioning), and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS of 3 which indicated severely impaired cognition. Record review of Resident #2's progress notes revealed the following: A note from 02/12/24 at 01:02 AM written by LVN E which stated Resident #2 had been complaining of not feeling well (nausea, uncontrolled shaking) and when Resident #2 was tested for COVID he tested positive. A note from 02/12/24 at 01:21 AM written by LVN E which stated Resident #2 was placed in quarantine. During an observation on 02/12/24 at 10:05 AM LVN A and PTA D were sitting at the nurses' station not wearing masks. During an observation on 02/12/24 at 10:16 AM LVN A was sitting at the nurses' station wearing a surgical mask. During an observation and interview on 02/12/24 at 10:17 AM ADM was wearing a surgical mask. She stated staff wore surgical masks in the building during a COVID outbreak and wore N95 masks when caring for COVID positive residents. She stated the facility was amid a COVID outbreak that started on 02/05/24 with two residents complaining of not feeling well. The residents tested positive for COVID as did a third resident and one staff member. ADM stated one of the positive residents had tested negative twice in 48 hours and was off isolation but Resident #1 and Resident #2 were still isolated in their rooms. ADM stated she and DON were the infection preventionists for the facility. During an interview on 02/12/24 at 10:23 AM LVN A stated she had worked for the facility for 2 years. When asked about the surgical mask she was wearing LVN A stated staff wore surgical masks when COVID was in the building. When asked why she was not wearing a mask earlier she stated, I kinda forgot to grab one. LVN A said when staff are caring for a COVID positive resident they wear a gown, gloves, an N-95 mask, and shoe covers. She stated staff put the PPE on outside the resident's room and take it off and throw it away inside the resident's room before exiting the resident's room. During an observation and interview on 02/12/24 at 10:34 AM Resident #1 was lying on her bed on her back with her TV on. She stated her throat hurt so bad she had trouble swallowing and talking. She stated staff come into her room wearing PPE. There was a clear trash bag with it's top tied shut sitting on the floor with what appeared to be a yellow PPE gown and some white gloves inside the bag. There was no other trash bag or trash can in the room. When asked what staff do with their PPE after they take it off before leaving her room, Resident #1 stated, They sit it on that chair there (Resident #1 gestured to an upholstered chair near the door of her room). During an observation and interview on 02/12/24 at 10:54 AM Resident #2 was lying on his back in bed with his TV on and his eyes closed receiving O2 via nasal cannula. CNA C arrived in the room wearing a gown, gloves, and an N-95 mask. She asked Resident #2 how he was feeling. He opened his eyes and asked, What are you girls doing? He did not respond to any other questions. There was a balled up yellow PPE gown sitting on top of a nightstand near the bathroom door in Resident #2's room. CNA C stated that was where staff left their used PPE when they were exiting Resident #2's room. CNA C was in the process of emptying the trash can near Resident #2's bed. She took the bag of trash and added the PPE from the top of the nightstand to the bag of trash. During an observation on 02/12/24 at 11:00 AM CNA C exited Resident #2's room with a clear bag of trash tied together at the top. She placed the trash into a covered receptacle on a rolling cart in the hall. During an observation and interview on 02/12/24 at 11:11 AM PTA D was wearing a surgical mask. He said he had worked for the facility for 3 months. He stated he was supposed to wear a surgical mask in the facility when COVID was in the building. When asked why he was not wearing one earlier in the day he stated, I thought our patients were off quarantine today, but I guess they have to test two times negative in two days and I wasn't sure if they had or not. During an observation on 02/14/24 at 12:18 PM CNA C was observed standing in the hall with her surgical mask hooked under her chin, thereby not covering her mouth or her nose. During an interview on 02/14/24 at 01:27 PM ADM stated she expected her staff to wear surgical masks in the building during a COVID outbreak. She stated a possible negative outcome of staff not wearing surgical masks was a possibility of contracting COVID. She stated there should be receptacles in each COVID positive resident's room for staff to discard their used PPE into. When asked a possible negative outcome of staff sitting used PPE on surfaces in the resident's room ADM stated the surfaces could be contaminated. ADM stated DON did the COVID, PPE, HH in-service on 02/05/24. She stated the information in the blue binder she provided was what was covered in the in-service. On 02/12/24 at 01:38 PM a voicemail message was left for DON asking her to return the call. DON did not return the call. Record review of staff in-services for the past three months revealed in-services covering COVID, PPE, and HH were done on 02/05/24, 12/27/23, and 11/27/23. Record review of the sign-in sheet for the in-service on 02/05/24 revealed ADM, LVN A, PTA D, and CNA C all three attended the in-service. Record review of material covered in the in-service on 02/05/24 revealed the following topics on separate sheets of paper: Prevention Actions to Add as Needed There are some additional prevention actions that may be done at any level, but CDC especially recommends considering in certain circumstances or at medium or high COVID-19 hospital admission levels. Wearing Masks . Standard Precautions for Infection Control . Personal protective equipment (PPE) .Before leaving the patient's room or cubicle, remove and discard PPE. HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1 There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucus membranes with potentially infectious materials. Remove all PPE before exiting the patient room . 1. GLOVES . Discard gloves in a waste container .3. GOWN . Fold or roll into a bundle and discard in a waste container. 4. MASK OR RESPIRATOR . Discard in a waste container . EXAMPLE 2 . 1. GOWN AND GLOVES . Place the gown and gloves into a waste container . 3. MASK OR RESPIRATOR . Discard in a waste container . Record review of facility policy titled Policies and Practices-Infection Control and dated 2001 revealed the following: . The objectives of our infection control policies and practices are to: a. Prevent . and control infections in the facility; b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions; . Record review of facility policy titled Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures and dated May 2023 revealed the following: . This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. Record review of CDC Infection Control Transmission Based Precautions dated 2016 revealed the following: . Contact Precautions Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. properly discarding before exiting the patient room is done to contain pathogens.

Based on interviews and record review, it was determined the facility failed to implement their written policies and procedure to prohibit neglect for 1 of 6 residents (Resident #1), when the facility: 1) Failed to ensure Resident #1 received the correct dose of [MEDICATION NAME] (an anticoagulant) for a total of 57 days. 2) Failed to ensure monthly laboratory draws were conducted to ensure Resident #1's PT/INR level was therapeutic. These failures resulted in the facility being unaware Resident #1 had a critical INR level of [MEDICATION NAME] (8.23) in her system. As a result, when Resident #1 sustained a fall with resulting neck fractures on 6/4/11, surgery was delayed until her PT/INR levels were within a safe range to prevent her from hemorrhaging during surgery and/or death. Resident #1 presently remains hospitalized . These failures placed the remaining five residents, who received an anticoagulant, at risk of their PT/INR's not being monitored resulting in the residents having undiagnosed critical PT/INR levels resulting in dizziness, weakness, prolonged clotting time of the blood, hemorrhage, and/or death. The evidence is as follows: 1. Review of the facility's "Abuse Policy and Procedure," dated 10/08/2010, documented Neglect as: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 2. Review of the policy titled, Drug Order Procedure, no date, documented the following: - Obtain written physician's orders [REDACTED]. 3. Review of the facility's policy for Laboratory Services, dated 12/7/2004, documented the following: - Laboratory services are obtained to meet resident needs. The facility assumes responsibility for the quality and timeliness of laboratory services. 4. Review of Resident #1's closed record revealed in the nurse's note, dated 6/4/11 at 11:05 a.m., the following: -that she was observed lying face down between her bedroom door entry way to the bathroom/bedroom with her walker underneath. There was a large amount of blood on the floor and immediate pressure was applied. The resident had a laceration measuring 3 x 1.0 cm. above her left eye and pressure was applied. The resident's right nares (nasal opening) was bleeding and staff packed it with gauze and pressure applied. The resident had a large bruise covering her nose. The resident had a superficial skin tear to her right hand and that pressure was applied to stop the bleeding. The resident's left hand had been under her and when removed, it was noted she had a laceration to her left hand below the thumb, which also required pressure be applied. The ambulance arrived at 11:15 a.m. The resident complained of neck and bilateral (both sides) knee pain, and a neck brace was applied. 5. During an interview on 6/15/11 at 10:00 a.m., Confidential Informant #1 (CI) said when he arrived on the scene the resident was halfway between the bathroom and bedroom. The resident complained of her neck hurting. She had a laceration over the left eye, and skin tears on both arms, she looked pretty beat up. The resident was lying face down and there were towel on the floor, there was a large amount of blood on the floor. We maintained cervical spine precautions, (use hard foam splint on neck, and kept body in straight alignment), and put her on an air splint. 6. Review of Resident #1's Ambulance Record, dated 6/4/11 at 11:66 a.m., documented the primary impression was traumatic injury with wounds to her arms and face. It documented she had a large laceration to her left eye and many skin tears to both arms. It documented she had back and neck pain, and that they put on vacuum splint, and cervical collar. 7. Review of Resident #1's closed hospital record at Hospital #1 revealed the following: a. The CT, Cervical Spine Series, done on 6/4/11 at 12:32 p.m., read by the Radiologist, dated 6/5/11 at 3:32 p.m. documented the following: - Fracture, base of the odontoid with anterior displacement of the body of C2. (A toothlike projection that rises from the upper surface of the body of the second vertebrae, which serves as a pivot allowing the head to turn. (Mosby's Medical, Nursing, and Allied Health Dictionary, Fifth Edition, Copyright 1998 pg. 1138) with a 12 mm anterior shift of the body of C2 (Cervical vertebrae 2). - 10 mm anterior subluxation of C2 relative to C1. - A fracture through the base of the odontoid process of C2 is noted. The body of C2 is displaced on e half shaft width anteriorly with respect to the odontoid. 10 mm of anterior subluxation of the lateral masses of C2 relative to C1 are noted bilaterally. b. The ER record, dated 6/5/11 at 6:22 p.m., documented she was transferred from outpatient services to another hospital for a higher level of care due to a C2 odontoid fracture. It documented that on 6/5/11 at 7:30 p.m., she left via helicopter. c. There was no documentation the hospital physician ordered a PT/INR laboratory test and no evidence of a report regarding her PT/INR levels. 8. Review of Resident #1's current hospital record at Hospital #2 (where she was transferred to), revealed the following: a. A [MEDICATION NAME] blood level report, dated 6/5/11 at 2135 (9:35 p.m.) (day after the fall with injury), revealed her INR level was 8.23 (normal level 0.90-1.20). b. A form titled, Consultation by a Hospitalist MD, dated 6/6/11, requested by the admitting neurosurgeon, documented Resident #1 had [MEDICATION NAME] toxicity. It documented she would be given 10 mg of Vitamin K (stops hemorrhaging and allows for the formation of clotting of thin blood) by slow IV, (intravenous infusion) and would receive 2 units of fresh frozen plasma.(unconcentrated form of blood which contains all clotting factors, correcting bleeding problems). It further documented the [MEDICATION NAME] would be held. 9. Further review Resident #1's closed nursing facility clinical record revealed the following: a. The face sheet documented Resident #1 admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. b. The Physician's Recapitulation orders, dated 1/19/11, documented she was to receive one 3 mg tablet of [MEDICATION NAME] once in the evening. There was no documented order for routinely laboratory monitoring of her INR levels. (International Normalization Ratio, used to monitor the clotting ability of the blood when taking [MEDICATION NAME]). c. The physician's standing orders, undated, documented all [MEDICATION NAME] is to be given at 1700 (5:00 p.m.) unless other wise specified. There was no documented laboratory orders for routine monitoring of INR levels. d. A laboratory report, dated 1/21/11, documented Resident #1's INR was 2.0 (normal range for this hospital 0.0-4.0). e. A laboratory report, dated 2/1/11, documented Resident #1's INR was 9.5 (a critical value), which had a hand written note to hold and recheck on Friday (2/4/11). A physician's telephone order, dated 2/4/11, documented to hold the [MEDICATION NAME] for one week, then restart with 1 mg of [MEDICATION NAME] daily. f. A laboratory report,dated 2/14/11, documented Resident #1's INR was 2.3 (within normal range). g. The February 2011 MAR, documented the [MEDICATION NAME] ([MEDICATION NAME]) 3 mg. was discontinued on 2/4/11, and a new order for [MEDICATION NAME] 1 mg. daily, had been written on the MAR. It was documented Resident #1 received [MEDICATION NAME] 1 mg. during the rest of her stay. h. The MARs for March and April 2011 documented Resident #1 was to received 3mg of [MEDICATION NAME] each day. The 3 mg dosage had been crossed out and 1 mg had been hand written on each form. i. A Discharge Summary, dated 4/16/11, and signed by the physician on 4/25/11, documented Resident #1 discharged to home on 4/16/11. It also documented Resident #1's [MEDICATION NAME] was decreased to 1 mg on 2/4/11. 10. Further review of Resident #1's closed nursing facility clinical record revealed the following: a. Review of Resident #1's admission orders [REDACTED]. 11. During an interview with the DON on 6/15/11 at 10:50 a.m., she said the resident readmitted to the facility late at night, and she called the MD and asked if he would take care of the resident. The MD said he would and to continue all of her previous medication orders. The DON confirmed the order to continue the resident's routine medications had not been written on the chart. The DON said she and 2 other nurses (ADON and MDS Coordinator) were the only nurses to input data information, medications, and order changes into the computer. 12. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., she said she went to the computer and the resident's medication list from her admission to the facility on [DATE] was still in the computer. The DON said she printed it out, and used it as the current medication list. The DON said she took the list to the MD the next morning, and he reviewed and signed it. When asked about the [MEDICATION NAME] 3 mg. being ordered instead of the [MEDICATION NAME] 1 mg., she said when the order was changed in February to [MEDICATION NAME] 1 mg. , the order had not been entered/changed in the computer, so the original admission [MEDICATION NAME] 3 mg. order (1/19/11) had been printed. 13. Review of Resident #1's Recapitulation orders, dated 4/28/11 documented the following: - [MEDICATION NAME] 3 mg., 1 tablet, once in the evening although a phone order on 2/4/11 had reduced the amount to 1 mg per day. 14. Review of Resident #1's MAR for April, May and June 2011 documented she received 3 mg of [MEDICATION NAME] daily (57 days). 15. Review of Resident #1's lab results from the local hospital, documented the following: on 5/2/11 the INR was 2.7, within therapeutic range. Note: There were no lab orders found for routine monitoring of INR levels in the chart. There were no [MEDICATION NAME] levels found on the chart for the months of March or April 2011. 16. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., when asked about how often lab values were done, the DON said the labs were usually drawn monthly, and were faxed to the MD, he would review the results, and then would call back with any orders. 17. During a telephone interview on 6/15/11 at 10:40 a.m., with the MD, he said he didn't know much about Resident #1. The MD said he didn't know "off the top of his head" when lab levels were done for monitoring the INR, but said it was usually done monthly. The MD said the only lab values he had in Resident #1's office chart were for 2/1/11, 2/14/11, and 5/2/11. 18. During a follow up telephone interview on 6/16/11 at 9:20 p.m., with the MD, he said if he had known the resident had been taking [MEDICATION NAME] 1 mg. at the time of admission he would not have changed it. The MD when asked if he reviewed the medication list before signing it said, "Apparently not, no I did not review the medications when they brought them over". The MD said the results are usually faxed to his office, and then he would call the facility with any order changes. 19. Review of a facility provided list, dated 6/16/2011, documented 5 residents who were receiving [MEDICATION NAME].

Based on interviews and record review, it was determined the facility failed to ensure 1of 22 resident's (Resident #1) did not receive an unnecessary drug in excessive dosage or duration, and without adequate monitoring when the facility: 1) Failed to ensure Resident #1 received the correct dose of [MEDICATION NAME] (an anticoagulant) for a total of 57 days. 2) Failed to ensure monthly laboratory draws were conducted to ensure Resident #1's PT/INR level was therapeutic. These failures resulted in the facility being unaware Resident #1 had a critical INR level of [MEDICATION NAME] (8.23) in her system. As a result, when Resident #1 sustained a fall with resulting neck fractures on 6/4/11, surgery was delayed until her PT/INR levels were within a safe range to prevent her from hemorrhaging during surgery and/or death. Resident #1 presently remains hospitalized . These failures placed the remaining five residents, who received an anticoagulant, at risk of their PT/INR's not being monitored resulting in the residents having undiagnosed critical PT/INR levels resulting in dizziness, weakness, prolonged clotting time of the blood, hemorrhage, and/or death. The evidence is as follows: 1. Review of Resident #1's closed record revealed in the nurse's note, dated 6/4/11 at 11:05 a.m., the following: -that she was observed lying face down between her bedroom door entry way to the bathroom/bedroom with her walker underneath. There was a large amount of blood on the floor and immediate pressure was applied. The resident had a laceration measuring 3 x 1.0 cm. above her left eye and pressure was applied. The resident's right nares (nasal opening) was bleeding and staff packed it with gauze and pressure applied. The resident had a large bruise covering her nose. The resident had a superficial skin tear to her right hand and that pressure was applied to stop the bleeding. The resident's left hand had been under her and when removed, it was noted she had a laceration to her left hand below the thumb, which also required pressure be applied. The ambulance arrived at 11:15 a.m. The resident complained of neck and bilateral (both sides) knee pain, and a neck brace was applied. 2. During an interview on 6/15/11 at 10:00 a.m., Confidential Informant #1 (CI) said when he arrived on the scene the resident was halfway between the bathroom and bedroom. The resident complained of her neck hurting. She had a laceration over the left eye, and skin tears on both arms, she looked pretty beat up. The resident was lying face down and there were towel on the floor, there was a large amount of blood on the floor. We maintained cervical spine precautions, (use hard foam splint on neck, and kept body in straight alignment), and put her on an air splint. 3. Review of Resident #1's Ambulance Record, dated 6/4/11 at 11:66 a.m., documented the primary impression was traumatic injury with wounds to her arms and face. It documented she had a large laceration to her left eye and many skin tears to both arms. It documented she had back and neck pain, and that they put on vacuum splint, and cervical collar. 4. Review of Resident #1's closed hospital record at Hospital #1 revealed the following: a. The CT, Cervical Spine Series, done on 6/4/11 at 12:32 p.m., read by the Radiologist, dated 6/5/11 at 3:32 p.m. documented the following: - Fracture, base of the odontoid with anterior displacement of the body of C2. (A toothlike projection that rises from the upper surface of the body of the second vertebrae, which serves as a pivot allowing the head to turn. (Mosby's Medical, Nursing, and Allied Health Dictionary, Fifth Edition, Copyright 1998 pg. 1138) with a 12 mm anterior shift of the body of C2 (Cervical vertebrae 2). - 10 mm anterior subluxation of C2 relative to C1. - A fracture through the base of the odontoid process of C2 is noted. The body of C2 is displaced on e half shaft width anteriorly with respect to the odontoid. 10 mm of anterior subluxation of the lateral masses of C2 relative to C1 are noted bilaterally. b. The ER record, dated 6/5/11 at 6:22 p.m., documented she was transferred from outpatient services to another hospital for a higher level of care due to a C2 odontoid fracture. It documented that on 6/5/11 at 7:30 p.m., she left via helicopter. c. There was no documentation the hospital physician ordered a PT/INR laboratory test and no evidence of a report regarding her PT/INR levels. 5. Review of Resident #1's current hospital record at Hospital #2 (where she was transferred to), revealed the following: a. A [MEDICATION NAME] blood level report, dated 6/5/11 at 2135 (9:35 p.m.) (day after the fall with injury), revealed her INR level was 8.23 (normal level 0.90-1.20). b. A form titled, Consultation by a Hospitalist MD, dated 6/6/11, requested by the admitting neurosurgeon, documented Resident #1 had [MEDICATION NAME] toxicity. It documented she would be given 10 mg of Vitamin K (stops hemorrhaging and allows for the formation of clotting of thin blood) by slow IV, (intravenous infusion) and would receive 2 units of fresh frozen plasma.(unconcentrated form of blood which contains all clotting factors, correcting bleeding problems). It further documented the [MEDICATION NAME] would be held. 6. Further review Resident #1's closed nursing facility clinical record revealed the following: a. The face sheet documented Resident #1 admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. b. The Physician's Recapitulation orders, dated 1/19/11, documented she was to receive one 3 mg tablet of [MEDICATION NAME] once in the evening. There was no documented order for routinely laboratory monitoring of her INR levels. (International Normalization Ratio, used to monitor the clotting ability of the blood when taking [MEDICATION NAME]). c. The physician's standing orders, undated, documented all [MEDICATION NAME] is to be given at 1700 (5:00 p.m.) unless other wise specified. There was no documented laboratory orders for routine monitoring of INR levels. d. A laboratory report, dated 1/21/11, documented Resident #1's INR was 2.0 (normal range for this hospital 0.0-4.0). e. A laboratory report, dated 2/1/11, documented Resident #1's INR was 9.5 (a critical value), which had a hand written note to hold and recheck on Friday (2/4/11). A physician's telephone order, dated 2/4/11, documented to hold the [MEDICATION NAME] for one week, then restart with 1 mg of [MEDICATION NAME] daily. f. A laboratory report,dated 2/14/11, documented Resident #1's INR was 2.3 (within normal range). g. The February 2011 MAR, documented the [MEDICATION NAME] ([MEDICATION NAME]) 3 mg. was discontinued on 2/4/11, and a new order for [MEDICATION NAME] 1 mg. daily, had been written on the MAR. It was documented Resident #1 received [MEDICATION NAME] 1 mg. during the rest of her stay. h. The MARs for March and April 2011 documented Resident #1 was to received 3mg of [MEDICATION NAME] each day. The 3 mg dosage had been crossed out and 1 mg had been hand written on each form. i. A Discharge Summary, dated 4/16/11, and signed by the physician on 4/25/11, documented Resident #1 discharged to home on 4/16/11. It also documented Resident #1's [MEDICATION NAME] was decreased to 1 mg on 2/4/11. 7. Further review of Resident #1's closed nursing facility clinical record revealed the following: a. Review of Resident #1's admission orders [REDACTED]. 8. During an interview with the DON on 6/15/11 at 10:50 a.m., she said the resident readmitted to the facility late at night, and she called the MD and asked if he would take care of the resident. The MD said he would and to continue all of her previous medication orders. The DON confirmed the order to continue the resident's routine medications had not been written on the chart. The DON said she and 2 other nurses (ADON and MDS Coordinator) were the only nurses to input data information, medications, and order changes into the computer. 9. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., she said she went to the computer and the resident's medication list from her admission to the facility on [DATE] was still in the computer. The DON said she printed it out, and used it as the current medication list. The DON said she took the list to the MD the next morning, and he reviewed and signed it. When asked about the [MEDICATION NAME] 3 mg. being ordered instead of the [MEDICATION NAME] 1 mg., she said when the order was changed in February to [MEDICATION NAME] 1 mg. , the order had not been entered/changed in the computer, so the original admission [MEDICATION NAME] 3 mg. order (1/19/11) had been printed. 10. Review of Resident #1's Recapitulation orders, dated 4/28/11 documented the following: - [MEDICATION NAME] 3 mg., 1 tablet, once in the evening although a phone order on 2/4/11 had reduced the amount to 1 mg per day. 11. Review of Resident #1's MAR for April, May and June 2011 documented she received 3 mg of [MEDICATION NAME] daily (57 days). 12. Review of Resident #1's lab results from the local hospital, documented the following: on 5/2/11 the INR was 2.7, within therapeutic range. Note: There were no lab orders found for routine monitoring of INR levels in the chart. There were no [MEDICATION NAME] levels found on the chart for the months of March or April 2011. 13. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., when asked about how often lab values were done, the DON said the labs were usually drawn monthly, and were faxed to the MD, he would review the results, and then would call back with any orders. 14. Review of the facility's "Abuse Policy and Procedure," dated 10/08/2010, documented Neglect as: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 15. Review of the policy titled, Drug Order Procedure, no date, documented the following: - Obtain written physician's orders [REDACTED]. 16. Review of the facility's policy for Laboratory Services, dated 12/7/2004, documented the following: - Laboratory services are obtained to meet resident needs. The facility assumes responsibility for the quality and timeliness of laboratory services. 17. During a telephone interview on 6/15/11 at 10:40 a.m., with the MD, he said he didn't know much about Resident #1. The MD said he didn't know "off the top of his head" when lab levels were done for monitoring the INR, but said it was usually done monthly. The MD said the only lab values he had in Resident #1's office chart were for 2/1/11, 2/14/11, and 5/2/11. 18. During a follow up telephone interview on 6/16/11 at 9:20 p.m., with the MD, he said if he had known the resident had been taking [MEDICATION NAME] 1 mg. at the time of admission he would not have changed it. The MD when asked if he reviewed the medication list before signing it said, "Apparently not, no I did not review the medications when they brought them over". The MD said the results are usually faxed to his office, and then he would call the facility with any order changes. 19. Review of a facility provided list, dated 6/16/2011, documented 5 residents who were receiving [MEDICATION NAME].

Based on interviews and record review, it was determined the facility failed to implement their policies and procedure to prohibit neglect for 1 of 6 residents (Resident #1), when the facility: 1) Failed to ensure Resident #1 received the correct dose of [MEDICATION NAME] (an anticoagulant) for a total of 57 days. 2) Failed to ensure monthly laboratory draws were conducted to ensure Resident #1's PT/INR level was therapeutic. These failures resulted in the facility being unaware Resident #1 had a critical INR level of [MEDICATION NAME] (8.23) in her system. As a result, when Resident #1 sustained a fall with resulting neck fractures on 6/4/11, surgery was delayed until her PT/INR levels were within a safe range to prevent her from hemorrhaging during surgery and/or death. Resident #1 presently remains hospitalized . These failures placed the remaining five residents, who received an anticoagulant, at risk of their PT/INR's not being monitored resulting in the residents having undiagnosed critical PT/INR levels resulting in dizziness, weakness, prolonged clotting time of the blood, hemorrhage, and/or death. The evidence is as follows: 1. Review of Resident #1's closed record revealed in the nurse's note, dated 6/4/11 at 11:05 a.m., the following: -that she was observed lying face down between her bedroom door entry way to the bathroom/bedroom with her walker underneath. There was a large amount of blood on the floor and immediate pressure was applied. The resident had a laceration measuring 3 x 1.0 cm. above her left eye and pressure was applied. The resident's right nares (nasal opening) was bleeding and staff packed it with gauze and pressure applied. The resident had a large bruise covering her nose. The resident had a superficial skin tear to her right hand and that pressure was applied to stop the bleeding. The resident's left hand had been under her and when removed, it was noted she had a laceration to her left hand below the thumb, which also required pressure be applied. The ambulance arrived at 11:15 a.m. The resident complained of neck and bilateral (both sides) knee pain, and a neck brace was applied. 2. During an interview on 6/15/11 at 10:00 a.m., Confidential Informant #1 (CI) said when he arrived on the scene the resident was halfway between the bathroom and bedroom. The resident complained of her neck hurting. She had a laceration over the left eye, and skin tears on both arms, she looked pretty beat up. The resident was lying face down and there were towels on the floor, there was a large amount of blood on the floor. We maintained cervical spine precautions, (use hard foam splint on neck, and kept body in straight alignment), and put her on an air splint. 3. Review of Resident #1's Ambulance Record, dated 6/4/11 at 11:66 a.m., documented the primary impression was traumatic injury with wounds to her arms and face. It documented she had a large laceration to her left eye and many skin tears to both arms. It documented she had back and neck pain, and that they put on vacuum splint, and cervical collar. 4. Review of Resident #1's closed hospital record at Hospital #1 revealed the following: a. The CT, Cervical Spine Series, done on 6/4/11 at 12:32 p.m., read by the Radiologist, dated 6/5/11 at 3:32 p.m. documented the following: - Fracture, base of the odontoid with anterior displacement of the body of C2. (A toothlike projection that rises from the upper surface of the body of the second vertebrae, which serves as a pivot allowing the head to turn. (Mosby's Medical, Nursing, and Allied Health Dictionary, Fifth Edition, Copyright 1998 pg. 1138) with a 12 mm anterior shift of the body of C2 (Cervical vertebrae 2). - 10 mm anterior subluxation of C2 relative to C1. - A fracture through the base of the odontoid process of C2 is noted. The body of C2 is displaced one half shaft width anteriorly with respect to the odontoid. 10 mm of anterior subluxation of the lateral masses of C2 relative to C1 are noted bilaterally. b. The ER record, dated 6/5/11 at 6:22 p.m., documented she was transferred from outpatient services to another hospital for a higher level of care due to a C2 odontoid fracture. It documented that on 6/5/11 at 7:30 p.m., she left via helicopter. c. There was no documentation the hospital physician ordered a PT/INR laboratory test and no evidence of a report regarding her PT/INR levels. 5. Review of Resident #1's current hospital record at Hospital #2 (where she was transferred to), revealed the following: a. A [MEDICATION NAME] blood level report, dated 6/5/11 at 2135 (9:35 p.m.) (day after the fall with injury), revealed her INR level was 8.23 (normal level 0.90-1.20) b. A form titled, Consultation by a Hospitalist MD, dated 6/6/11, requested by the admitting neurosurgeon, documented Resident #1 had [MEDICATION NAME] toxicity. It documented she would be given 10 mg of Vitamin K (stops hemorrhaging and allows for the formation of clotting of thin blood) by slow IV, (intravenous infusion) and would receive 2 units of fresh frozen plasma.(unconcentrated form of blood which contains all clotting factors, correcting bleeding problems). It further documented the [MEDICATION NAME] would be held. 6. Further review Resident #1's closed nursing facility clinical record revealed the following: a. The face sheet documented Resident #1 admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. b. The Physician's Recapitulation orders, dated 1/19/11, documented she was to receive one 3 mg tablet of [MEDICATION NAME] once in the evening. There was no documented order for routinely laboratory monitoring of her INR levels. (International Normalization Ratio, used to monitor the clotting ability of the blood when taking [MEDICATION NAME]). c. The physician's standing orders, undated, documented all [MEDICATION NAME] is to be given at 1700 (5:00 p.m.) unless other wise specified. There was no documented laboratory orders for routine monitoring of INR levels. d. A laboratory report, dated 1/21/11, documented Resident #1's INR was 2.0 (normal range for this hospital 0.0-4.0). e. A laboratory report, dated 2/1/11, documented Resident #1's INR was 9.5 (a critical value), which had a hand written note to hold and recheck on Friday (2/4/11). A physician's telephone order, dated 2/4/11, documented to hold the [MEDICATION NAME] for one week, then restart with 1 mg of [MEDICATION NAME] daily. f. A laboratory report,dated 2/14/11, documented Resident #1's INR was 2.3 (within normal range). g. The February 2011 MAR, documented the [MEDICATION NAME] ([MEDICATION NAME]) 3 mg. was discontinued on 2/4/11, and a new order for [MEDICATION NAME] 1 mg. daily, had been written on the MAR. It was documented Resident #1 received [MEDICATION NAME] 1 mg. during the rest of her stay. h. The MARs for March and April 2011 documented Resident #1 was to received 3mg of [MEDICATION NAME] each day. The 3 mg dosage had been crossed out and 1 mg had been hand written on each form. i. A Discharge Summary, dated 4/16/11, and signed by the physician on 4/25/11, documented Resident #1 discharged to home on 4/16/11. It also documented Resident #1's [MEDICATION NAME] was decreased to 1 mg on 2/4/11. 7. Further review of Resident #1's closed nursing facility clinical record revealed the following: a. Review of Resident #1's admission orders [REDACTED]. 9. During an interview with the DON on 6/15/11 at 10:50 a.m., she said the resident readmitted to the facility late at night, and she called the MD and asked if he would take care of the resident. The MD said he would and to continue all of her previous medication orders. The DON confirmed the order to continue the resident's routine medications had not been written on the chart. The DON said she and 2 other nurses (ADON and MDS Coordinator) were the only nurses to input data information, medications, and order changes into the computer. 10. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., she said she went to the computer and the resident's medication list from her admission to the facility on [DATE] was still in the computer. The DON said she printed it out, and used it as the current medication list. The DON said she took the list to the MD the next morning, and he reviewed and signed it. When asked about the [MEDICATION NAME] 3 mg. being ordered instead of the [MEDICATION NAME] 1 mg., she said when the order was changed in February to [MEDICATION NAME] 1 mg. , the order had not been entered/changed in the computer, so the original admission [MEDICATION NAME] 3 mg. order (1/19/11) had been printed. 11. Review of Resident #1's Recapitulation orders, dated 4/28/11 documented the following: - [MEDICATION NAME] 3 mg., 1 tablet, once in the evening although a phone order on 2/4/11 had reduced the amount to 1 mg per day. 12. Review of Resident #1's MAR for April, May and June 2011 documented she received 3 mg of [MEDICATION NAME] daily (57 days). 13. Review of Resident #1's lab results from the local hospital, documented the following: on 5/2/11 the INR was 2.7, within therapeutic range. Note: There were no lab orders found for routine monitoring of INR levels in the chart. There were no [MEDICATION NAME] levels found on the chart for the months of March or April 2011. 14. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., when asked about how often lab values were done, the DON said the labs were usually drawn monthly, and were faxed to the MD, he would review the results, and then would call back with any orders. 15. Review of the facility's "Abuse Policy and Procedure," dated 10/08/2010, documented Neglect as: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 16. Review of the policy titled, Drug Order Procedure, no date, documented the following: - Obtain written physician's orders [REDACTED]. 17. Review of the facility's policy for Laboratory Services, dated 12/7/2004, documented the following: - Laboratory services are obtained to meet resident needs. The facility assumes responsibility for the quality and timeliness of laboratory services. 18. During a telephone interview on 6/15/11 at 10:40 a.m., with the MD, he said he didn't know much about Resident #1. The MD said he didn't know "off the top of his head" when lab levels were done for monitoring the INR, but said it was usually done monthly. The MD said the only lab values he had in Resident #1's office chart were for 2/1/11, 2/14/11, and 5/2/11. 19. During a follow up telephone interview on 6/16/11 at 9:20 p.m., with the MD, he said if he had known the resident had been taking [MEDICATION NAME] 1 mg. at the time of admission he would not have changed it. The MD when asked if he reviewed the medication list before signing it said, "Apparently not, no I did not review the medications when they brought them over". The MD said the results are usually faxed to his office, and then he would call the facility with any order changes. 20. Review of a facility provided list, dated 6/16/2011, documented 5 residents who were receiving [MEDICATION NAME].

Based on interviews and record reviews, it was determined the facility failed to prohibit incidents of significant medication errors for 1 of 22 sampled residents, (Resident's #1) when: a. Resident #1 received the wrong dose of [MEDICATION NAME] for a total of 57 days. The facility's failure being unaware that Resident #1 was receiving the wrong dosage of [MEDICATION NAME] placed her and the 5 other residents who were receiving [MEDICATION NAME] at risk of dizziness, weakness, prolonged clotting time of the blood, hemorrhage, and/or death. As a result, when Resident #1 sustained a fall with resulting neck fractures on 6/4/11, surgery was delayed until her PT/INR levels were within a safe range to prevent her from hemorrhaging during surgery and/or death. Resident #1 presently remained hospitalized . This facility failure could place the 32 residents, who were receiving psychoactive medications at risk for increased psychotic behaviors, dizziness, headache and [MEDICAL CONDITION] due to not having received the correct dosage. These facility failures could affect the 45 residents in the facility who receive medications, from getting the correct dosage and for the correct duration clinically indicated to treat the resident. The evidence is as follows: I. Resident #1 1. Review of Resident #1's closed record revealed in the nurse's note, dated 6/4/11 at 11:05 a.m., the following: -that she was observed lying face down between her bedroom door entry way to the bathroom/bedroom with her walker underneath. There was a large amount of blood on the floor and immediate pressure was applied. The resident had a laceration measuring 3 x 1.0 cm. above her left eye and pressure was applied. The resident's right nares (nasal opening) was bleeding and staff packed it with gauze and pressure applied. The resident had a large bruise covering her nose. The resident had a superficial skin tear to her right hand and that pressure was applied to stop the bleeding. The resident's left hand had been under her and when removed, it was noted she had a laceration to her left hand below the thumb, which also required pressure be applied. The ambulance arrived at 11:15 a.m. The resident complained of neck and bilateral (both sides) knee pain, and a neck brace was applied. 2. During an interview on 6/15/11 at 10:00 a.m., Confidential Informant #1 (CI) said when he arrived on the scene the resident was halfway between the bathroom and bedroom. The resident complained of her neck hurting. She had a laceration over the left eye, and skin tears on both arms, she looked pretty beat up. The resident was lying face down and there were towel on the floor, there was a large amount of blood on the floor. We maintained cervical spine precautions, (use hard foam splint on neck, and kept body in straight alignment), and put her on an air splint. 3. Review of Resident #1's Ambulance Record, dated 6/4/11 at 11:66 a.m., documented the primary impression was traumatic injury with wounds to her arms and face. It documented she had a large laceration to her left eye and many skin tears to both arms. It documented she had back and neck pain, and that they put on vacuum splint, and cervical collar. 4. Review of Resident #1's closed hospital record at Hospital #1 revealed the following: a. The CT, Cervical Spine Series, done on 6/4/11 at 12:32 p.m., read by the Radiologist, dated 6/5/11 at 3:32 p.m. documented the following: - Fracture, base of the odontoid with anterior displacement of the body of C2. (A toothlike projection that rises from the upper surface of the body of the second vertebrae, which serves as a pivot allowing the head to turn. (Mosby's Medical, Nursing, and Allied Health Dictionary, Fifth Edition, Copyright 1998 pg. 1138) with a 12 mm anterior shift of the body of C2 (Cervical vertebrae 2). - 10 mm anterior subluxation of C2 relative to C1. - A fracture through the base of the odontoid process of C2 is noted. The body of C2 is displaced on e half shaft width anteriorly with respect to the odontoid. 10 mm of anterior subluxation of the lateral masses of C2 relative to C1 are noted bilaterally. b. The ER record, dated 6/5/11 at 6:22 p.m., documented she was transferred from outpatient services to another hospital for a higher level of care due to a C2 odontoid fracture. It documented that on 6/5/11 at 7:30 p.m., she left via helicopter. 5. Review of Resident #1's current hospital record at Hospital #2 (where she was transferred to), revealed the following: a. A form titled, Consultation by a Hospitalist MD, dated 6/6/11, requested by the admitting neurosurgeon, documented Resident #1 had [MEDICATION NAME] toxicity. It documented she would be given 10 mg of Vitamin K (stops hemorrhaging and allows for the formation of clotting of thin blood) by slow IV, (intravenous infusion) and would receive 2 units of fresh frozen plasma.(unconcentrated form of blood which contains all clotting factors, correcting bleeding problems). It further documented the [MEDICATION NAME] would be held. 6. Further review Resident #1's closed nursing facility clinical record revealed the following: a. The face sheet documented Resident #1 admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. b. The Physician's Recapitulation orders, dated 1/19/11, documented she was to receive one 3 mg tablet of [MEDICATION NAME] once in the evening. c. The physician's standing orders, undated, documented all [MEDICATION NAME] is to be given at 1700 (5:00 p.m.) unless other wise specified. d. A laboratory report, dated 2/1/11, documented Resident #1's INR was 9.5 (a critical value), which had a hand written note to hold and recheck on Friday (2/4/11). A physician's telephone order, dated 2/4/11, documented to hold the [MEDICATION NAME] for one week, then restart with 1 mg of [MEDICATION NAME] daily. e. The February 2011 MAR, documented the [MEDICATION NAME] ([MEDICATION NAME]) 3 mg. was discontinued on 2/4/11, and a new order for [MEDICATION NAME] 1 mg. daily, had been written on the MAR. It was documented Resident #1 received [MEDICATION NAME] 1 mg. during the rest of her stay. f. The MARs for March and April 2011 documented Resident #1 was to received 3mg of [MEDICATION NAME] each day. The 3 mg dosage had been crossed out and 1 mg had been hand written on each form. g. A Discharge Summary, dated 4/16/11, and signed by the physician on 4/25/11, documented Resident #1 discharged to home on 4/16/11. It also documented Resident #1's [MEDICATION NAME] was decreased to 1 mg on 2/4/11. 7. Further review of Resident #1's closed nursing facility clinical record revealed the following: a. Review of Resident #1's admission orders [REDACTED]. 8. During an interview with the DON on 6/15/11 at 10:50 a.m., she said the resident readmitted to the facility late at night, and she called the MD and asked if he would take care of the resident. The MD said he would and to continue all of her previous medication orders. The DON confirmed the order to continue the resident's routine medications had not been written on the chart. The DON said she and 2 other nurses (ADON and MDS Coordinator) were the only nurses to input data information, medications, and order changes into the computer. 9. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., she said she went to the computer and the resident's medication list from her admission to the facility on [DATE] was still in the computer. The DON said she printed it out, and used it as the current medication list. The DON said she took the list to the MD the next morning, and he reviewed and signed it. When asked about the [MEDICATION NAME] 3 mg. being ordered instead of the [MEDICATION NAME] 1 mg., she said when the order was changed in February to [MEDICATION NAME] 1 mg. , the order had not been entered/changed in the computer, so the original admission [MEDICATION NAME] 3 mg. order (1/19/11) had been printed. 10. Review of Resident #1's Recapitulation orders, dated 4/28/11 documented the following: - [MEDICATION NAME] 3 mg., 1 tablet, once in the evening although a phone order on 2/4/11 had reduced the amount to 1 mg per day. 11. Review of Resident #1's MAR for April, May and June 2011 documented she received 3 mg of [MEDICATION NAME] daily (57 days). 12. Review of the policy titled, Drug Order Procedure, no date, documented the following: - Obtain written physician's orders [REDACTED]. 13. During a telephone interview on 6/15/11 at 10:40 a.m., with the MD, he said he didn't know much about Resident #1. The MD said he didn't know "off the top of his head" when lab levels were done for monitoring the INR, but said it was usually done monthly. The MD said the only lab values he had in Resident #1's office chart were for 2/1/11, 2/14/11, and 5/2/11. 14. During a follow up telephone interview on 6/16/11 at 9:20 p.m., with the MD, he said if he had known the resident had been taking [MEDICATION NAME] 1 mg. at the time of admission he would not have changed it. The MD when asked if he reviewed the medication list before signing it said, "Apparently not, no I did not review the medications when they brought them over". The MD said the results are usually faxed to his office, and then he would call the facility with any order changes. II. Review of the policy titled, Medication Application, revised date June 2005, documented the following: - Medications are administered as prescribed. - Prior to administration, the medication and dosage schedule on the patient's MAR indicated [REDACTED] III. Review of a facility provided list, dated 6/16/2011, documented 5 residents who were receiving [MEDICATION NAME]. The CMS 672, signed and dated 6/13/2011, documented 32 residents receiving Psychoactive medications.

Based on interviews and record review, it was determined the facility failed to ensure 6 of 6 residents (Resident's #1, 13, 14, 15, 16, 17) who were prescribed [MEDICATION NAME], a blood thinning medication, received timely routine laboratory tests to monitor [MEDICATION NAME] levels in the blood, as ordered by their physician. a. Resident #1 did not have any PT/INR levels drawn for March or April 2011. b. Resident #13 had PT/INR levels drawn 6 to 24 days late. c. Resident #14 had PT/INR levels drawn 9 to 12 days late. d. Resident #15 had PT/INR levels drawn 13 to 24 days late. e. Resident #16 had PT/INR levels drawn 20 to 28 days late, and f. Resdient #17 had PT/INR levels drawn 6 to 24 days late. The facility's failure to ensue laboratory services to meet the residents' needs, placed the 6 residents at risk for high levels of [MEDICATION NAME] in their blood, and at risk for not receiving treatment for [REDACTED]. Resident #1 was curently hospitalized . The evidence is as follows: I. Resident #1 1. Review of Resident #1's closed record revealed in the nurse's note, dated 6/4/11 at 11:05 a.m., the following: -that she was observed lying face down between her bedroom door entry way to the bathroom/bedroom with her walker underneath. There was a large amount of blood on the floor and immediate pressure was applied. The resident had a laceration measuring 3 x 1.0 cm. above her left eye and pressure was applied. The resident's right nares (nasal opening) was bleeding and staff packed it with gauze and pressure applied. The resident had a large bruise covering her nose. The resident had a superficial skin tear to her right hand and that pressure was applied to stop the bleeding. The resident's left hand had been under her and when removed, it was noted she had a laceration to her left hand below the thumb, which also required pressure be applied. The ambulance arrived at 11:15 a.m. The resident complained of neck and bilateral (both sides) knee pain, and a neck brace was applied. 2. During an interview on 6/15/11 at 10:00 a.m., Confidential Informant #1 (CI) said when he arrived on the scene the resident was halfway between the bathroom and bedroom. The resident complained of her neck hurting. She had a laceration over the left eye, and skin tears on both arms, she looked pretty beat up. The resident was lying face down and there were towel on the floor, there was a large amount of blood on the floor. We maintained cervical spine precautions, (use hard foam splint on neck, and kept body in straight alignment), and put her on an air splint. 3. Review of Resident #1's Ambulance Record, dated 6/4/11 at 11:66 a.m., documented the primary impression was traumatic injury with wounds to her arms and face. It documented she had a large laceration to her left eye and many skin tears to both arms. It documented she had back and neck pain, and that they put on vacuum splint, and cervical collar. 4. Review of Resident #1's closed hospital record at Hospital #1 revealed the following: a. The CT, Cervical Spine Series, done on 6/4/11 at 12:32 p.m., read by the Radiologist, dated 6/5/11 at 3:32 p.m. documented the following: - Fracture, base of the odontoid with anterior displacement of the body of C2. (A toothlike projection that rises from the upper surface of the body of the second vertebrae, which serves as a pivot allowing the head to turn. (Mosby's Medical, Nursing, and Allied Health Dictionary, Fifth Edition, Copyright 1998 pg. 1138) with a 12 mm anterior shift of the body of C2 (Cervical vertebrae 2). - 10 mm anterior subluxation of C2 relative to C1. - A fracture through the base of the odontoid process of C2 is noted. The body of C2 is displaced on e half shaft width anteriorly with respect to the odontoid. 10 mm of anterior subluxation of the lateral masses of C2 relative to C1 are noted bilaterally. b. The ER record, dated 6/5/11 at 6:22 p.m., documented she was transferred from outpatient services to another hospital for a higher level of care due to a C2 odontoid fracture. It documented that on 6/5/11 at 7:30 p.m., she left via helicopter. c. There was no documentation the hospital physician ordered a PT/INR laboratory test and no evidence of a report regarding her PT/INR levels. 5. Review of Resident #1's current hospital record at Hospital #2 (where she was transferred to), revealed the following: a. A [MEDICATION NAME] blood level report, dated 6/5/11 at 2135 (9:35 p.m.) (day after the fall with injury), revealed her INR level was 8.23 (normal level 0.90-1.20). b. A form titled, Consultation by a Hospitalist MD, dated 6/6/11, requested by the admitting neurosurgeon, documented Resident #1 had [MEDICATION NAME] toxicity. It documented she would be given 10 mg of Vitamin K (stops hemorrhaging and allows for the formation of clotting of thin blood) by slow IV, (intravenous infusion) and would receive 2 units of fresh frozen plasma.(unconcentrated form of blood which contains all clotting factors, correcting bleeding problems). It further documented the [MEDICATION NAME] would be held. 6. Further review Resident #1's closed nursing facility clinical record revealed the following: a. The face sheet documented Resident #1 admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. b. The Physician's Recapitulation orders, dated 1/19/11, documented she was to receive one 3 mg tablet of [MEDICATION NAME] once in the evening. There was no documented order for routinely laboratory monitoring of her INR levels. (International Normalization Ratio, used to monitor the clotting ability of the blood when taking [MEDICATION NAME]). c. The physician's standing orders, undated, documented all [MEDICATION NAME] is to be given at 1700 (5:00 p.m.) unless other wise specified. There was no documented laboratory orders for routine monitoring of INR levels. d. A laboratory report, dated 1/21/11, documented Resident #1's INR was 2.0 (normal range for this hospital 0.0-4.0). e. A laboratory report, dated 2/1/11, documented Resident #1's INR was 9.5 (a critical value), which had a hand written note to hold and recheck on Friday (2/4/11). A physician's telephone order, dated 2/4/11, documented to hold the [MEDICATION NAME] for one week, then restart with 1 mg of [MEDICATION NAME] daily. f. A laboratory report,dated 2/14/11, documented Resident #1's INR was 2.3 (within normal range). g. The February 2011 MAR, documented the [MEDICATION NAME] ([MEDICATION NAME]) 3 mg. was discontinued on 2/4/11, and a new order for [MEDICATION NAME] 1 mg. daily, had been written on the MAR. It was documented Resident #1 received [MEDICATION NAME] 1 mg. during the rest of her stay. h. The MARs for March and April 2011 documented Resident #1 was to received 3mg of [MEDICATION NAME] each day. The 3 mg dosage had been crossed out and 1 mg had been hand written on each form. i. A Discharge Summary, dated 4/16/11, and signed by the physician on 4/25/11, documented Resident #1 discharged to home on 4/16/11. It also documented Resident #1's [MEDICATION NAME] was decreased to 1 mg on 2/4/11. 7. Further review of Resident #1's closed nursing facility clinical record revealed the following: a. Review of Resident #1's admission orders [REDACTED]. 9. During an interview with the DON on 6/15/11 at 10:50 a.m., she said the resident readmitted to the facility late at night, and she called the MD and asked if he would take care of the resident. The MD said he would and to continue all of her previous medication orders. The DON confirmed the order to continue the resident's routine medications had not been written on the chart. The DON said she and 2 other nurses (ADON and MDS Coordinator) were the only nurses to input data information, medications, and order changes into the computer. 10. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., she said she went to the computer and the resident's medication list from her admission to the facility on [DATE] was still in the computer. The DON said she printed it out, and used it as the current medication list. The DON said she took the list to the MD the next morning, and he reviewed and signed it. When asked about the [MEDICATION NAME] 3 mg. being ordered instead of the [MEDICATION NAME] 1 mg., she said when the order was changed in February to [MEDICATION NAME] 1 mg. , the order had not been entered/changed in the computer, so the original admission [MEDICATION NAME] 3 mg. order (1/19/11) had been printed. 11. Review of Resident #1's Recapitulation orders, dated 4/28/11 documented the following: - [MEDICATION NAME] 3 mg., 1 tablet, once in the evening although a phone order on 2/4/11 had reduced the amount to 1 mg per day. 12. Review of Resident #1's MAR for April, May and June 2011 documented she received 3 mg of [MEDICATION NAME] daily (57 days). 13. Review of Resident #1's lab results from the local hospital, documented the following: on 5/2/11 the INR was 2.7, within therapeutic range. Note: There were no lab orders found for routine monitoring of INR levels in the chart. There were no [MEDICATION NAME] levels found on the chart for the months of March or April 2011. 14. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., when asked about how often lab values were done, the DON said the labs were usually drawn monthly, and were faxed to the MD, he would review the results, and then would call back with any orders. 15. Review of the facility's "Abuse Policy and Procedure," dated 10/08/2010, documented Neglect as: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 16. Review of the policy titled, Drug Order Procedure, no date, documented the following: - Obtain written physician's orders [REDACTED]. 17. Review of the facility's policy for Laboratory Services, dated 12/7/2004, documented the following: - Laboratory services are obtained to meet resident needs. The facility assumes responsibility for the quality and timeliness of laboratory services. 18. During a telephone interview on 6/15/11 at 10:40 a.m., with the MD, he said he didn't know much about Resident #1. The MD said he didn't know "off the top of his head" when lab levels were done for monitoring the INR, but said it was usually done monthly. The MD said the only lab values he had in Resident #1's office chart were for 2/1/11, 2/14/11, and 5/2/11. 19. During a follow up telephone interview on 6/16/11 at 9:20 p.m., with the MD, he said if he had known the resident had been taking [MEDICATION NAME] 1 mg. at the time of admission he would not have changed it. The MD when asked if he reviewed the medication list before signing it said, "Apparently not, no I did not review the medications when they brought them over". The MD said the results are usually faxed to his office, and then he would call the facility with any order changes. II. Resident # 13 1. Review of Resident #13's clinical face sheet documented an admitted to the facility of 10/9/09, with the following Diagnoses: [REDACTED]. 2. Review of Resident #13's quarterly MDS, dated [DATE] documented the following: The resident had no long/short term memory or decision making impairment. The resident required the minimal assist of 1 for transfer, dressing, and hygiene. The resident is occasionally incontinent of bowel and bladder. The resident is able to propel himself in a wheelchair. 3. Review of the Recapitulation orders dated 6/1/11 documented the following: - PT/INR, draw the 1st Tuesday of each month. 4. Review of Resident #13's INR lab results documented the following: - January: Lab due to be drawn on 1/4/11. No lab results on chart. - February: Lab due to be drawn on 2/1/11, drawn 2/7/11, (6 days late). - March: Lab due to be drawn on 3/1/11, no lab results found in chart. - May: Lab due to be drawn on 5/3/11, drawn on 5/27/11. (24 days late). - June: Lab due to be drawn on 6/7/11, no lab results found in chart. III. Resident #14 1. Review of Resident #14's clinical face sheet documented an admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 2. Review of Resident #14's 60 day MDS, dated [DATE], documented the following: The resident had no long/short term memory, or decision making impairment. The resident required minimal assist with transfers, dressing and hygiene. The resident was continent of bowel and bladder. The resident could self propel in a wheelchair. 3. Review of the Recapitulation orders dated 2/18/11 documented the following: - PT/INR, draw the 1st Friday of each month. 4. Review of Resident #14's INR lab results documented the following: - April: Lab due to be drawn on 4/1/11, drawn on 4/13/11. (12 days late) - May: Lab due to be drawn on 5/6/11, drawn on 5/15/11. (9 days late) - June: Lab due to be drawn on 6/3/11, drawn on 6/3/11 IV. Resident #15 1. Review of Resident #15's clinical face sheet documented an admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 2. Review of Resident #15's quarterly MDS, dated [DATE] documented the following: The resident had no long/short term memory, or decision making impairment. Required minimal assist with transfers, dressing and hygiene. The resident was continent of bowel and bladder. The resident ambulated with the assistance of a walker. 3. Review of the Recapitulation orders dated 6/1/11 documented the following: - PT/INR, draw the 1st Tuesday of each month. 4. Review of Resident #14's INR lab results documented the following: - January: Lab due to be drawn on 1/4/11, drawn 1/18/11 (14 days late) - Feburary: Lab due to be drawn on 2/1/11, drawn 2/18/11 (17 days late) - March: Lab due to be drawn on 3/1/11, drawn 3/21/11 (20 days late) - April: Lab due to be drawn on 4/5/11, drawn on 4/19/11. (14 days late) - May: Lab due to be drawn on 5/3/11, drawn on 5/27/11. (24 days late) - June: Lab due to be drawn on 6/7/11, no lab results found in chart. V. Resident #16 1. Review of Resident #16's clinical face sheet documented an admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 2. Review of the Recapitulation orders dated 6/1/11 documented the following: - PT/INR, draw the 1st Tuesday of each month. 3. Review of Resident #16's INR lab results documented the following: - March: Lab due to be drawn on 3/1/11, drawn 3/21/11 (20 days late) - April: Lab due to be drawn on 4/5/11, drawn on 4/26/11. (21 days late) - May: Lab due to be drawn on 5/3/11, drawn on 5/31/11. (28 days late) - June: Lab due to be drawn on 6/7/11, no lab results found in chart. VI. Resident #17 1. Review of Resident #17's clinical face sheet documented an admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 2. Review of the Recapitulation orders dated 6/1/11 documented the following: - PT/INR, draw the 1st Tuesday of each month. 3. Review of Resident #17's INR lab results documented the following: - January: Lab due to be drawn on 1/4/11, no lab results found in the chart. - February: Lab due to be drawn on 2/1/11, drawn 2/7/11 (6 days late) - March: Lab due to be drawn on 3/1/11, no lab results found in chart - April: Lab due to be drawn on 4/5/11, no lab results found in the chart. - May: Lab due to be drawn on 5/3/11, drawn on 5/27/11. (24 days late) - June: Lab due to be drawn on 6/7/11, drawn on 6/16/11 (9 days late) VII. Review of a facility provided list, dated 6/16/2011, documented 5 residents who were receiving [MEDICATION NAME].

Based on observation, interviews and record review, it was determined the facility failed to ensure 1 of 22 residents Resident (Resident #1) did not receive an unnecessary drug in excessive dosage or duration. The facility failed to provide pharmaceutical services, including procedures to meet the needs of each resident, that assured accurate accounting of narcotic medications when 1. Resident #1's Coumadin (Blood thinner) 3 mg. daily order was changed to Coumadin 1 mg. daily, per physician's order on 2/4/1. The order was not entered/changed in the computer. The resident received Coumadin 3 mg. daily from 4/29/11 until 6/4/11 (57 days). 2. The facility failed to follow facility policy and procedures for counting medications for accuracy at the change of shifts, and removing expired medications from one of two medication carts. The facility's failure could affect the 26 residents with orders for routine and/or PRN narcotic medications, by not having an accurate accounting of their medications which could lead to adverse effects, ineffective treatment or drug diversions. These failures resulted in the facility being unaware Resident #1 had a critical level of Coumadin in her system. As a result, when Resident #1 sustained a fall with resulting neck fractures on 6/4/11, surgery was delayed until her PT/INR levels were within a safe range to prevent her from hemorrhaging during surgery and/or death. Resident #1 presently remained in critical condition. These failures placed the remaining five residents, who received an anticoagulant, at risk of their PT/INR's not being monitored resulting in the residents having undiagnosed critical PT/INR levels resulting in dizziness, weakness, prolonged clotting time of the blood, hemorrhage, and/or death. The evidence is as follows: 1. Review of Resident #1's closed record revealed in the nurse's note, dated 6/4/11 at 11:05 a.m., the following: -that she was observed lying face down between her bedroom door entry way to the bathroom/bedroom with her walker underneath. There was a large amount of blood on the floor and immediate pressure was applied. The resident had a laceration measuring 3 x 1.0 cm. above her left eye and pressure was applied. The resident's right nares (nasal opening) was bleeding and staff packed it with gauze and pressure applied. The resident had a large bruise covering her nose. The resident had a superficial skin tear to her right hand and that pressure was applied to stop the bleeding. The resident's left hand had been under her and when removed, it was noted she had a laceration to her left hand below the thumb, which also required pressure be applied. The ambulance arrived at 11:15 a.m. The resident complained of neck and bilateral (both sides) knee pain, and a neck brace was applied. 2. During an interview on 6/15/11 at 10:00 a.m., Confidential Informant #1 (CI) said when he arrived on the scene the resident was halfway between the bathroom and bedroom. The resident complained of her neck hurting. She had a laceration over the left eye, and skin tears on both arms, she looked pretty beat up. The resident was lying face down and there were towel on the floor, there was a large amount of blood on the floor. We maintained cervical spine precautions, (use hard foam splint on neck, and kept body in straight alignment), and put her on an air splint. 3. Review of Resident #1's Ambulance Record, dated 6/4/11 at 11:66 a.m., documented the primary impression was traumatic injury with wounds to her arms and face. It documented she had a large laceration to her left eye and many skin tears to both arms. It documented she had back and neck pain, and that they put on vacuum splint, and cervical collar. 4. Review of Resident #1's closed hospital record at Hospital #1 revealed the following: a. The CT, Cervical Spine Series, done on 6/4/11 at 12:32 p.m., read by the Radiologist, dated 6/5/11 at 3:32 p.m. documented the following: - Fracture, base of the odontoid with anterior displacement of the body of C2. (A toothlike projection that rises from the upper surface of the body of the second vertebrae, which serves as a pivot allowing the head to turn. (Mosby's Medical, Nursing, and Allied Health Dictionary, Fifth Edition, Copyright 1998 pg. 1138) with a 12 mm anterior shift of the body of C2 (Cervical vertebrae 2). - 10 mm anterior subluxation of C2 relative to C1. - A fracture through the base of the odontoid process of C2 is noted. The body of C2 is displaced on e half shaft width anteriorly with respect to the odontoid. 10 mm of anterior subluxation of the lateral masses of C2 relative to C1 are noted bilaterally. b. The ER record, dated 6/5/11 at 6:22 p.m., documented she was transferred from outpatient services to another hospital for a higher level of care due to a C2 odontoid fracture. It documented that on 6/5/11 at 7:30 p.m., she left via helicopter. c. There was no documentation the hospital physician ordered a PT/INR laboratory test and no evidence of a report regarding her PT/INR levels. 5. Review of Resident #1's current hospital record at Hospital #2 (where she was transferred to), revealed the following: a. A Coumadin blood level report, dated 6/5/11 at 2135 (9:35 p.m.) (day after the fall with injury), revealed her INR level was 8.23 (normal level 0.90-1.20) b. A form titled, Consultation by a Hospitalist MD, dated 6/6/11, requested by the admitting neurosurgeon, documented Resident #1 had Coumadin toxicity. It documented she would be given 10 mg of Vitamin K (stops hemorrhaging and allows for the formation of clotting of thin blood) by slow IV, (intravenous infusion) and would receive 2 units of fresh frozen plasma.(unconcentrated form of blood which contains all clotting factors, correcting bleeding problems). It further documented the Coumadin would be held. 6. Further review Resident #1's closed nursing facility clinical record revealed the following: a. The face sheet documented Resident #1 admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. b. The Physician's Recapitulation orders, dated 1/19/11, documented she was to receive one 3 mg tablet of Coumadin once in the evening. There was no documented order for routinely laboratory monitoring of her INR levels. (International Normalization Ratio, used to monitor the clotting ability of the blood when taking Coumadin). c. The physician's standing orders, undated, documented all Coumadin is to be given at 1700 (5:00 p.m.) unless other wise specified. There was no documented laboratory orders for routine monitoring of INR levels. d. A laboratory report, dated 1/21/11, documented Resident #1's INR was 2.0 (normal range for this hospital 0.0-4.0). e. A laboratory report, dated 2/1/11, documented Resident #1's INR was 9.5 (a critical value), which had a hand written note to hold and recheck on Friday (2/4/11). A physician's telephone order, dated 2/4/11, documented to hold the Coumadin for one week, then restart with 1 mg of Coumadin daily. f. A laboratory report,dated 2/14/11, documented Resident #1's INR was 2.3 (within normal range). g. The February 2011 MAR, documented the Warfarin (Coumadin) 3 mg. was discontinued on 2/4/11, and a new order for Warfarin 1 mg. daily, had been written on the MAR. It was documented Resident #1 received Coumadin 1 mg. during the rest of her stay. h. The MARs for March and April 2011 documented Resident #1 was to received 3mg of Coumadin each day. The 3 mg dosage had been crossed out and 1 mg had been hand written on each form. i. A Discharge Summary, dated 4/16/11, and signed by the physician on 4/25/11, documented Resident #1 discharged to home on 4/16/11. It also documented Resident #1's Coumadin was decreased to 1 mg on 2/4/11. 7. Further review of Resident #1's closed nursing facility clinical record revealed the following: a. Review of Resident #1's admission orders [REDACTED]. 9. During an interview with the DON on 6/15/11 at 10:50 a.m., she said the resident readmitted to the facility late at night, and she called the MD and asked if he would take care of the resident. The MD said he would and to continue all of her previous medication orders. The DON confirmed the order to continue the resident's routine medications had not been written on the chart. The DON said she and 2 other nurses (ADON and MDS Coordinator) were the only nurses to input data information, medications, and order changes into the computer. 10. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., she said she went to the computer and the resident's medication list from her admission to the facility on [DATE] was still in the computer. The DON said she printed it out, and used it as the current medication list. The DON said she took the list to the MD the next morning, and he reviewed and signed it. When asked about the Coumadin 3 mg. being ordered instead of the Coumadin 1 mg., she said when the order was changed in February to Coumadin 1 mg. , the order had not been entered/changed in the computer, so the original admission Coumadin 3 mg. order (1/19/11) had been printed. 11. Review of Resident #1's Recapitulation orders, dated 4/28/11 documented the following: - Coumadin 3 mg., 1 tablet, once in the evening although a phone order on 2/4/11 had reduced the amount to 1 mg per day. 12. Review of Resident #1's MAR for April, May and June 2011 documented she received 3 mg of Coumadin daily (57 days). 13. Review of Resident #1's lab results from the local hospital, documented the following: on 5/2/11 the INR was 2.7, within therapeutic range. Note: There were no lab orders found for routine monitoring of INR levels in the chart. There were no Coumadin levels found on the chart for the months of March or April 2011. 14. During a follow up interview with the DON on 6/15/11 at 2:40 p.m., when asked about how often lab values were done, the DON said the labs were usually drawn monthly, and were faxed to the MD, he would review the results, and then would call back with any orders. 15. Review of the facility's "Abuse Policy and Procedure," dated 10/08/2010, documented Neglect as: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 16. Review of the policy titled, Drug Order Procedure, no date, documented the following: - Obtain written physician's order for all drugs. NOTE: The facility did not obtain the correct dosage. 17. Review of the facility's policy for Laboratory Services, dated 12/7/2004, documented the following: - Laboratory services are obtained to meet resident needs. The facility assumes responsibility for the quality and timeliness of laboratory services. 18. During a telephone interview on 6/15/11 at 10:40 a.m., with the MD, he said he didn't know much about Resident #1. The MD said he didn't know "off the top of his head" when lab levels were done for monitoring the INR, but said it was usually done monthly. The MD said the only lab values he had in Resident #1's office chart were for 2/1/11, 2/14/11, and 5/2/11. 19. During a follow up telephone interview on 6/16/11 at 9:20 p.m., with the MD, he said if he had known the resident had been taking Coumadin 1 mg. at the time of admission he would not have changed it. The MD when asked if he reviewed the medication list before signing it said, "Apparently not, no I did not review the medications when they brought them over". The MD said the results are usually faxed to his office, and then he would call the facility with any order changes. II. Shift to Shift Narcotic Inventory Sheets 1. Review of the narcotic inventory sheets for April 2011, May 2011,and through June 15, 2011 documented the following: - April 2011 narcotic inventory sheets for Medication Cart #1 had 28 missing signatures, Medication Cart #2 had 56 missing signatures. - May 2011 narcotic inventory sheets for Medication Cart #1 had 39 missing signatures, Medication Cart #2 had 55 missing signatures. - June 1st through 15th, 2011 narcotic inventory sheets for Medication Cart #1 had 22 missing signatures, and Medication Cart #2 had 36 missing signatures. 3. During an interview on 6/15/11 at 10:02 a.m., the DON confirmed each nurse was supposed to initial the narcotic count log at the beginning and end of their shift to verify the count of controlled medications was correct. 4. Review of the facility policy entitled Narcotic Count, undated, documented the following: - Purpose: To complete a physical inventory of narcotics at change of each shift by two licensed nurses to identify discrepancies and need for reconciliation and accountability. - Procedure: a. One R.N. or one L.V.N. going off duty and one R.N. or one L.V.N. coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift. b. Narcotic records are reconciled by a physical count of the remaining narcotic supply at the change of each shift by the oncoming and outgoing licensed nurse. c. After the supply is counted and justified, each nurse must record the date and his/her signature verifying that the count is correct. 5. Review of a list of residents, received from the facility on 6/17/11, documented 26 residents who received controlled medications. III. Expired Medication 1. During an observation on 6/14/11 at 4:58 p.m., during Medication Pass, Resident #18 was given Natural Fiber Powder 5 ml, which was dissolved in 4 ounces of water. The expiration date on the original container was dated 3/11. 2. During an interview on 6/15/11 at 4:40 p.m., the DON was unsure how the expired medication was in either medication cart because the facilities pharmacy consultant checked each cart every month for expired medications. The DON stated, "I guess the pharmacy consultant was not doing their job." 3. Review of the facility policy entitled Consultant Pharmacist Services Provider Requirements, dated 10/07, documented the following: - Policy: Regular and reliable consultant pharmacist services are provided to residents. - Procedure: a. Quality assurance (random) inspections of medication storage areas, carts and rooms at appropriate intervals to check for proper storage, cleanliness and dating of medications. 4. Review of the Resident Census and Conditions of Residents (CMS Form 672), dated 6/13/2011, documented 45 residents receiving medications.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure the environment of the van was accident free, which resulted in 1 of 5 sampled residents, who had been transported by means of the facility's van, receiving a severe injury. The facility transported Resident #1 to a physician's appointment in a town approximately 60 miles away. The resident sat in her wheelchair with the wheels of the wheelchair unsecured, which resulted in the wheelchair flipping backwards. The resident sustained [REDACTED]. Failure to ensure Resident #1 and the wheelchair she was seated in, were appropriately secured when transported by means of the facility's van, resulted in Resident #1 experiencing actual harm (i.e., a laceration of her head, which required staples). Failure to ensure residents transported by means of a wheelchair were appropriately secured to ensure the wheelchair was secured, placed all 39 residents, who used a wheelchair and potentially would be transported by means of the facility van, at risk of injuries. The evidence is as follows: 1. Review of an Incident/Accident Report, dated 9/21/10, documented on that day at 11:30 a.m., Resident #1 was transported by means of the facility's van to an appointment in another town (approximately 60 miles away). It documented Resident #1 was seated in a wheelchair and flipped over resulting in a 2 cm by 0.5 cm laceration, which required 2 staples. 2. Review of the facility's Provider Investigation Report documented the following: - Licensed Vocational Nurse (LVN) "A" said Resident #1 was strapped in the proper position in the van with the appropriate buckles in place and the wheelchair brakes locked. - The resident was being transported to an appointment in a town approximately 60 miles away from the facility. - The resident was seen at a hospital approximately 60 miles from the facility to receive sutures to the back of her head. - A local automotive body shop checked the wheelchair straps and safety devices and identified no deficiencies with the straps and safety belts. - A local automotive dealer conducted a complete review for any safety problems or issues mechanically and no problems were identified. - A re-enactment of the incident revealed the straps, which the facility had used for many years, held the arms of the wheelchair securely, but not the wheelchair wheels, which would allow a resident to tip a chair with their feet or allow some movement to the wheelchair. - To prevent further incidents, the facility was going to install a new ratchet strap to hold down the wheelchair wheels, and drivers and accompanying staff would receive in-service training on how to properly apply the new straps. - All drivers and accompanying staff will be in-serviced on how to properly apply the new straps. 3. Review of Resident #1's clinical record revealed the following: - The face sheet documented she admitted to the faclity on 9/6/10 at the age of 83 with a primary [DIAGNOSES REDACTED]. - The nurse's notes, dated 9/21/10, documented she left the facility via the facility's van at 8:30 a.m. and returned at 11:30 a.m. It documented that on the way to an appointment in another town, her wheelchair flipped over and she hit her head resulting in a 2 cm by 0.5 cm laceration to the back of her head. It documented she was taken by facility van to the other town's hospital where she received 2 staples to the back of her head. - A hospital Discharge Instruction sheet, dated 9/21/10, documented she received a scalp laceration and was to return in 7 days for removal of the staples. 4. During an interview with Resident #1 on 10/6/10 at 10:50 a.m., she said she had resided at the facility for approximately one month and had admitted for therapy following a hip fracture. She said the incident in the van occurred while traveling to an appointment in another town. She said she knew the seat belt had been applied, but she did not recall if the wheelchair itself had been secured. She said just prior to the incident, the wheelchair started rolling and she fell backwards and hit her head. 5. An observation of the van while transporting Resident #6 to an appointment on 10/6/10 at 12:20 p.m., revealed Resident #6 was seated in a wheelchair with the seat belt applied and two tie-downs used to secure the large wheel of the wheelchair to the floor. The tie downs had an "S" shaped hook on either end. The "S" shaped hooks had been hooked to two floor bars, flush with the floor on either side of the wheelchair. The tie-downs had brackets that were tightened to hold the "S" shaped hooks in place. The "S" shaped hooks were not a closed system; thus, the hooks could slip off the bar. The tie-downs did not prevent the wheelchair from being able to slide from side to side. The resident was transported to an appointment less than 1 mile from the facility without incident. 6. During an interview with the Administrator on 10/6/10 at 12:43 p.m., she said she had worked for the facility many years (date of hire: 9/17/1990), and did not recall the facility previously using a tie-down system to secure wheelchairs in the van. When asked for the instruction manual for the van's wheelchair restraint system, the Administrator said they had not located the manual due in part to the age of the facility's van, approximately a 1993 model. When asked how they determined the current tie-downs were adequate to ensure the safety of residents, who sat in a wheelchair during van transportation, she said one of the local mechanics had suggested they purchase the tie-downs (with the "S" shaped hooks on either end) from a local store. When asked how they ensured their staff received the appropriate training to ensure a wheelchair was adequately restrained per the manufacturers guidelines, she said they had no reference material to base their training on and simply had instructed staff to secure the seat belt and use the current tie-downs. 7. Review of the list of employees, who had been trained to drive the van and use the van's wheelchair restraint system, revealed 5 had been trained to secure the seat belt and tie-downs. 8. During an interview with LVN "C" on 10/6/10 at 12:35 a.m., she said she had worked for the facility for five plus years and did not recall the facility securing wheelchairs beyond using the seat belt when transporting residents. She said since the incident with Resident #1, they had been instructed to use the tie-downs. She said they had no other means of securing the wheelchairs. 9. During a confidential interview, the resident said the facility had provided transportation to an appointment in the last month. The resident said they sat in the wheelchair on the facility's van. The resident said the facility previously only applied the seat belt, but they were not using tie-downs to secure the wheelchair. The resident said even with the tie-downs in use, when the van made turns, they held the seat in front of them due to the wheelchair moving. 10. During a subsequent interview with the Administrator on 10/6/10 at 3:20 p.m., she said she had been unable to locate the van's wheelchair restraint system manual. She said an on-line research of van wheelchair restraint systems revealed each one used a 4-point restraint system that locked down the wheels from 4 directions to prevent the wheels from moving. The Administrator said they had scheduled a company to install a wheelchair restraint system the following week and provided evidence of a statement from the company for installation of the system. 11. Review of the Resident Roster, dated 10/6/10, documented 39 residents used a wheelchair for mobility.