Every finding on record at Concho Health & Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure residents had the right to comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely for 2 of 3 halls reviewed (Halls, A, C and D) for environment. The facility installed screamer alarms on doors used multiple times a day disrupting the resident's life and care. This failure could place residents at risk for a diminished quality of life. Findings include:Observation on 8/11/26 at 1:00 p.m., screamer alarms were noted placed on exit doors for halls A, C, and D. The alarm on D-Hall was for housekeeping. The alarm on A-hall was for the smokers. The alarms could be heard down the hall into the lobby at the nurse's station. There was already an access key-pad alarm Interview on 8/11/26 at 1:07 p.m., the ADON stated the residents did not like the alarms. The ADON said the residents complained to the Ombudsman and the Ombudsman asked why when there was already a key-pad alarm on the door. Observation on 8/11/26 at 1:20 p.m., revealed the A-hall had one room as an office before an in-use resident room. The D-Hall had 3 rooms between the screamer alarm and an in-use resident's room. Interview on 8/11/26 at 1:23 p.m., the Housekeeping Supervisor stated the alarms were put in not too long ago because the corporate office wanted magnetic locks and they did not know how long it would be until they were approved for them. The housekeeper stated the D-hall door for housekeeping was probably in use beginning at 4 a.m. when the aides took the night trash out. The Housekeeping Supervisor stated she did not know why the screamer door was there because the facility had a key-pad alarm and the facility changed the code monthly and the alarm went off if a person entered the wrong code. The Housekeeping Supervisor stated the residents near the door did not like it going off constantly and the key-code door was the only way to go to laundry or trash. The Housekeeping Supervisor stated the alarms were loud and some of the staff get agitated and if we get agitated, how do the residents not get agitated? Review of the Daily Census, dated 8/11/26, revealed Resident #1 lived on the D-Hall. Review of Resident #1's BIMS score, dated 7/3/0/26, showed she scored an 11 of 15 (indicating she was interviewable). Interview on 8/11/26 at 3:10 p.m., Resident #1 stated she was in the facility for rehabilitation services, and she initially needed a pill so she could finally sleep. Resident #1 said the alarm would go off at 3 a.m. and make her anxious. Interview on 8/11/26 at 3:31 p.m., the Director of Rehabilitation stated the residents complained about the door to her all the time. The Director of Rehabilitation said residents refused to come to therapy due to the alarms. Review of the Daily Census, dated 8/11/26, revealed Resident #2 lived on the D-Hall. Review of Resident #2 BIMS score, dated 7/9/26, showed she scored a15 of 15 (indicating she was interviewable). Interview and observation on 8/11/26 at 3:36 p.m., Resident #2 said the alarms rang all night and kept her awake. Resident #2 stated sometimes it increased her anxiety. Resident #2 said she did not know why the facility had to have the screamer alarm because they did not have one when she first came to the facility. The alarm was clearly heard when activated even though the door was shut. Interview on 8/11/26 at 4:36 p.m., the Activity Director stated she got a lot of complaints about the screamer alarms when she had to take the smokers out to the smoking area. The Activity Director stated there was a key-pad entry on the door to the smoking area. Interview on 8/11/26 at 5:58 p.m., NA B said the alarms woke up residents, especially the ones near the door. NA B said she did not have an alarm that sounded at 4 a.m. NA B said the alarm was very annoying. NA B said the alarm would wake her up when it sounded and she would not be happy about it. NA B said there were no confused, wandering residents in the non-secured part of the facility and if a resident started wandering, they were moved to the secured unit of the facility. NA B stated staff were already becoming complacent with the alarms on A-hall and D-hall and were not looking when the screamer alarm sounded. Interview on 8/11/26 at 7:08 p.m., the ADON stated she hated the alarms because they were loud and obnoxious. The ADON said there was an alarm for the key-pad alarm at the nurse's station, and the screamer alarms were too much and described the alarm as blaring. The ADON stated it was people heard. The ADON stated the alarms triggered headaches. The ADON said she understood the purpose of them, but the staff were becoming immune to them. The ADON stated it agitated some of the residents, and one resident stood under the alarm and yelled shut up at it. The ADON stated it had increased anxiety in some residents. The ADON said a home did not have alarms going off all the time and she did not know anyone who had an alarm that went off constantly. Interview on 8/11/26 at 8:36 p.m., the Administrator stated she was instructed by the corporate headquarters to put the screamer alarms on the doors. The Administrator stated the residents hated the screamer alarm on the front door so much the facility had to take it off. The Administrator said she did not know how it contributed to a homelike environment. The Administrator said the facility had to use the screamer alarms until the magnetic lock doors came in. The Administrator stated she did not know when they were going to get the magnetic locks but she was following orders on installing the alarms. Review of the email sent by the Ombudsman (resident advocate) on 8/11/26 revealed the Ombudsman reported I have heard people complaint about those door alarms. Review of the undated Customer Service Standard revealed: We pledge to provide the finest personal service and home-like accommodations.

Based on interview, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 residents reviewed for accuracy and completeness.Facility failed to document that Resident #1 wound care was completed on 12.9.25, 12.13.25, 12.17.25, 12.19.25 and 12.22.25. This deficient practice could put residents at risk of not receiving needed services although services are documented as having been provided. Record review of Resident #1's detailed summary report/face sheet dated 12.18.25 indicated he was admitted to facility on 11.17.25 with diagnoses of heart failure, anemia, and type 2 diabetes. Record review of Resident #1's Minimum Data Set (MDS) dated 11.25.25 indicated the Brief Interview Mental Status (BIMS) score = 14 indicating resident had no impairment. Record review of Resident #1's care plan dated 12.18.25 indicated the resident has a pressure ulcer or potential for pressure ulcer development. The resident's pressure ulcer will show signs of healing and remain free from infection. Avoid positioning the resident on the location of the pressure ulcer. During an interview on 12.18.25 at 9:25 a.m., Resident #1 stated he does get his wound care as ordered by his physician. He stated he has never had an issue with his wound care and all of his wounds were healing. He stated he has never missed wound care. Record review of Resident #1's TAR indicated missed wound care for dates of 12.9.25, 12.13.25, 12.17.25, 12.19.25 and 12.22.25. During an interview on 12.18.25 at 2:15 p.m., the DON stated that she knows all residents get their wound care. She stated that if there was a blank in the TAR, this indicated an employee did not click that the care was completed. She stated but none of the residents in the facility have ever missed their wound care. During an interview on 12.18.25 at 2:35 p.m., LVN A stated that the gap in a TAR indicated that the wound care was either not done or the employee did not click complete in the electronic tracking system indicating the task was completed. She stated the miss on 12.19.25 for Resident #1 was on her shift but she remembers directly that she did do the residents wound care. She stated she must have gotten super busy and just forgot to click that the treatment was completed. She stated overall this can happen sometimes because it gets so busy in the facility. During an interview on 12.18.25 at 2:45 p.m., RN B stated she made sure to do everyone's wound care. She stated when looking at Resident #1's TAR she does see the gaps and stated that does not mean the residents missed their care it means whoever provided the care did not click out of the system notifying that the task was completed. She stated for example Resident #1's treatment on the 22nd she knows she did it but might have gotten distracted to help another resident or by other staff and just didn't click completed. Record review of facility policy titled documentation, not dated indicated: Goal-1. the facility will maintain complete and accurate documentation for each resident on all appropriate clinical records sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed.

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #1) reviewed for Abuse. The facility did not report an allegation of abuse per facility policy to the State Survey Agency (HHSC) when Resident #1 alleged abuse occurred during a recent hospital visit. This deficient practice could delay assessment and care of residents who report abuse. The findings were:Record review of Resident #1 's face sheet dated 10/17/25 revealed a [AGE] year-old female originally admitted to the facility on [DATE], readmitted on [DATE] after observation stay at Hospital #1 for delirium (a state of acute mental confusion and disorientation that can cause significant changes in a person's behavior, thinking, and perception) and readmitted [DATE] after a hospital stay at Hospital #2 with the diagnosis that included: altered mental status (a significant change in a person's level of consciousness, awareness, and cognitive function. Record review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated moderate cognitive impairment. Section G revealed Resident #1 required moderate to maximum assistance with dressing and toileting. MDS indicated no behaviors present.Record review of Resident #1's progress note dated 10/8/2025 at 3:00PM written by DON revealed she was sent to Hospital #1 emergency room at 1:00PM due to physically aggressive behavior. Record review of Resident #1's hospital records Hospital #1 revealed on 10/8/25 at 1:30PM upon arrival she was administered Ativan (a benzodiazepine medication that is used for anxiety, insomnia, and seizures) 1mg for agitation and Haldol (antipsychotic medication used to treat psychotic disorders) and placed in soft restraints. Resident #1 was discharged back to the nursing facility on 10/10/2025.Record review of Resident #1's progress note dated 10/12/2025 at 11:15AM written by RN C revealed Resident #1 reported an allegation of abuse that occurred during her hospital stay on 10/8/2025. Resident #1 stated while at Hospital #1 they took her to a back room and a very big, tall man began to repeatedly hit her with his hands on her private area and was repeatedly called her name. Record review of Resident #1's progress note dated 10/10/2025 by Nurse Practitioner indicated upon returning to facility reveals no wounds and generalized bruising to bilateral upper and lower extremities.Record review of Resident #1's progress notes on 10/12/2025 at 12:15PM written by RN C revealed there was no bruising to perineal/private area and posterior buttocks/anal area. There was an elongated bruise to the left upper anterior thigh and a circular bruise to the right upper anterior thigh. Further review of the progress note revealed resident does carry her wallet inside her brief. The progress note revealed this was reported to the Administrator. The progress note revealed Resident #1 has had a history of behaviors that have escalated in the last 2 weeks which included hallucinations, delusions, verbal and physical aggression and increased falls. Observation of Resident #1 on 10/17/2025 at 1:46PM revealed she was in bed with eyes closed lying on her back. An interview with the Administrator on 10/17/25 at 1:45 P.M. revealed she did not report the allegation from Resident #1, as the allegation occurred outside the facility. She stated RNC reported Resident #1's allegation to her. She stated she did call the ADO but did not follow up because the allegation occurred outside the facility. However, upon reviewing the abuse guidelines from HHSC, she stated she should have reported the incident.An interview with the ADO on 10/17/25 at 9:20 AM revealed they did not report this allegation to the State office when it was first reported to the Administrator on 10/12/2025. It was not reported to the State office until 10/16/2025 after ADO and Regional Compliance nurse read the progress notes. They were performing an audit of Resident #1's chart prior to readmission and read the residents allegations in the progress note. ADO stated they did not have a DON at the facility at this time and the DON reviewed all progress notes. She stated the Administrator attempted to call her on 10/12/2025 but they did not speak, and no messages were left. The ADO stated she was traveling at that time and unable to answer. She stated her expectations are for the Administrator to leave a message or continue to call. The ADO stated she did not follow up because she was traveling and forgot to return the phone call. On 10/17/2025 at 10:30AM the surveyor attempted to reach the RN C with no success. The surveyor left a message but did not receive a return call. An interview with DON on 10/17/2025 at 2:30PM revealed she was not employed on the date this allegation occurred. She was the current Interim DON and started on 10/15/2025 and does not have access to electronic health records as of this time. She stated her expectation is for and abuse, neglect, or misappropriation to be reported to her or the Administrator immediately. Record review of facilities in-service records revealed a one-on-one written in-service dated 10/17/2025 with the administrator, DON, ADON, and MDS coordinator regarding reporting every allegation of abuse or neglect to HHSC per guidelines. Abuse and Neglect in-services were started on 10/16/2025 with facility policy labeled Abuse and Neglect attached. Record review of Texas Unified Licensure Information Portal (TULIP) on 10/16/25 at 4:30 P.M. revealed no self-reported incidents regarding allegations of abuse were reported for Resident # 1 . Record review of undated facility policy on 10/17/2024 titled, Abuse, Neglect revealed: 1. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants and volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. 2. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/2024.a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegationb. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record Review of Provider Letter 2024-14 dated 8/29/2024 revealed a nursing facility must report the following types of incidents, in accordance with applicable state and federal requirements: abuse, neglect, exploitation, death due to unusual circumstances, a missing resident, misappropriation, drug theft, suspicious injuries of unknown source, fire, emergency situations that pose a threat to resident health and safety, communicable disease situations that are an unusual or abnormal event that poses a threat to resident health and safety. Do report abuse or an incident that results in serious bodily injury immediately but not later than two hours after the incident occurs or is suspected. Do report an incident that does not result in serious bodily injury immediately but no later that 24 hours after the incident occurs or is suspected.

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 (Resident #7) of two residents reviewed for infection control practices. LVN A failed to sanitize the glucometer with a germicidal wipe after she performed a blood sugar check on Resident #7. This failure could affect the residents by placing them at risk for the spread of infection. Finding include: Record review of Resident #7's admission record, dated 07/24/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included diabetes mellitus type 2 and chronic kidney disease. Record review of Resident #7's Medication Order summary, dated 07/24/25, revealed she received Insulin Solution (Insulin Asp art) subcutaneously before meals and at bedtime per sliding scale related to type 2 diabetes mellitus. During an observation and interview on 07/23/2025 at 4:14 PM, revealed LVN A used a glucometer to perform a blood sugar check on Resident #7 in her room. After the nurse checked the resident's blood sugar she went to her medication cart, cleaned and sanitized the glucometer with an alcohol prep pad. LVN A said she normally used alcohol prep pads to clean and sanitize the glucometer. She said as far as she knew that was an acceptable way to sanitize the glucometer. During an interview on 07/23/2025 at 4:55 PM, the DON said the nurse was not supposed to use an alcohol prep pad but instead they were supposed to use the germicidal wipes. The DON said if the nurse did not use the germicidal wipes it could lead to cross contamination and the spread of infections. The DON said she had not noticed the nurses not using the germicidal wipes and would be conducting more training. During an interview on 07/24/2025 at 3:46 PM, the Administrator said the nurse should have used the germicidal type of wipe to sanitize the glucometer to properly sanitize the glucometer. She said the germicidal was used to spread of germs and infections. Review of the facility's, undated, policy titled Glucometer indicated in part: Maintenance 2. Meter will be cleaned with a germicidal and allowed to air dry between patient testings.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described services that attained or maintained the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #2) reviewed for care plans. : The facility failed to ensure a Care Plan was developed to address Resident #2's dry skin (skin was not falling off the body the way it should). This failure could place residents at risk of not receiving individualized care and services to meet their needs. The findings include:Record review of Resident #2's admission Record, dated 7/23/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Vitamin D deficiency (deficiency that may cause skin to become dry and flakey) and Diabetes (a condition where the body cannot regulate its blood sugar effectively). Record review of Resident #2's Quarterly MDS Assessment, dated 4/23/25, revealed:He scored an 8 of 15 on his Brief Mental Status exam, which indicated he was moderately cognitively impaired.Resident #2 did not receive any Skin Treatments. Record review of Resident #2's Order Summary, dated 7/23/25, revealed an order dated 6/6/25 for lotion to bilateral (both sides) upper extremities every day. Record review of Resident #2's Care Plan, last updated 4/30/25, revealed no care plan for the order of lotion. Observation and interview on 07/22/2025 at 11:31 AM revealed Resident #2 in the dining room. Resident #2's cheeks were covered with flakes of dead skin build up. Resident #2 stated it was just old man stuff. The resident stated he didn't like to take shower. Interview on 07/24/2025 at 9:45 AM, the DON said Resident #2 had dry-skin scales all over his face and arms and used regular lotion to soften it. The DON stated it helped, but Resident #2 did not like to take showers. The DON said Resident #2 had a diagnosis of seborrheic keratosis, which meant the skin did not want to detach the way it should. The DON said Resident #2 stated he had a history of skin cancer years ago, but she did not follow up with Resident #2's responsible party to confirm that the information. The DON stated it did not look like Resident #2's skin condition was care planned. The DON said if the facility was doing the lotion as a treatment it should be care planned. The DON stated she had been at the facility six weeks and had not had a chance to review charts, so she did not know why the care plan was missed. The DON said the order for the lotion was signed on 6/8/25 so the facility had a month to get it into the care plan. Interview on 07/24/2025 at 11:07 AM, the MDS Coordinator stated after 14 days of admission she was responsible for the initial care plan and any MDS update. The MDS Coordinator stated the DON was responsible for putting in acute care plans which was anything between the MDS cycles. The MDS Coordinator stated the facility had Standards of Care meetings where doctor orders were discussed. The MDS Coordinator stated frequently the computer was in with the nurses at the Standards of Care meeting so they would put it in the computer at the time of the meeting. The MDS Coordinator stated she would expect a standing order to be care planned if the lotion was ordered 6/6/25. The MDS Coordinator stated she did not know why the care plan was missed. The MDS Coordinator stated she felt the care plan process was effective because the facility did not have a DON for a long time. The MDS Coordinator said the ADON would go to morning meetings and bring up changes in resident conditions in the morning meetings. Record review of the facility's policy and procedure on Comprehensive Care Planning, undated, revealed: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

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 in the facility's only kitchen in that: The facility failed to ensure kitchen staff wore facial hair restraints during meal preparation. These failures could place residents who received meals prepared in the kitchen at risk for food borne illness and cross-contamination. Findings include: During an observation and interview on 05/21/24 at 10:24 AM Dietary [NAME] D and Dietary Aide C were not wearing facial hair restraints as they each had a moustache and beard. Dietary [NAME] D and Dietary Aide C said they normally wore their facial hair restraints but had forgotten to put them on this morning. There was food set out such as chicken and cake which both staff members were currently preparing when seen without the restraints. During an interview on 05/22/24 at 10:54 AM the Dietary Manager said when staff were in the kitchen, they were supposed to wear hair restraints including facial hair restraints. The DM was made aware of dietary cook and aide not wearing facial hair restraints when they were in the process of preparing food. The DM said the staff were supposed to wear their facial hair restraints when they were in the kitchen and they knew that. The DM said she was not sure why they were not wearing them. The DM said if the staff did not wear their hair restraints that could lead to hair getting on the food. The DM said she would do some training on them wearing their facial hair restraints. During an interview on 05/23/24 at 03:24 PM the Administrator said it was expected for kitchen staff to wear their hair restraints to include facial hair restraints. The Administrator said the DM was responsible for making sure the staff wore their hair restraints. The Administrator said if the staff did not wear their hair restraints, then there was a possibility of hair landing on the food. The Administrator said she believed the failure occurred because the staff forgot to put the restraints on. Record review of the facility's document titled dietary services policy and procedures manual 2012 indicated in part: Sanitation and food handling: All employees receive instruction in sanitation during orientation and through in-services training programs. Hair nets or hats covering the hairline are worn at all times. [NAME] guards are required for facial hair.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #5, #9 and #31) of 5 residents reviewed for infection control. The facility failed to ensure: CNA E did not turn off the faucet with her bare hands after washing them and before performing personal care for Resident #5. CNA's E and F change their gloves after they became contaminated during incontinent care while assisting Resident #9. CNA B change her gloves after they became contaminated during incontinent care while assisting Resident #31. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: RESIDENT #5 During an observation on 05/21/24 at beginning at 02:46 PM CNA E entered Resident #5's bathroom and rinsed her hands (no soap was used), turned off the faucet with her bare hands and then dried her hands with a paper towel. Immediately after, CNA E entered the bathroom washed her hands with soap but turned off the faucet with her bare hands. During an interview on 05/22/24 at 4:24 p.m. CNA E stated she worked for the facility on and off for 1.5 years. CNA E confirmed she washed her hands after doing performing care for Resident #5. She said she turned on the faucet, soaped her hands, rinsed them, turned the faucet off with a paper towel and then dried her hands with a paper towel. Surveyor read the observation that she turned the faucet off with her bare hands, and CNA E said she was flustered from helping another CNA with care. During an interview on 05/23/24 at 9:42 a.m. the DON and Regional Consultant stated the expectation for handwashing was to wet hands, use soap, wash the entire hand and nails, rinse, dry the hands with a paper towel, and then use a paper towel to turn off the faucet. When asked what the expectation about handwashing was, the DON sighed, let me guess, they turned off the faucet with their hands? The DON said staff were in-serviced on how to wash their hands. During an interview on 05/23/24 at 10:24 a.m. the Administrator was informed of the handwashing observation. The Administrator agreed there was a chance of cross contamination and asked how the investigation was completed. RESIDENT #9 Record review of Resident #9's admission record dated 05/23/2024 indicated she was a [AGE] year-old female that was initially admitted to facility on 04/02/2022 with medical diagnosis that include muscle weakness, age-related cognitive decline and care provider dependency. Record review of Resident #9's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3. Always incontinent. Bowel Continence = 3. Always incontinent. Record review of Resident #9's care plan dated 05/15/2024 indicated in part: Focus: The resident has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use. Interventions/Task: Notify nursing if incontinent during activities. Apply barrier cream after each incontinent episode. Brief use: the resident uses disposable briefs. Change every 2 hours and prn. During an observation of incontinent care on 05/22/24 at 02:26 PM with CNA E and CNA F for Resident #9. CNA F wiped Resident #9 perineal area from front to back with a clean wipe each time, she did not change her gloves. Resident #9 was rolled to the side to CNA E who then wiped the resident's bottom, removed the old brief, did not change gloves and placed new clean brief. CNA E then placed barrier cream, removed the one glove that had barrier cream and put on one new glove. Both CNA's adjusted the brief, both pulled resident up in bed and without changing her gloves CNA E touched the wipes, the remote, the barrier cream container and the dresser drawer. During an interview with both CNA F and CNA E on 05/22/24 at 2:40 pm. Both CNA's stated they should have changed their gloves and hand sanitized or washed their hands before going from dirty to clean on Resident #9. CNA E stated that changing gloves and hand hygiene were used to help prevent cross contamination. RESIDENT #31 Record review of Resident #31's admission record dated 05/23/2024 indicated she was admitted to the facility on [DATE] with diagnoses which included dementia and muscle weakness. She was [AGE] years of age. Record review of Resident #31's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 2. Frequently incontinent. Bowel Continence = 3. Always incontinent. Record review of Resident #31's care plan dated 06/01/22 indicated in part: Focus: The resident has bladder incontinence. The resident has bowel incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through review date. The resident will not have any complications related to bowel incontinence. Interventions: Incontinent care at least every 2 hours and apply moisture barrier after each episode. Apply barrier cream after every incontinent episode. Check resident every two hours and assist with toileting as needed. Provide pericare after each incontinent episode. During an observation on 05/22/24 at 03:34 PM CNA B performed incontinent care for Resident #31. CNA B entered the resident's room, washed her hands and put on a pair of new gloves. CNA B then undid the resident's brief and it was noted that the brief was wet with urine. CNA B then took some wet wipes and wiped the resident's vaginal area. The CNA then rolled Resident #31 on her right side and took some more wet wipes and wiped the resident's rectal area. While CNA B performed the wiping her gloves came in contact with the resident's vaginal and rectal areas. While still wearing the same gloves CNA B then took the clean brief and fastened it to Resident #31. During an interview on 05/22/24 at 03:46 PM CNA B said she usually changed her gloves before going from clean to dirty but this time she was in a hurry and did not do it. CNA B said not changing her gloves and touching the clean items could lead to cross contamination. During an interview on 05/23/24 at 01:44 PM the DON said it was expected for staff to remove their gloves and wash their hands and install a pair of new gloves once they became contaminated. The DON said staff were supposed to change their gloves to prevent from contaminating other items. The DON believed the failure occurred because the staff got nervous and forgot to change their gloves once they became contaminated. During an interview on 05/23/24 at 03:28 PM the Administrator was made aware of the incontinent observations. The Administrator said staff were supposed to change their gloves and wash their hands once they became contaminated. The Administrator said it was the DON's and ADON's job to monitor staff to make sure those steps were followed. The Administrator said the failure probably occurred because the staff got nervous and forgot to change their gloves at the appropriate time. Record review of the facility's document titled Personal care and dated 05/11/2022 indicated in part: Start: Perform hand hygiene. DON (put on) gloves and all other PPE per standard precautions. Gently perform perineal care wiping from clean urethral area to dirty rectal area to avoid contaminating the urethral area- clean to dirty. DOFF (remove) gloves and PPE, perform hand hygiene. Provide resident comfort and safety by re-clothing (if applicable - incontinence pads and briefs), straightening bedding, adjusting the bed and/or side rails and placing call light within residents reach. Perform hand hygiene. Important points: Doffing and discarding of gloves are required if visibly soiled, always perform hand hygiene before and after glove use.

Based on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 2 medication carts (Med Cart #1), reviewed for labeling/storage of drugs and biologicals. The facility failed to secure controlled medication in a locked compartment. These failures could place the facility at risk of drug diversion and access to medications. Findings included: Observation of the facility Med Cart #1 on 05/21/24 at 03:27 PM with LVN A revealed one sublingual morphine medication blister pack in the regular section of the chart instead of in the locked narcotic drawer. An interview with LVN A on 05/21/24 at 03:50 PM LVN A stated she did not remember putting the morphine in the regular part of the med cart. LVN A stated she must have just grabbed all the medication packs and put them in the regular section. LVN A stated that she knows all narcotics need to be in the locked part of the medication for safety reasons. LVN A stated at the beginning and end of the shift the oncoming and off going nurse will do a narcotic check on the cart to ensure count is correct. An interview with the DON on 05/23/24 at 03:46 PM the DON stated that all carts should be kept orderly, medication carts should be locked when unattended and all narcotics should be double locked and signed out on narcotic sheet when given. DON stated the nurses or medication aids do a Narcotic count with each shift. A review of the facility policy titled Storage of controlled substance dated 2003, provided by the DON, reads, in part, Controlled drugs (schedule II) .will be kept in a separate, permanently affixed compartment .

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accident hazards/supervision (Resident #5). The facility failed to ensure CNA E and G demonstrated appropriate transfer techniques while using the mechanical lift for Resident #5. These failures could place residents at risk for injuries. Findings included: Review of Resident #5's Admission Record, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fibromyalgia (a condition causing widespread pain and fatigue) and reduced mobility. Review of Resident #5's state MDS assessment dated [DATE] revealed: She had a mental status score of 6 of 15 (indicating severe cognitive impairment) She needed extensive assistance of two or more people to transfer between bed and wheelchair. Observation and interview on [DATE] at 02:34 PM revealed Resident #5 was in her room in her wheelchair. Resident #5 said she was waiting to be transferred to bed. CNA E and CNA G entered the room with the lift . CNA E instructed CNA F to spread the legs of the mechanical lift and lock it. Both aides secured the sling to the mechanical lift. CNA E operated the lift while CNA G steadied Resident #5. Resident #5's wheelchair rolled forward by approximately 6 - 8 inches. Once lifted, CNA E checked Resident #5's wheelchair locks and moved the wheelchair out of the way. CNA E steadied Resident #5 as CNA G moved the lift to the bed. CNA G lowered Resident #5's bed and CNA E positioned Resident #5 in the center of the bed. CNA E told her (CNA G) to lock the lift which CNA G did. Once Resident #5 was lowered into the bed, CNA E immediately took the sling off and CNA G took the mechanical lift out of the room. Interview on [DATE] at 4:24 PM CNA E stated she worked at the facility on and off for 1.5 years as agency staff. CNA E stated she knocked on the door, found out what Resident #5 needed, left and got CNA G. CNA E stated they returned to Resident #5's room and CNA G operated the mechanical lift. CNA E stated they (CNA E and CNA G) got Resident #5 hooked to the lift. CNA E said she had to remind CNA G to spread the legs to the lift and lock it. CNA E said she locked the right side of Resident #5's wheelchair. When informed Resident #5's wheelchair moved easily 6- 8 inches, CNA E stated, it didn't lock. CNA E said she held onto Resident #5 as Resident #5 was lifted into the air and then she had to move Resident #5's wheelchair. CNA E said she remembered she had to tell CNA G to unlock the lift and she (CNA G) started to close the legs to the lift and CNA E had to tell her to stop. CNA E said they got Resident #5 moved to the bed, but the bed was so high and there was a cord in the way, CNA G had to close the legs slightly to push the legs under the bed. CNA E said she told CNA G to lock the lift before lowering Resident #5. CNA E said she remembered having to push Resident #5 to the center of the bed. CNA E said when they got Resident #5 down, they got her unhooked and CNA G took the lift out as quickly as possible. CNA E said she knew the motions and if she was focusing on her instead of trying to help her coworker she would not have messed up. Interview on [DATE] at 09:42 AM the DON said she trained the staff to get a second person. The DON said the operator of the lift, spread the legs of the lift to go around the wheelchair, locked the lift, made sure the sling was on the right way, lifted the resident, unlocked the lift, steered the lift to where it needed to go, locked the lift, lowered the lift and unhooked the resident. The DON stated the spotter made sure the sling was on the resident, held the resident while the resident was being lifted, pulled the wheelchair waly, held onto the resident while the resident was being moved, positioned the resident over the bed, held the resident while the resident was going down, and unhooked the sling. The DON said the wheelchair had to be locked before anything because they did not what the wheelchair moving out from under the resident. The DON said in-services on the lift were done on the facility's computer Inservice program. She did not answer why the therapy department did not do a return demonstration. The DON said the facility did (skill) check-offs upon hire, annually, and as needed. The DON said the aide's surveyor observed were an agency staff and a new aide who had not been a CNA long enough to need an annual check off. Interview on [DATE] at 10:24 AM the Administrator was read the lift observation. The Administrator identified that the wheelchair not being locked was an error and was a risk for injury to the resident. Observation on [DATE] at 10:59 AM of the mechanical lift revealed nothing on the boom about how to operate the mechanical lift. (There were no instructions posted on the lift on how to use it) Review of in-service provided by the facility revealed the facility provided an in-service to the staff on the correct use of the hydraulic lift [DATE]. Review of the facility's policy and procedure on Hydraulic Lift, undated, revealed: The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by the manufacturer recommendations. Goals. The resident will achieve safe transfer to bed or chair via mechanical lift device. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift. Procedure: Prepare the lift by setting the adjustable base to its widest position. Lock or unlock the base wheels according to the lift manufacturer's recommendations. Connect the sling. Pump the lift while holding the steering arm until a sitting position is assumed and the buttocks are lifted off the bed. Reassure the resident at this time. Move the lift away from the bed while holding the knees with one hand to guide the movement of the resident in the sling and steadily into the chair until the proper position has been achieved. Guide the resident to the chair and steady the chair to receive the resident. Remove the resident straps. Move the lift away from the resident. To return the resident to bed, reverse the procedure.

Based on interviews and record reviews the facility failed to ensure a notice of transfer or discharge required under this section was made by the facility at least 30 days before the resident was transferred for one (Resident #1) of 3 Residents reviewed for discharge requirement. 1) The facility failed and refused to readmit Resident #1 from the hospital where she was transferred for evaluation and treatment. 2) The facility did not give Resident #1 or the representative a discharge notice when she was transferred to another facility from the hospital. 3) The facility did not permit Resident #1 to remain in the facility and failed to initiate a 30-day discharge based upon the facility's ability to meet the resident's needs and welfare. 4) There was no documentation from the physician indicating that the resident had specific needs that could not be met in the facility. 5) The facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay that included, but was not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. 6) The facility failed to establish and follow a written policy on permitting resident to return to the facility after she was hospitalized . This failure affected discharged residents and could place the residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process. Findings Included: Record review of the face sheet for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Paraplegic (paralysis), urinary tract infection, schizoaffective disorder (chronic mental health), cerebellar ataxia (inflamed brain), cervicalgia (neck injury), dry eye syndrome, postmenopausal atrophic vaginitis (inflamed vagina), mood disorder, restless leg syndrome and insomnia (difficulty sleeping). Review of Resident #1's admission MDS assessment, dated 06/09/23, reflected the resident had a BIMS score of 08, which reflected the resident was moderately impaired. Section BO300 indicated highly impaired hearing. Resident #1 required extensive assistance with two persons for bed mobility, transfer, and toilet use, dressing, and locomotion on and off unit. Extensive assistance with one person for personal hygiene and eating. The resident required total assistance in bathing activity. Resident #1 had an impairment on both sides of upper and lower upper extremities (paralysis). Review of Resident #1's care plan dated 06/06/23 reflected care area problems with potential for uncontrollable pain, use of anti-anxiety medication and hearing deficit. However, there was no care plan for behavioral issues as reflected on the interviews with staffs and administration. During interview with SWH on 07/11/23 at 12:37pm, she said she was the Social Worker at the hospital where Resident #1 was transferred for evaluation and treatment of suicidal ideation. SWH explained Resident #1 was hard of hearing and communicated with her through a white board. SWH noted Resident#1 said she was being abuse by a staff member in the facility which made her say she didn't want to live any longer. SWH stated they treated Resident #1 and was ready to discharge the resident to the facility. She contacted ADM of the facility who said they are not taking Resident #1 back because they cannot meet her psychological needs. SWH informed the Administrator (ADM) the hospital was not a place to keep the resident and should take her back and initiate a proper discharge. She said ADM refused to take back the Resident #1. Meanwhile, Resident #1 said she did not want to go back to the facility because she did not feel safe in the facility. During interview with SWG on 07/11/23 at 1:32p.m, he said he was the Social Worker of the facility. SWG explained he was not involved in the discharge of Resident #1. He found out in the Morning meeting after Resident #1 was discharged . He said he did not know the facility did not want Resident #1 back after her discharge from the hospital. SWG explained Resident #1 has been trying to leave the facility to move to Abilene close to his brother. He called the brother who stated no facility will take her because of behavioral issues. SWG said he made several calls to different facility and none will take the resident. He explained Resident #1 constantly calls for assistance and gets very angry if the facility did not respond fast enough. SWG noted the DON and Administrator were involved with the discharge of Resident #1. He normally calls discharge residents to ensure they were getting services at home. However, Resident #1went to another facility and he did not call her. During interview with ADM on 07/10/2023 at 3:15p.m, she said she was the Administrator and responsible for the discharge of Resident #1. ADM explained Resident #1 was transferred to the hospital for suicidal ideation and did not return to the facility. The ADM was asked to provide information about the discharge of Resident #1. She said did not have documentation because she was not planning on discharging Resident #1 when she went to hospital. She stated she did not have the following: 1) Resident/Representative verbal or written notice of intent to leave the facility. 2) Comprehensive care plan that includes the resident's goals for admission and discharge 3) Discharge planning process 4) Discharge summary 5) Signed physician order of discharge 6) Notice to Adult Protective Service (APS) 7) Meeting with Interdisciplinary Team (IDT) about discharge 8) Required 30-day notice to Resident #1 9) No communication with receiving facility The ADM went on to say Resident #1 has some behavioral problems which included calling police for staff member. Resident #1 she said calls staff terrible names and was difficulty to care for. ADM explained when the hospital called to return Resident #1 to facility, she informed them she was not sure if the facility can meet the psychological needs of the resident. She told hospital she will contact corporate and let them know. In an interview with LVNA on 07/11/23 at 3:21p.m, she said was the charge nurse responsible for Resident #1 during the evening shifts. LVNA explained she admitted Resident #1to the facility and was familiar with her care. She said she was the nurse who transferred Resident #1 for suicidal ideation. She was told Resident was not coming back. LVNA explained Resident #1 was rude and hateful. She made it hard on staffs to care for her. Resident #1 she said, throws trays and utensils on the floor for no reason. She says racial words on demand and yells on staffs. LVNA stated resident told her she wanted to die which was the reason she transferred her to the hospital for psych evaluation and treatment. She said it was not safe for the Resident #1 to be in the facility because they don't have one-on-one care which she requires. During interview with PhyP on 07/11/23 at 3:45p.m, he said he was the medical doctor for Resident#1. PhyP explained Resident#1 was threatening to commit suicide and gave order to transfer resident to the hospital. He said Resident #1 was denied inpatient psychological care and the facility could not meet his needs. PhyP stated Resident #1 has chronic history attempting suicide and the facility don't have the needed staff to care for the resident. When informed of lack of documentation, phyP insisted the facility followed the discharge process. Review of Resident #1 clinical records revealed there was no documentation from the PhyP indicating the specific needs of the resident, the efforts to meet those needs and specific services the receiving facility will be able to provide that was not present in the current facility. Furthermore, there was no documentation that the safety of the residents or other residents are endangered due to clinical or behavioral status of the resident. Closed record review of Resident #1's EHRs revealed there was no documentation of the following in either resident's record: The basis for the transfer or discharge (i.e., the specific resident needs that cannot be met, the facility's attempt to meet those needs); that an appropriate notice was provided to the resident and/or legal representative; disposition of personal effects, or any documentation by a physician that the transfer or discharge was necessary for the residents' welfare or the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident or the health of individuals in the facility would otherwise be endangered. Record review of undated facility policy Admission, Transfer and Discharge reflected The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiate transfers or discharges: A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs services provided by the facility. C) The safety of individuals is endangered due to the clinical or behavioral status of the resident. D) The health of the individuals in the facility would otherwise be endangered. E) The resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicare or Medicaid, for his or her stay at the facility. F) The facility ceases to operate. Emergent Transfers to Acute Care Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected. Residents who are not sent to the emergency room , will be permitted to return to the facility, unless the residents meet one of the criteria under which the facility can initiate discharge.

Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 10 residents (Resident #44, Resident # 148) reviewed for resident rights . The facility failed to obtain informed consent from Resident #44 prior to administering Bupropion, an antidepressant used to treat depression. The facility also failed to obtain informed consent from Resident #44 prior to administering Duloxetine, an antidepressant used to treat depression in adults and generalized anxiety disorders (excessive worry and tension that disrupts daily life and lasts 6 months or longer). The facility failed to obtain informed consent for Resident #148 for Seroquel with a start date of 03/20/23. The consent on file was not signed by prescribing provider, by resident, or by resident representative prior to the facility administering Seroquel Tablet related to psychotic disorder with delusions. This failure places residents at risk of being administered medications without consent. Findings include: Record review of Record review of Resident #44's face sheet revealed admitted [DATE] with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), Type 2 Diabetes Mellitus , metabolic encephalopathy (a problem in the brain caused by a chemical imbalance), dementia a condition characterized by progressive or persistent loss of intellectual functioning), hypertension, Stage 3 kidney failure (moderate kidney damage), hypothyroidism (abnormally low activity of the thyroid gland). She was [AGE] years of age. Record review of Resident #44's admission MDS, dated [DATE], indicated he had a BIMS score of 08, which indicated he was cognitively moderately impaired. The MDS also indicated Resident #44 was receiving antidepression medications. Record review of Resident #44's care plan indicated, in part: Focus: resident requires antidepressant medication. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through review date. Intervention: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #44's medication profile dated 01/27/23 indicated in part: Bupropion Sustained Release Tablet Extended Release, every 12 Hour, 200 MG, Give 1 tablet by mouth two times a day for Depression. Duloxetine Hydrochloride capsule Delayed Release Particles, 60 MG, Give 1 capsule by mouth two times a day for Depression. Record review of Resident #44's clinical records, revealed the consent on file was signed by Family Nurse Practitioner, but not signed by resident or representative prior to the facility administering Bupropion SR Tablet Extended Release for depression with a start date of 01/27/23 and Duloxetine HCl Capsule Delayed Release Particles for depression with start date of 01/27/23. Record review of Record review of Resident #148's face sheet revealed admitted [DATE] with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), Type 2 Diabetes Mellitus, dysphagia (impairment of speech), dementia (progressive loss of intellectual functioning, memory, and abstract thinking), generalized anxiety disorder (severe ,ongoing anxiety that interferes with daily activities), psychotic disorder with delusions (unshakeable belief in something implausible). He was [AGE] years of age. Record review of Resident #148's admission MDS, dated [DATE], indicated he had a BIMS score of 08, which indicated he was cognitively moderately impaired. The MDS also indicated Resident #148 was diagnosed with major depressive disorder, psychotic disorder with delusions. Record review of Resident #148's care plan indicated, in part: Focus: resident requires antipsychotic and anticonvulsant medications for diagnosis of psychotic disorder with delusions due to known physiological condition. Goal: resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Discuss with MD, family regarding ongoing need for use of medication. Record review of Resident #148's medication profile dated 03/20/23 indicated in part: Seroquel Tablet, Give 100 mg via PEG-Tube two times a day related to psychotic disorder with delusions. Record review of Resident #148's clinical records, revealed the consent on file was not signed by prescribing provider, by resident, or by resident representative prior to the facility administering Seroquel Tablet related to psychotic disorder with delusions with start date of 03/20/23. Interview on 04/12/2023 at 1:00pm, the DON stated that the ADON and DON are in charge of obtaining consents for medications from residents or resident representatives. She stated that she was aware medication should not be administered without obtaining consents first. Record review of the facility's policy revised 02/01/2007, titled Resident Rights and Consent to Receive Psychotropic Medications indicated, in part: Consent must be obtained before the medication may be started. The attempt to receive this consent must be documented. Consent may be obtained by residents or their legal representatives giving the facility consent as indicated by signing the psychotropic consent form or, The person who prescribes the medication or his/her designee, including facility nursing staff, obtains consent from the resident or legal representative, documents in the chart that the required information was discussed with the resident or legal representative and the circumstances under which consent was given. Telephone consent will be acceptable. The facility staff will fill out the Psychotropic Permission Form which will be kept as permanent document to be kept in chart.

Based on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 10 of 41 residents (Residents #6, #10, #11, #13, #14, #17, #18, #25, #28, #32) reviewed for safe, functional equipment, in that: Residents #6, #10, #11, #13, #14, #17, #18, #25, #28 and #32 wheelchairs, to include the brakes, were not in safe working order. These failures could place residents at risk for skin issues, discomfort, and falls. Findings included: Observation, interview and record review on 4/11/23 at 3:40 PM during resident council meeting Resident #18 complained the brakes on her wheelchair were loose and that she was concerned because she knew most of the other wheelchairs in the building had similar issues. Resident #11 stated that her wheelchair brakes were also loose and had wobbly wheels but, she stated she had not reported it to anyone. On Inspection, the wheelchair brakes did not properly engage on either wheel of the wheelchair for Resident #18, #11, #10, #25 and #32. The brakes would lock but were not tight and the wheels would continue to roll even with the brake in the locked position. Resident #18 stated she had reported her brakes to a CNA but could not remember their name . No other resident had reported the brakes not working correctly to any facility staff. Record review of resident council meeting minutes book revealed no reports of any issues related to wheelchairs. Observation on 4/11/23 at 6:00 PM revealed Resident #28's right wheelchair brake not engaged. The brake would lock, but the wheel would still roll. Observation on 4/12/23 at 2:05 PM of residents gathered in the dayroom, revealed Resident #14's right wheelchair brake did not properly engage when in the locked position, Resident #6 and Resident #17's wheelchair brakes on both sides did not properly engage when in the locked position, and Resident #13's left wheelchair brake did not properly engage when in the locked position. All of the brakes locked, but the wheels continued to roll. Interview on 4/12/23 at 2:15 PM the DON, ADON, and Corporate RN stated wheelchair safety monitoring included determining which wheels roll and if the brakes worked. The ADON added they checked if brakes engaged would the wheelchair actually stop. The Corporate RN stated there was no set schedule of wheelchair monitoring. The DON stated the staff would come and tell them if there were problems with a wheelchair. The DON said if it was a weekday, the aides would come and tell the management and if it was a weekend, they would text. The Corporate RN stated there was a maintenance log and there were QR codes they could scan into their phones to access the maintenance log . They all stated loose brakes would not wait because if the resident transferred the wheelchair could move out from under them. The Corporate RN stated fixing brakes on the wheelchair was usually a quick fix completed by the Maintenance Director. Once informed of the observation the ADON stated there needed to be a sweep of the building. The DON stated the aides washed wheelchair and should check then Interview on 4/12/23 at 2:30 PM the Administrator was informed of the wheelchair brake observations. She said they don't lock?! I'll get maintenance on it right now. The Administrator stated anyone who found wheelchair brakes not working could report the issue. The Administrator said the risk to the residents was an increased risk of falls during transfers. She stated anytime there was anything wrong with equipment it should go into the maintenance book. The Administrator added if the Maintenance Director could not fix it they would order a new wheelchair. Interview on 4/12/23 at 6:34 PM the DON and Corporate RN stated there was no policy for wheelchair maintenance or resident equipment. Record review on 4/12/23 of maintenance Status Task List for date range 3/12/23 through 4/12/23 revealed no requests regarding wheelchair brake repairs.

45411 Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #5, #20, and #32) reviewed for care plans in that: Resident #5 did not have a care plan to address her pain. Resident #20 did not have a care plan to address her pain. Resident #32 did not have a care plan to address her Alzheimer's/Dementia or pain. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #5's Admission Record dated 4/12/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included arthritis. Record review of Resident #5's Annual MDS Assessment, dated 3/27/23, revealed: She scored a 9 of 15 on her mental status exam (indicating moderate cognitive impairment). She received scheduled and as-needed pain medications. She reported she frequently experienced pain at a level of 6 of 10. She received opiate medications for 7 of 7 days prior to the assessment Resident #5's MDS CAA documented pain as a triggered area that needed to be care planned. Record review of Resident #5's Order Summary Report, dated 4/12/23, revealed orders: Fentanyl Transdermal Patch 72 hours 12 mcg/hour - apply 1 patch transdermally one time a day every 72 hours (3 days) for pain and remover per schedule beginning 3/3/23 (no diagnosis) Meloxicam Tablet 15 mg, give 1 tablet by mouth one time a day related to arthritis. beginning 7/4/22 Oxycodone-acetaminophen 7.5mg/325 mg 1 tablet by mouth every 6 hours as needed for pain beginning 1/26/23. Tizanidine 2 mg 1 capsule every 8 hours as needed for pain and muscle spasms. beginning 2/7/23 Review of Resident #5's care plan, last updated 3/30/23, revealed no care plan for pain. Interview on 4/12/23 at 4:23 PM the MDS Coordinator stated there was no care plan for Resident #5's pain or pain medication. The MDS Coordinator stated she did not know why pain medication interventions were getting missed. She said any time there was a medication change the DON or whoever could do a care plan. She said new orders were reviewed every morning in the morning meetings and were on the 24-hour report and in the nurse's notes which she had access too. The MDS Coordinator stated the facility did not have a stable DON or ADON in she did not know how long so the Compliance RN had been reviewing the care plans on Monday - Wednesday - Friday . She said usually medications were added when they reviewed new orders in the morning meetings. Review of Resident #20's Admission Record, dated 4/12/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and restless leg syndrome (uncontrollable, painful urge to move legs). Review of Resident #20's Initial MDS Assessment, dated 12/13/22, revealed: She scored a 15 of 15 on her mental status exam and showed no signs of delirium (indicating she was cognitively intact). She received as needed pain medication but reported frequently experiencing pain at an intensity of 8 of 10. Review of Resident #20's Quarterly MDS Assessment, dated 3/22/23, revealed: She scored a 15 of 15 on her mental status exam and showed no signs of delirium (indicating she was cognitively intact). She received as needed pain medication but reported frequently experiencing pain at an intensity of 8 of 10. Her CAA Summary documented Pain was a triggered item and was addressed in the care plan . Review of Resident #20's Order Summary Report, dated 4/12/23, revealed orders for: Gabapentin 300 mg twice a day for Neuropathic pain dated 12/2/22. Meloxicam 15 mg for pain dated 3/25/23 Methadone 5 mg every 8 hours as needed for pain dated 12/2/22 Morphine Sulfate 15 mg twice a day for pain dated 1/25/23 Hydrocodone-Acetaminophen every 6 hours as needed for pain dated 12/2/22 Tizanidine 4 mg every 8 hours as needed for muscle relaxant. Review of Resident #20's Care Plan, last updated 1/18/23, revealed no care plan for pain. In an interview on 04/12/23 at 2:40 PM the MDS nurse stated that the comprehensive plan of care was created based upon the MDS assessment and initial baseline care plan by herself (the MDS nurse). She stated the comprehensive care plan for Resident #20 was created on 12/5/22, and although pain was triggered on the MDS assessment, it was not addressed in the comprehensive care plan on 12/5/22. The MDS nurse stated, it was an oversight on my part and I should have caught this. She also stated that changes to the care plans were done upon identified issues such as when a resident started an antibiotic or had a change in condition. She stated that she was made aware of changes to resident status during the morning meetings that occurred at 9:00AM each weekday since all department heads were present (Administrator, DON, ADON, Director of Rehab, Dietary, Maintenance, Medical Records), and each party present reported issues regarding the residents related to their discipline. Review of Resident #32's Admission Record, dated 4/12/23, revealed she was an [AGE] year old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with psychotic disturbance and anxiety, Alzheimer's Disease, and Seizures (abnormal brain activity that causes abnormalities in muscles, movement and consciousness needing specialized medication/ monitoring to control and/or other interventions to prevent injury during a seizure). Review of Resident #32's Initial MDS Assessment, dated 3/24/23, revealed: She scored a 2 of 15 on her mental status exam with no signs of delirium (indicating she was severely cognitively impaired). Identified diagnoses included: Alzheimer's Disease, Dementia, and Anxiety. (Seizures were not indicated) Review of the CAA Summary revealed Cognitive status was a triggered care area and was addressed in the care plan Review of Resident #32's Order Summary Report, dated 4/12/23, revealed orders: Gabapentin 300 mg three times a day for mild pain Memantine HCL 10mg twice a day related to Alzheimer's Disease Review of Resident #32's care plan, last updated 3/20/23 revealed no care plan for dementia/Alzheimer's disease or pain. Interview on 4/12/23 at 3:10 PM the DON stated she went and reviewed the MDS assessments to make sure the CAA Areas were triggered. In an interview on 04/12/23 at 3:20 PM the Administrator and the Director of Nurses, confirmed that plans of care were reviewed and or implemented by the Director of Nurses or Assistant Director of Nurses. The Administrator stated that the corporate Program Compliance nurse conducted audits on assessments and for Risk Management for the facility, ensured assessments matched orders and care plans, and then shared her findings with the Director of Nurses and Administrator as well as the Assistant Director of Operations. Review of the facility's policy and procedure on Comprehensive Care Planning, undated, revealed: The facility will develop and implement a comprehensive care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and the right to refuse treatment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintain his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a minimum, used the Minimum Data Set to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record. There may be times when a resident risk, weakness or need is identified within the context of the MDS assessment but may not cause a CAA to trigger. The facility will address these areas and will document the assessment of these risks, weakness or needs in the medical record and determine whether or not to develop a care plan and interventions to address the area. If the decision to proceed to care planning is made, the interdisciplinary team, in conjunction with the resident and/or resident's representative, if applicable, will develop and implement the comprehensive care plan and describe how the facility will address the resident's goals, preferences, strengths, weaknesses, and needs. 48043

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for 1 of 3 medication carts and 1 of 1 surplus-stocked medication cart reviewed for medication storage. Medication Cart #1 had seven (7) expired medications. Medication Surplus Cart had one (1) expired controlled medication of ten (10) capsules in the med storage room, available for use. This failure could place residents at risk for not receiving the therapeutic effects of the medications ordered. The findings included: Observation on 04/12/23 at 08:30 AM, of surplus-stocked medication cart, revealed: - Temazepam 7.5mg (10 capsules) expiration date 3/11/23 Interview on 04/12/23 at 09:00 AM , the ADON stated that the Consulting Pharmacist checked the locked medication cart in the medication storage room. She stated the Consulting Pharmacist rotated a review of medication in the medication storage room followed by medication carts on the floor one month and the next month conducted a review of medication carts on the floor only. He does not review all med carts and storage area each month. The ADON said the Pharmacist reviewed the medication in the medication storage area in February 2023. The ADON said the nurses look for expiration dates on medication packages prior to administration. Observation of medication cart #1 on 04/12/23 beginning at 09:30 AM, revealed : - Three foil packages of Hemorrhoidal Suppositories expiration date 3/23 - One 16 oz bottle Isopropyl Alcohol expiration date 03/23 - One package Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg/ml expiration date 2/10/23 - Two Povidone Iodine Swab sticks single-use package expiration date 08/22 - One 4 oz bottle Tincture of Benzoin Prep Spray expiration date 07/22 - One 30 oz bottle of ProStat Sugar free expiration date 6/6/22 - One 16 oz bottle Ultra Tuss Dextromethorphan Cough Suppressant expiration date 5/22 - One Povidone Iodine Swab sticks single-use package expiration date 01/21 The expired medications were stored with non-expired medications, not separated and could be inadvertently dispensed Record review of the facility policy titled Recommended Medication Storage (PA 03-3.02h) Revised date 7/2012. There is no mention of an audit process for removal of expired medications nor a responsible party who would remove the medications.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accidents hazards/supervision/devices, in that: (Resident #42). CNA A failed to complete an appropriate one-person gait belt transfer. This failure could place residents at risk of inadequate supervision and preventable injuries. Findings included: Review of Resident #42's Admission Record dated 4/11/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anorexia (lack of appetite causing abnormal weight loss), dementia with behavioral disturbance , muscle weakness, lack of coordination, and stroke. Resident #42 was on hospice services. Review of Resident #42's Significant Change MDS, dated [DATE], revealed: He scored a 6 of 15 on his mental status exam (indicating severe cognitive impairment) He needed stand by assistance of two staff for transfers. Review of Resident #42's Care Plan, updated 1/21/23, revealed a Focus: Resident has a terminal prognosis and/or is receiving hospice services. The Goal was the resident's comfort will be maintained through review. Interventions included: adjust provision of ADLs to compensate for resident's changing abilities. Review of Resident #42's Care plan, updated 10/21/22, revealed a focus of: Resident has an ADL self- care performance Deficit. The Goal was: the resident will maintain or improve current level of function through the revies date. Identified interventions included: Transferring: requires staff x2 for assistance and the resident requires total assistance with transfers, initiated 1/21/23. Observation on 04/10/23 at 12:55 PM revealed CNA A took Resident #42 to his room. CNA A rolled Resident #42 to his and checked his dresser for a gait belt; when she was unable to find the gait belt she left the room to find one. Resident #42 was observed to have tremors on his left said. LVN B came into the room with CNA A stating she had a gait belt. CNA A put the gait belt around Resident #42, scooted the resident to the end of the wheelchair and locked the brakes. CNA A tried to lift Resident #42. Resident #42 was not cooperative (did not participate in the process) and the gait belt slid up to his arm pits. CNA A let Resident #42 sit again and tightened the gait belt. CNA A put one hand on either side of Resident #42 and assisted him to stand, when the gait belt started sliding up his ribs, CNA A slightly pushed in to lift him with her hands on the sides. LVN B reached over the wheelchair and grabbed Resident #42 by the waistband. Resident #42 was not able to straighten his legs or bear weight. CNA A lifted Resident #42 into the bed where he laid back with his knees in the air like he was still sitting. CNA A took off the belt, straightened Resident #42's legs and covered him with a blanket. Interview on 4/11/23 at 6:01 PM CNA stated she worked at the facility for about a month. CNA A said she worked at the facility for about a month but had received in-service on how to transfer residents. CNA A said to complete a one-person gait belt transfer the aide was to wash her hands, put on the gait belt tight enough to fit two-fingers under it, put their feet on either side of the resident, put the aide's hands on either side of the resident, lift with the knees and transfer. CNA A said the 4/10/23 transfer did not go that way because she had not worked on Resident #42's hall and did not know the residents and what they were capable of doing . CNA A said Resident #42 had a bad day and was not bearing weight on 4/10/23. She stated a mechanical lift would have been more appropriate, but she did not think to get it. Interview on 4/12/23 at 9:45 AM the DON, ADON, and Corporate RN stated the expectation for a one-person gait belt transfer was to make sure the bed was at the same level as the wheelchair, make sure the gait belt was tight enough, explain what the person was doing with the resident, make sure the wheelchair was locked, put a hand on either side of the resident and lift with the knees. They stated if a resident was not weight-bearing they were not appropriate for a gait belt transfer and the aides did have the ability to say if a resident needed to use a mechanical lift. They said all the aides needed to do was to go to the ADON or DON and let them know . They were informed of the observation and stated the aide should have asked for help with the transfer. Interview on 4/12/23 at 10:09 AM the Administrator was informed of the improperly completed transfer. Review of the computerized in-services revealed CNA A was in-serviced on safely moving residents - lifting and transferring on 1/2/23. Review of the in-service Transfer from Bed to Wheelchair using a Transfer Belt Inservice, completed 1/10/23, revealed: Procedure guidelines for transferring from a bed to a wheelchair using a transfer belt. Lock the bed brakes and wheelchair wheels. Adjust the height of the bed to the level of the wheelchair seat. Place the wheelchair facing toward the foot of the bed, midway between the head and the foot of the bed. Position the wheelchair at a 45-degree angle to the bed on the same side of the patient's stronger side. Secure the wheels by pushing handles forward on the locks above the wheel rims. Place the transfer belt on the waist of the patient over the gown (clothes) With the tag of the belt touching the patient's gown, slide the metal trimmed end of the gait belt through the teeth on the other end. Pull the metal trimmed end away from the teeth. Tighten the belt until snug on the patient's center of gravity. The belt should be tight enough for 2 fingers to slide into the belt. Spread your feet, flex you r hips and knees and align your knees with those of the patient. Grasp the transfer belt along the patient's sides. Position yourself slightly in front of the patient, to guard and protect him or her throughout the transfer. Safety points Determine if the patient can fully assist or partially assist. Do not start the procedure until all required care givers are at the bedside. Properly apply the transfer belt. Review of the facility's policy and procedure on Moving a Resident, Bed to Chair /Chair to Bed, undated, revealed: Purpose: The purpose of this procedure is to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure: Lower the height of the bed to the lowest position. If moving a Resident from chair to bed: Place the chair so it touches the side of the bed and faces the foot of the bed (Note: have the chair on the resident's strong side) Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or the edge of the bed. If the resident can assist in the procedure, stand on the resident's weak side (Note: encourage the resident to use his or her strong side and to assist in the procedure as much as possible.) Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident. Instruct the resident to place his or her hands on the arms of the chair for support. Instruct the resident to stand and turn with his or her back to the bed and sit on the edge of the bed. Move with the resident. Should the resident become weak, pale, begin to perspire, complain of chest pain, feel dizzy or any other symptoms of acute distress, cease the procedure and summon the charge nurse.

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program, designed to provide a safe, sanitary, and comfortable environment, and help prevent the development and transition of communicable disease and infection for 6 Staff for COVID-19 (MA A, CNA C, CNA D, LVN B, EVS F and LVN E). The facility employees (MA A, CNA C, CNA D, LVN B, EVS F and LVN E) failed to wear face mask, face shield, and perform hand hygiene per facility policy. These failures could place residents at risk for contracting an infection/COVID-19. Findings include: During an observation on 9/6/2022 at 12:20 PM, MA A moved from Resident #3 room located on the hot zone (A hot zone is a section of a facility (sometimes an entire facility or even a city district) where there is a high risk of contamination by patients with an infectious disease. All individuals entering a hot zone must respect appropriate protective measures.), where she had helped her into bed. MA A left Resident #3's room proceeded to warm zone (contamination reduction zone (or warm zone) is the transition area between the exclusion and support zones. This area is where responders enter and exit the exclusion zone and where decontamination activities take place), then removed her face mask, removed her gown and other PPE , did not use hand sanitizer, and then left hot zone to come to nurse's station, (which is centrally located in the facility for all nurses and aides to work from). MA A then went to Resident #4's room to help her into bed, this was located on hallway B, another hot zone. MA A had a KN95 mask on while going back and forth between hot and warm zones. During an interview on 9/6/2022 at 3:35 PM, MA A stated the required PPE to enter the hot or warm zone was a face mask N95, face shield, gown, and gloves. She stated she wore a new set of PPE between every single resident. She stated she felt her KN95 mask was perfectly fine and was told by the facility it was good. She has been wearing a KN95 everyday she has worked. She stated she really does not understand the company's policy between working warm zone/hot zone. She stated all employees that work or enter the hot zone on hallway B, are to stay on that zone for the rest of the day or leave the facility immediately. She stated however the zone she worked, hallway D, which was both warm and hot zones, she could move about the facility even after going onto that hot zone, if any other hallway needed help. She stated you doff PPE inside the resident's room and once you exit residents room you wash your hands or hand sanitize. She stated if she doesn't not follow the policies, she can put the residents at risk for COVID 19. During an observation on 9/6/2022 at 1:03 PM, LVN B entered the warm zone, she donned a gown and gloves; no face shield was put on. She proceeded to enter the hot zone and went into Resident #3's room to help resident back into bed and came out of the room to leave the hot zone. She doffed her PPE at the entrance of the warm zone, no hand sanitation was done, and went to the nurse's station, which located centrally between all 4 hallways and started working at the computer. LVN B then went back to Hallway D's warm zone, donned PPE except for face shield, and went to Resident #2's room to assist the resident out of bed. During an interview on 9/6/2022 at 2:40 PM, LVN B stated she started working at the facility about a month ago, they had 1 positive resident. She stated there are 30 positive residents today (9/6/2022). She stated her understanding was when she was in the warm zone or hot zone the required PPE was N95 mask, face shield, gown, and gloves. She stated she did not have her face shield on because she wears glasses and was told glasses were okay to wear, she stated they are not goggles they are my everyday glasses she needed to see. She stated she was not sure why she worked the warm and hot zone on hallway D but for hallway B which was only a hot zone those nurses and aides must stay on that unit all day long and cannot come to the nurse's station or throughout the facility. She stated the N95 mask must be worn to always cover the face and nose. She stated she sometimes she did not realize it but pulled her mask down to breath. She stated you doff PPE inside the resident's room and once you exit residents room you wash your hands or hand sanitize. She stated if she doesn't not follow the policies, she can put the residents at risk for COVID 19. During an observation on 9/6/2022 at 1:05 PM CNA C on hallway D moved from Resident #5's room on the warm zone to Residents #6 room on the hot zone to get trash from the residents' rooms and the doffed PPE for both units. CNA C only had N95 mask on, she never donned face shield, gloves, or gown while on the unit going between resident's #5 and #6 rooms. The trash did touch her scrubs. During an interview on 9/6/2022 at 3:55 PM, CNA C stated the PPE to be worn in the hot zone was N95 mask, face shield/goggles, gloves, and gown. She stated she was not entering the resident's room so did not have all the PPE on. She stated she should have had the PPE on just because she was on the warm and hot zone. She stated normally she stayed in full PPE, but sometimes it just gets too hot to stay in. She stated she only works hallway D, which included the warm and hot zone. She stated she never went to any other hallway in the facility. She stated the correct order to doff PPE is, remove gloves first, then face shield/goggles, then gown, then mask and finally wash/sanitize hands. She stated that if you go into a resident's room, you are to doff your PPE inside the room in the trash can by the door. She stated but if you are working in the hallway D and have your PPE on, you are to doff the PPE in the trash can right inside the hot zone line. During an observation on 9/6/2022 at 1:35 PM, EVS F entered hallway B, full hot zone without donning any PPE. Employee only had N95 mask on. Employee walked entire hot zone to last door on left and delivered a box. Left hot zone. During an interview on 9/6/2022 at 3:05 PM, EVS F stated that he did not put any PPE on because he was not going into the resident's rooms. He stated he was only delivering some supplies to the breakroom at the end of the hallway for CNA D and LVN E. During an observation on 9/6/2022 at 2:15 PM CNA D and LVN E were on Hallway B (hot zone) with mask pulled below chin talking to each other and MA A was standing on the outside of the hot zone line wearing only a KN95 mask. All employees were only 2-3 feet apart. During an interview on 9/6/2022 at 4:30 PM, LVN E stated she believes the employees brought covid in the building and spread it through the facility by not wearing PPE properly or using hand sanitizer enough. She stated the PPE needed to enter the hot zone were N95 mask, face shield/goggles, gloves, and gown. She stated she didn't even realize she had her mask pulled down but sometimes it is difficult to breath/gets hot, so she pulls it down. During an interview on 9/6/2022 at 4:15 PM, CNA D stated she has been working the hot zone every day. She stated the required PPE to be worn on Hallway B, Hot Zone, is N95 mask, face shield/goggles, gloves, and gown. She stated because she is stuck on the hot unit all day long, she will go and check on residents and not even think about the PPE needed. She stated when she talks to her co-workers across the hot zone line, she does pull down her mask sometimes, but doesn't mean to. She stated that by not following the infection control policies, she could put the residents at risk for getting COVID 19. During an interview on 9/7/2022 at 1:45 PM, the DON stated her expectation of PPE to be worn on the warm and hot unit was N95 mask, face shield/goggles, gloves, and gown. She stated her expectation was anytime an employee is to enter the hot or warm zone all PPE must be donned to enter the zone, even if dropping something off. She stated glasses were not a substitute for goggle/face shield because they do not fully cover the eyes. She stated it must be a N95 mask and not a KN95 mask being worn on the hot and warm zones because a KN95 does not give the airtight fit needed to protect the employee. She stated all her employees know better because she did an in-service on 8/24/2022 covering donning and doffing PPE and proper PPE to be worn in warm and hot zones. She stated her expectation was any staff that was on the hot or warm zone should have a N95 that covered their mouth and nose. Record review of an In-service titled donning and doffing PPE, dated 8/24/2022, led by DON for entire staff. Addressed the instructions on proper PPE to be worn and step by step instructions for proper donning/doffing (correct order is gloves first, then face shield/goggles, then gown, then mask and finally wash/sanitize hands) of PPE before entering any warm or hot zone. Signature sheets indicated MA A, CNA C, CNA D, and LVN E had attended the in-service. Record review of an In-service titled aerosol contact precautions (aerosol procedure are procedures that create are minute respiratory particles that are small enough and light enough to remain suspended in the air), dated 8/24/2022, led by DON for entire staff. Addressed the proper PPE (N95 mask, face shield/goggle, gloves and gown) to be worn in warm and hot zones. Signature sheets indicated MA A, CNA C, CNA D, and LVN E attended the in-service. Record review of the facility's policy: Infection Control COVID-19 Response Plan, updated 3/23/2022 revealed: To minimize exposures and spread of respiratory pathogens including 2019-COVID. PPE-Specialized clothing or equipment is worn by nursing facility staff for protection against transmission of infectious diseases such as COVID-19, including N95 mask, goggles, face shield, gloves, and disposable gowns. The facility will require staff to wash/sanitize their hands after each direct resident contact.

Based on observation, interview, and record review, the facility failed to ensure resident's environment remained free of accident hazards for one of four residents reviewed for accident hazards. (Resident #1) The facility failed to: Ensure Resident #1 was unloaded from the facility van in a manner to prevent an accident. Transport Aid A failed to properly use the lift gate and lower Resident #1 to the ground. Resident #1 sustained multiple rib fractures, a compression fracture to her lower back causing her pain and psychosocial harm due to injuries that required hospitalization for pain management, physical therapy, and the need to readmit to a long-term care facility to continue rehabilitation, which prevented her from discharging home as planned. An immediate jeopardy existed from 04/14/22 until 04/22/22. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. These failures could place residents who ride the facility van at risk for severe injury or death. Findings included: Record review of Resident #1's electronic face sheet dated 04/28/22 revealed she was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses to include: Reduced Mobility, Muscle Weakness, Major Depressive Disorder, [CONDITION(S)], Pin in right hip, pain in left hip, Long term use of opiate analgesic . Record review of Resident #1's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a BIMS score of 15, which indicated she was cognitively intact. Section D Mood revealed Resident #1 experienced in a two week look back period that she felt down, depressed or hopeless, had trouble falling asleep, feeling tired or having little energy for (several days); and a total severity score of 04, which indicated minimal depression; Section G revealed that Resident #1 required limited assistance of one staff for locomotion off the unit, extensive assistance by two people for transfers and that Resident #1 required a wheelchair for her mobility device. Section J revealed Resident #1 received scheduled pain medication and received PRN pain medication. Resident #1's pain assessment interview indicated she frequently had pain, and it made it hard for her to sleep at night and limited her day-to-day activities due to pain. Resident #1's pain intensity was rated at an '8' with zero being no pain and ten as the worst pain you can imagine . Record review of Resident #1's care plan dated 03/02/22 revealed the following: .Focus: The resident has a potential for uncontrolled pain r/t fractured ankle .Goal: the resident will not have an interruption in normal activities due to pain through review date. Date Initiated: 02/04/22, Target date 05/10/2022 . Focus: The resident requires antidepressant medication for diagnosis of Major Depressive Disorder Date initiated: 02/07/22 . Monitor document and report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, [CONDITION(S)], negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fe ar of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance, date initiated: 2/07/22 .Focus: The resident has an ADL Self-Care Performance Deficit .Goal: The resident will maintain or improve current level of function in bed mobility, transfers, dressing, toilet use and personal hygiene through the review date .Interventions/Tasks: The resident uses a wheelchair .Transfer .The resident requires mechanical aid for transfers. Focus: The resident has limited physical mobility Date Initiated 03/02/22 Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date .Mobility The resident uses a wheelchair for locomotion .Provide supportive care, assistance with mobility as needed. Document assistance as needed . Record review of Resident #1's Post Op visit orthopedic surgeon consult on 04/14/22 at 11:45am revealed the following: . [Resident #1] has good radiographic and clinical healing of her injury (right ankle closed reduction and external fixation). Given her significant comorbidities, I do still want to be cautious with advancing her activities .As soon as she can safely perform transfers, I am okay with her leaving her current SNF for home .I would like to see her back in 2 months with repeat x-rays . Record review of the Event Nurses-Note 12hr Fall dated 04/14/2022 13:35 (1:35pm) .Event .Nursing description of the event .Resident returning from doctor appointment, lift lowering with resident in it, chair caught on lift causing resident to flip backwards, hitting head .location event occurred: outside .fall, witnessed, hit head .injury: yes, skin tear or laceration .back of head .unknown sent to ER .other information related to skin tear or laceration .unable to assess related to resident complaints of chest pain, back pain .vitals blood pressure 128/86 .Temperature 97.6 .Pulse 98, regular .Respiration 16 breaths per minute .Initial Treatment .sent to ER .Notification [Physician A] 04/14/2022 (physician A was at the facility at the time of the incident) .Resident #1 was her own responsible party .Physical Factors .None .Electronically Signed by [LVN A]. Record review of the Provider Investigation Report dated 04/14/2022 at 8:00pm revealed the following: Resident #1 was not independently ambulatory, did have the capacity to make informed decisions .Description of the Allegation: Resident had returned from transportation on 04/14/22 and was in the van with facility van driver, [Transport Aid A]. [Transport Aid A] was in the process of unloading resident and moving her from the van to the lift when the resident's wheelchair began tilting backwards resulting in a fall .Injury or adverse effect; yes .Description of injury: Resident was transferred via EMS d/t expression of pain in torso area. After evaluation at ER, X-ray results indicated multiple displaced left sided rib fractures .Received results on injury at approximately 6:30pm. No other injuries noted at this time .Assessment: Date 04/14/2022 Time 1:30pm, Description of Assessment: [LVN A] charge nurse, immediately assessed the resident. Vitals taken WNL, bleeding noted to back of head area and treated as indicated, DON and AIT were in the facility at time of incident and assessed with care as well, Medical Director [Physician F] was also in facility at time of incident and helped with care. Resident alert and oriented at time of fall and able to make needs known .Provider Response: Immediately following incident, charge nurse, DON and medical director completed assessment of injury and treated as indicated. EMS was called and resident was transported to ER. DON, AIT, and administrator were present in facility at time of incident. Compliance nurse and ADO notified .Investigation Summary .Resident had returned from transportation and was in the van with facility van driver, [Transport Aid A]. [Transport Aid A] was in the process of unloading resident and moving her from the van to the lift when the resident wheelchair began tilting backwards resulting in a fall. Resident was transported to hospital via EMS D/T expression of pain in torso area during initial assessment. Upon receipt of Xray results at approximately 6:30pm, it was determined that resident had multiple displaced left side rib fractures. D/T Xray indication rib fractures witness fall with injury is confirmed at this time. Investigation Findings: Confirmed .Provider Action Taken Post-Investigation: AIT and Administrator completed drug screen on driver [Transport Aid A], all results negative. Post-accident injury packet was completed. Driving record checked and clear, witness statements from staff obtained at time of the incident. Driver has been removed from driving van until retraining and reeducation. In-serviced initiated with returned demonstration to all facility van drivers. Initiated in-service on loading/unloading and abuse/neglect. Self-report monitoring tools for neglect or unknown injury and unloading and loading. Electronically Signed [AIT] Date 04/21/22. Record review of the witness statement, dated 04/14/22 revealed the following: name of witness: [Transport Aid A] .Issue Related to: [Resident #1] .Got back from transport got [other resident being transported] off. [Maintenance Director] came and took her in. I went to unstrap [Resident #1]. I thought I had put the lift back up, when I unstrapped her pushed back, then the beeping went off, thought it was going off because the wheelchair was getting stuck next, I know she is flipping back to the ground. I was standing in front of her .The statement above is true to the best of my knowledge. [Transport Aid A] Date of Statement 04/14/2022. In an interview on 04/28/22 at 12:50pm, Resident #1 recalled the incident and stated that she had been to a follow up appointment with her orthopedic surgeon [Physician C] earlier that day (04/14/22) and that Transport Aid A was driving her and there was her and another resident when the transportation van arrived at the facility. Resident #1 said that Transport Aid A assisted the other resident off of the van first and then proceeded to assist her. Resident #1 recalled the Maintenance Director coming out to assist Transport Aid A with unloading the residents and stated that he took the other resident after she was unloaded and proceeded to push them into the facility. Resident #1 stated that Transport Aid A proceeded to climb into the van and unfasten the safety belts that were holding her wheelchair in place. Transport Aid A then went to push me in a backwards motion towards the back of the van, the lift gate was not level with the van, it was still on the ground from the resident prior and when she pushed me off, my wheelchair went down and I basically fell out of the wheelchair, landed on my back; I immediately was in a lot of pain and was very anxious. I was having a] hard time breathing and [Physician F] came out there to check on me. Resident #1 said she knew something bad was wrong because she was having a hard time breathing. Resident #1 said EMS came and took her across the street, Resident #1 did not feel that Transport Aid A did anything intentional and felt that it was just a mistake and knew she felt terrible. Resident #1 stated she had gone on many trips in the facility transportation van and had always felt safe and was secured properly. Resident #1 said she felt that Transport Aid A didn't realize she forgot to bring the lift back up after unloading the previous resident and just didn't see that the lift was not back there when she was pushing me from inside the van. Resident #1 said that she had been transferred to a higher level of care hospital, where she was currently receiving pain management and physical therapy. Resident #1 said that she had plans to discharge home within a week prior to the accident and that now since she has had this setback, she would not be able to go home for a long time and was scared that she was going to lose her low-income housing due to being gone for longer than a 90-day period. Resident #1 said that the facility had reached out to her, come by to visit a couple of times and stated she was not angry at anyone specifically but was just angry at the situation since it was not going to allow her to be able to discharge home as planned. Resident #1 voiced that she was scared to return back to the nursing home for fear that she might not ever get to regain her strength and be able to live independently. Resident #1 stated that she was not sure what pain medication she was taking but knew that it had increased from what she was taking in the nursing home, which was a [MEDICATION(S)] patch and Tylenol #3. Resident #1 said she was taking oral medications, patches and IV medications for her pain management. In an interview on 04/28/22 at 1:41pm, Transport Aid A said that she had worked at the facility for five years and lately had been doing most of the transports. Transport Aid A said that she had received training on the transportation van and the lift gate before she started driving the transportation van, which was about 3 years ago. Transport Aid A said that she recalled the incident on 04/14/22 and stated that she had taken Resident #1 to a doctor's appointment and had picked another resident up that was a new admission. Transport Aid A said that when she arrived back at the facility, she unloaded the resident that was a new admission and when she had unloaded her, the maintenance director had come outside to assist her with wheeling that resident into the facility. Transport Aid A said that as she transferred care from that resident, she then proceeded to climb into the van and started assisting Resident #1 with her wheelchair straps and unsecured her from the facility van, she said that she then proceeded to push Resident #1 in a backward motion towards the back of the van to place her on the wheelchair lift. Transport Aid A said that she heard a beeping from the facility van and noticed that Resident #1's wheelchair wheels were caught on the metal plate so she then proceeded to pull Resident #1 forward and then push her back when she heard the alarm sound again, however by that time, Resident #1's back wheels to the wheelchair had already started falling from the facility van and Transport Aid A could not hold on and then she realized the lift gate had not been raised up and was still at ground level. Transport Aid A said Resident #1 proceeded to fall from the back of the facility van onto the lift that was on the ground. Transport Aid A said that she got out of the van to help Resident #1 and the Maintenance Director was still outside and hollered at the facility staff inside the building to come and assess the resident and alert them of the accident. Transport Aid A said that staff immediately responded to Resident #1 to assess her and provide assistance, EMS was called and [Physician F] was in the facility and came immediately to the incident. Transport Aid A said Resident #1 was complaining of chest pain and was telling staff that she could not breathe. Transport Aid A said she was immediately asked to go inside and write a statement, she received one on one training and in-servicing, had to take a drug test, and had voluntarily removed herself from transporting residents in the facility van due to the emotional distress it had caused her. The Transport Aid A said that she did not feel she was distracted or recalled anything specific that occurred prior to the incident other than it might have been a distraction for the Maintenance Director to have come out and taken the resident she initially unloaded and that could have possibly disrupted her routine and caused her to forget to return the lift to its upward position, but she didn't feel it was any one thing. Transport Aid A said she had been battling a family loss and perhaps that was it. In an interview on 04/28/22 at 2:16pm, the Maintenance Director said that he was working the day of the incident and recalled the incident. The Maintenance Director said that he saw Transport Aid A pull up in the facility van and went out to assist her with unloading a resident. The Maintenance Director said that he assumed care of the resident Transport Aid A had unloaded and proceeded to take that resident inside the facility. The Maintenance Director said he was waiting for staff to open the facility door when he heard Transport Aid A hollering for help. The Maintenance Director said he went around and saw Resident #1 on her back in her wheelchair and Resident #1 was verbalizing that she was hurt. The Maintenance Director said that he alerted the facility staff to come and assist with the accident and there was even a doctor [Physician F] in the facility that responded. Resident #1 voiced that she was hurting really bad and all the nursing staff and [Physician F] stayed with her until EMS arrived, then she was taken across the street to the hospital and later transferred to another hospital. The Maintenance Director recalled training Transport Aid A prior to the incident how to operate the transportation van and lift gate. The Maintenance Director said that the beeping is caused by limit switches that tells the person unloading or loading a resident that something is not right. The beeping was sounding that day because the ramp was still in a lowered position and was not at the level of the van. The Maintenance Director stated that Transport Aid A should have stopped and inspected the ramp to see why it was beeping. The Maintenance Director said on the day of the incident the facility transportation van and the lift gate were functioning as it should with no need of any kind of repairs to his knowledge. Record review of Transport Aid A's transportation aid training and Driving Test as well as a Driver Training Post Test was performed on 12/19/19 and again on 04/22/22. In addition, there were seven other staff members that were trained and approved to drive and transport residents in the facility van; all of which had had previous training prior and were all retrained with return demonstration on 04/14/22 and 04/19/22. In an interview on 04/28/22 at 2:54pm, the Administrator said that she was in the facility at the time of the incident. She said that she recalled she was in her office and staff had come and alerted her of the incident. The Administrator said that she was told the Maintenance Director had gone out and was helping Transport Aid A with unloading residents from the facility van. Transport Aid A was unloading Resident #1 from inside the van and the lift was in its lowered position and as she was pushing Resident #1 backwards Resident #1 fell from the van onto the lift that was already on the ground. The Administrator said that the medical director [Physician F] was in the building and the DON and Director of Rehab immediately responded to the incident as well as EMS was contacted. The Administrator said that once Resident #1 was transferred to the high level of care hospital it was learned that she had sustained multiple fractures to her ribs and would be admitting there for pain management. The Administrator knew that herself, the admissions coordinator, and the DON had all been by to check on Resident #1 since she had been in the hospital and was awaiting her to return to the facility for additional therapy. The Administrator said that it was an unfortunate event, and that Resident #1 was actually very close to being able to discharge home. The Administrator said that after the incident immediate action was taken and statements were obtained from Transport Aid A, drug testing was performed, immediate in-servicing began for all van drivers and transport aids. We suspended Transport Aid A during our investigation, our risk management team from the corporate level got involved and assessed the incident, review of transport policy and procedures was performed, procedure has changed and now is to where staff must inspect, walk onto the ramp prior to unloading a resident to ensure the ramp is safe, secure and in the proper location to unload a resident from the facility van. The Administrator said she had only been the interim Administrator for a short amount of time in the facility and said that the Maintenance Director is responsible for training staff to drive and operate the facility transportation van and unless a new vehicle or equipment was received to her knowledge there was no additional training required. In an interview on 04/29/22 at 8:58am, Physician F said that he was in the facility the day of the incident and recalled being asked to go out and assist with the incident. Physician F recalled being on the scene of the accident within about two minutes from the time it occurred and recalled Resident #1 had fallen from the facility van while attempting to be unloaded by staff member. Physician F said that Resident #1 went backwards out of the van and hit herself in the back of her head. Physician F said that we did not move Resident #1 and EMS was contacted immediately. Physician F indicated that the paramedics were the ones to move Resident #1 from her wheelchair and that he recalled upon his initial assessment of her that she complained of pain in her lower back, she was fearful, she was emotional and crying, she was upset and voiced that she was just about to be able to discharge home. Physician F did not recall Resident #1 voicing to him about chest pain or having difficulty breathing. Physician F said that she had a small abrasion to the back of her head but no other visible injuries and recalled she was alert and responsive. In an interview on 04/29/22 at 9:27am, Resident #1 indicated that she did have chronic pain prior to the incident but not in the location she is suffering from now. Resident #1 indicated that she was managed well in the facility prior to the incident on a [MEDICATION(S)] Patch and Tylenol #3. Resident #1 indicated that her pain is a 10 on a 0-10 pain scale with 0 being no pain and 10 being the worst pain ever. Resident #1 said that once she is medicated and remains still her pain level is reduced to a 7, which she still has the pain, but it is not as intense. Resident #1 said it does interfere with her sleeping and mobility. Resident #1 said that the incident has affected her tremendously from an emotional standpoint, she said she was about to get to go home and live independently, however now this has her in rehabilitation for at least 6-8 weeks longer and that has her concerned about getting evicted from her apartment and fears she will have to live at the nursing home long term. Resident #1 said that she had a lot of anxiety and fear over everything that has happened to her. In an interview on 04/29/22 at 1:05pm, the AIT said that she had learned about Resident #1's anxiety and concern about losing her apartment and had reached out to Resident #1 to offer assistance with contacting the apartment complex but Resident #1 stated that she had a friend helping her. The AIT said that as far as she understood Resident #1 was to readmit back to the facility for rehabilitation, where she would be given her own private room due to the extent of the incident and that a non-emergent ambulance had been offered to her if she was fearful of riding in the facility transportation van when she is discharged from the hospital. In an interview on 04/29/22 at 1:17pm, the DON said that she was in the facility the day of the incident and recalled a staff member running inside the facility and asked for assistance outside. The DON said she ran outside and there were already two other nurses and Physician F, along with Transport Aid A and the Maintenance Director. The DON said that she grabbed a towel due to the injury to the back of Resident #1's head and knew that EMS were on their way. The DON said that Resident #1 was not moved until EMS arrived. The DON recalled Resident #1 voicing that she had pain, however she was in good humor laughing and singing with Physician F. The DON did not recall Resident #1 being in distress or complaining of pain. The DON said after the incident we immediately got on a conference call with the corporate office and started the investigation, which led to suspending Transport Aid A, obtaining a drug test from her, retraining not only her but all staff that transported residents or drove the facility van. The DON said that the training consisted of proper loading/unloading of a resident, the beeping sound indicated something was wrong with the lift and that inspection was necessary to proceed further if unloading or loading a resident. Observation and interviews on 04/29/22 at 1:20pm with three employees that are trained and operate the facility transportation van, the Activity Director, the ADON and the Maintenance Director all were able to recall the in-service performed on 04/14/22 and 04/19/22 and were able to verbalize the appropriate steps to load/unload a resident from the facility transport van as well as verbalize what the alarm sounding on the facility van signified and indicated that they would stop and inspect the lift if the alarm started sounding. In an interview on 04/29/22 at 1:43pm, Physician A said that he had been one of the physician's overseeing Resident #1's care at the local hospital and implied that she had suffered from multiple rib fractures and implied that there was a deformity on her lower lumber 5 vertebrae, however he did not have a definitive answer as if the fracture to her L5 vertebrae was new or if had been seen on a previous study. Physician A felt that it was reasonable to assume it was from the incident but would need to reach out to the radiologist and the neurosurgeon to confirm the findings. Physician A indicated that the L5 fracture was not present on a previous study from November 2021. Physician A said that currently Resident #1 was still being treated as an inpatient for pain management and indicated that due to the multiple rib fractures there was significant pain no doubt, however the plan would be to move toward trying to wean her off of the IV [MEDICATION(S)] and [MEDICATION(S)]. Physician A indicated she was on quite a bit more pain medication currently from what she was admitted on and his expectation was for Resident #1 to remain in the hospital through the weekend. In an interview on 04/30/22 at 11:10am, Physician A, the lumbar spine CT shows a burst fracture at L5 that neurosurgery is going to reevaluate. It was felt that this is certainly new and related to her injury. According to [NAME]-[NAME].org, A compression fracture is a condition in which a vertebra is crushed only in the front part of the spine, causing a wedge shape. If a vertebra is crushed in all directions, the condition is called a burst fracture. Burst fractures are much more severe than compression fractures. The bones spread out in all directions and may damage the spinal cord. This damage can cause paralysis or injury to the nerves, which control the body's ability to move or feel sensations. Symptoms; Signs of a burst fracture include: Moderate to severe back pain made worse by moving, numbness, tingling and weakness, inability to empty the bowel or bladder properly, if the spinal cord is involved .Causes and Risk Factors . Burst fractures are usually the result of a motor vehicle accident or a fall from a great height . Treatment depends on how bad the burst fracture is. Options may include either nonsurgical approaches or surgery. If there is pressure on the spinal cord, the nerve roots or both, surgical treatment is usually recommended . Accessed on 05/02/22. https://www.[NAME]-[NAME].org/health-library/diseases-and-conditions/b/burst-fracture.html#:~:text=A%20compression%20fracture%20is%20a,is%20called%20a%20burst%20fracture. Record review of Resident #1's emergency department Provider Notes dated 04/14/22 6:19pm revealed the following: .Chief Complaint Patient presents with fall, XXX[AGE] year-old female presents emergency department via EMS with multiple rib fractures. Patient was in a wheelchair van and with her caretaker went to back her off onto the wheelchair ramp in the ramp was down on the ground and she fell approximately 3 feet onto her back. She was taken to the local emergency department she had a CT of her head which showed no acute abnormality. CT of her cervical spine showed no CT evidence of acute fracture. CT of her lumbar spine showed age indeterminate Schmorl's nodes (disc herniation) and concavity as the superior endplates of L3 and L5. Diffuse osteopenia. CT of the chest showed multiple bilateral displaced non-displaced rib fractures some involving the anterior to the lateral second through 8th rib with non-displaced fracture of the lateral left 9th and 10th rib. Non-displaced fractures of the anterior right 4th and 5th with displaced fractures of the lateral right 6th and non-displaced fractures of the right 7th and eighth. There is no CT report of her thoracic spine we are currently attempting to reach out to the local hospital for that. Patient's main complaint is pain on bilateral chest with pain with breathing .Physical Exam: She is in acute distress .Chest wall: tenderness present . BONES: There is compression deformity of the L5 vertebral segment on today's study. This was not seen on prior exam. Acute to subacute compression deformity of L5 is suspected. Displaced slightly impacted fractures of the left seventh, eighth and ninth ribs anteriorly are noted. This is not fully evaluated on this study. According to the American Association of Neurological Surgeons, Vertebral compression fractures (VCFs) occur when the bony block or vertebral body in the spine collapses, which can lead to severe pain, deformity and loss of height. These fractures more commonly occur in the thoracic spine (the middle portion of the spine), especially in the lower part . People with healthy spines most commonly suffer a VCF through severe trauma, such as a car accident, sports injury or a hard fall .Symptoms: the main clinical symptoms of VCFs may include any of the following, alone or in combination: sudden onset of back pain, an increase of pain intensity while standing or walking, A decrease in pain intensity while lying on the back, Limited spinal mobility .Pain secondary to acute vertebral fracture appears to be caused in part by vertebral instability (nonunion or slow-forming union) at the fracture site. VCF-related pain that is allowed to heal naturally can last as long as three months. However, the pain usually decreases significantly in a matter of days or weeks. Traditionally, people with severe pain from VCFs have been treated with reduction in activities other than those which involve caring for yourself, medications, bracing or invasive spinal surgery, often with limited effectiveness. Extended inactivity should be avoided. Over-the-counter pain medications are often effective in relieving pain. Both acetaminophen and nonsteroidal anti-[CONDITION(S)] drugs (NSAIDs) are commonly recommended. Muscle relaxants and medicines for nerve/bone pain are often prescribed. Opioids should only be used for very short periods of time (1-2 weeks) for acute pain . Accessed on 05/02/22 https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Vertebral-Compression-Fractures Record review of the hospitalist admission History and Physical dated 04/14/22 at 10:00pm revealed the following: .Patient was following up with Orthopedic surgery today [Physician C]. After the appointment patient was taken back to SNF rehab where she is supposed to be for another week. Unfortunately, while being transferred with her wheelchair patient fell from a height about 4 ft and landed on the ground. Apparently, she landed on her head. No loss of consciousness. Injured chest area. Was seen at outside hospital and had extensive workup, imaging. Findings of multiple bilateral rib fractures. Patient was then transferred to local hospital. Prior to transfer patient received [MEDICATION(S)], [MEDICATION(S)] and insulin. On arrival heart rate 126 and now 111. CT T-spine with no acute findings. CT abdomen pelvis with contrast demonstrated L5 compression fracture. In the ER patient received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]. ER physician discussed this case with [surgeon] . Musculoskeletal Bilateral rib pain, lower back pain [GD.1M] . Assessment and Plan: 1 Multiple bilateral displaced and nondisplaced rib fractures. Some acute while some appear chronic. Continue [MEDICATION(S)] patch, [MEDICATION(S)] patch. Incentive spirometry. Physician D surgery was consulted by ER physician. Patient also on [MEDICATION(S)], [MEDICATION(S)][GD.1M] 2. Compression deformity L5. Continue pain medication. May require neurosurgery consult a.m. Pain meds as noted above [GD.1M] 3. [CONDITION(S)], likely sinus tachy [TRUNCATED]

Based on observation, interview and record review, the facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status for 1 (Resident #9) of 13 residents reviewed for resident assessment. The facility failed to accurately assess Resident #9's weight loss. This failure could result in the resident not receiving appropriate treatment and interventions to maintain an ideal weight. Findings include: Observation of Resident #9 on [DATE] at 1:29 PM revealed an [AGE] year-old female resting in bed. Resident #9's bed was in the lowest possible position with fall mat at bedside. Resident #9 was frail and malnourished. Resident #9 restless but content. Resident #9 was not able to answer questions asked of her. Review of Resident #9s care plan dated [DATE] lists significant weight loss and resident had medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident care plan dated [DATE] revealed the following: Focus: Potential Risk for Malnutrition; Goal: Maintain stable weight and nutritional parameters; Interventions: Monitor and document meal intake, monitor resident weights, monitor resident's labs, notify the physician for any negative findings, abnormal labs, or resident non-compliance, offer diet as ordered by the physician, update food preferences as needed Focus: Resident has a Regular diet Pureed Diet; Goal: Resident will maintain ideal weight and receive proper nutrition daily x 90 days; Interventions: Determine food preferences and provide within dietary limitations, encourage meal completion and document amount consumed, monitor weight per facility protocol, offer sub, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%, Serve diet and snacks as ordered Focus: The resident has a significant unplanned/unexpected weight loss; Goal: The resident's weight will stabilize within 4 weeks; Interventions: Encourage food related activities, give the resident supplements as ordered. Alert nurse if not consuming on a routine basis. Health Shake three times a day for Weight Loss with meals. Labs as ordered. Report results to physician and ensure dietician is aware. Monitor and record food intake at each meal. Monitor and report any changes in the residents eating habits to the DON. Notify the dietician of the weight loss upon their next visit. Notify the physician, resident, and family of the weight loss. Place a Red Glass on the resident's meal tray to identify the resident to staff as possibly needing assistance, encouragement, and substitutes. Provide hands on assistance with resident during meals. Provide resident the diet as ordered by the physician. Regular diet, Pureed texture, Regular consistency ** ADD RED GLASS PROGRAM**. Weigh the resident weekly for at least 4 weeks or until weight has stabilized. A review of Resident #9s MDS dated [DATE], Section K revealed no weight loss noted for the resident and no swallowing disorder. Review of MDS dated [DATE] and MDS dated [DATE] revealed the same. There was no significant change MDS completed for Resident #9 at the time of record review. A review of Resident #9's dietary note dated [DATE] which stated WT: 112.2#, down 23# for past 90 days, down 15# for past 30 days. Diet: Pureed, red glass, health shakes TID, eating ,d+[DATE]% of meals, improved appetite per nursing. No skin breakdown is noted. Labs from [DATE]: Gluc-75, Bun-13, Cr-.8, K-3.4, TP-7.1, Alb-3.6. [MEDICATION(S)] noted [DATE], [MEDICATION(S)] noted [DATE]. Pepcid noted [DATE]. Diet ordered and fortified foods adequate for weight gain/maintenance. Encourage good po/fluid intake. Monitor closely. A review of Resident #9's assessments on [DATE] at 10:15 AM revealed a nutrition risk assessment dated [DATE] which stated the resident's risk score was 19 or at risk for malnutrition. A review of Resident #9's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 11:25 AM with the Administrator, DON, ADON, MDS Coordinator and the Regional Compliance RN, the DON stated that the dietician is in the facility monthly to give recommendations. The dietician completes a Nutritional risk assessment annually, unless there is a significant change, at which time the risk assessment is completed again. The MDS Coordinator stated that the resident MDS assessment is done quarterly unless there is a significant change, at which time a new MDS is done, and the care plan is adjusted. She stated the weight loss should have been addressed as a significant change. Speech therapy determines need for diet change which is passed on to and approved through resident's physician. She was unable to explain why the Resident #'9s MDS did not reflect any changes in weight or the admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Compliance RN stated that the physician is or should be notified when a weight watchers assessment is done. The assessment also has an area for orders if any are given when the physician is notified. The Administrator stated that care team/standards of care meetings are held at least once a month, but each resident is discussed in daily meetings. Weights trigger on 24-hour report if there is a decrease so the team is able to address the issue immediately. The DON stated that if a resident is losing weight, the nurses notify speech therapy to evaluate, the ADON will talk with resident about what's going on and why they might not be eating, and a medication review is done to determine if the weight loss is a medication side effect. The ADON stated that Resident #9's husband died in [DATE] and Resident #9 was having behavioral issues before he died relating to his presence (he was also a resident at the facility, and they shared a room). The ADON stated that Resident #9s weight loss began in [DATE]. ADON stated that the weight loss appeared to be due to the grieving process. ADON stated that Resident #9 seemed to always eat well and that she was provided foods of her preference. ADON stated that even though she was not able to communicate well Resident #9 did tell them if she liked something or not when asked in a manner that she could say yes or no.

Based on interview and record review, the facility failed to inform residents and/or responsible parties in advance of the risks and benefits of proposed care and treatment for 1 of 3 (Resident #1) reviewed for consent to receive the covid-19 vaccination. The facility failed to obtain written/verbal consent from Resident #1's legal guardian prior to Resident #1 receiving his first Pfizer vaccination on 01/16/21. This failure could place residents and/or their legal guardians at risk of being unable to exercise their rights to make informed decisions regarding their treatment. Record review of Resident #1's electronic face sheet dated 10/28/21 revealed he was an [AGE] year old male admitted to the facility on [DATE]; Guardian A was listed as Resident #1's Guardian under emergency contacts, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Letters of Guardianship dated 09/16/20 revealed, [Guardian A] appointed as Guardian of the Person and Estate of [Resident #1] on the 20th day of August 2020, with full authority except as provided by law. The Guardian qualified as such on the 16th day of September 2020 Record review of Resident #1's most recent quarterly assessment dated [DATE], revealed a Brief Interview of Mental Status score of 03, which indicated severe cognitive impairment. Record review of Resident #1's care plan dated 9/22/20 revealed the following: Date initiated: 09/22/20, Revision on 10/15/20 Focus: The resident has impaired cognitive related to (r/t) dementia and impaired thought processes . Focus: I have recently recovered from COVID-19 .Date initiated 11/18/20, Revision on 12/04/20 .I will return to my prior health status prior to COVID-9 within 90 days .interventions/tasks .Notify primary care physician (PCP) and family changes as needed (prn) . Record review of Resident #1's immunization record in his electronic health record revealed he received the first vaccination for Covid-19 on 01/16/21 in his left deltoid muscle. Record review of the facility provided Covid Vaccine Intake Consent Form revealed the following: Patient Information [Resident #1] .If someone else manages health decisions on behalf of the resident, please provide the following: [Guardian A] .Signature of patient to receive vaccine or person authorized to make the request was blank, vaccine administration information for immunizer/Pharmacist use only was also blank. In an interview on 10/26/21 at 8:46am, Guardian A said that she is Resident #1's legal guardian and that she was not contacted prior to him receiving his first COVID vaccination on 1/16/21. Guardian A said that after seeing the local news talk about the long term care facilities holding vaccine clinics she contacted the facility and asked the staff when they were going to get the vaccines for residents, Guardian A said that a staff member told her that the facility had already had their first vaccine clinic. Guardian A then questioned the staff member if Resident #1 had received the vaccine because she had not been contacted. Guardian A said that the staff member could not find the documentation and would have someone contact her. Guardian A said that later that evening she received a phone call from the DON and she said that it was her fault, that she had forgotten Resident #1 had a legal guardian and he had been vaccinated. Guardian A was upset because she did not want Resident #1 to receive the vaccine. Guardian A said that the DON told her that she had asked Resident #1 the day of the vaccines (1/16/21) if he wanted the covid vaccine and he said he did. Guardian A said that she was furious about finding out that Resident #1 had received the COVID vaccination In an interview on 10/26/21 at 3:01pm, Resident #1 was oriented to his name only and did not recall being vaccinated for COVID-19 on 1/16/21. In an interview on 10/26/21 at 4:50pm, the DON said that she spoke to Resident #1 on 1/16/21, the day of the covid vaccination to get a verbal consent and she asked him if he wanted the vaccine. The DON said that she forgot he had a legal guardian and was unable to make his own medical decisions regarding his treatment. The DON said that Guardian A was not contacted prior to Resident #1 receiving the Covid Vaccine on 01/16/21. The DON said that the guardianship paperwork was in Resident #1's chart and it was documented on his face sheet that Guardian A was Resident #1's guardian. The DON said that she forgot to fill out the consent form for Resident #1 on the day of the vaccination clinic. In an interview on 10/27/21 at 1:25pm, Pharmacist A confirmed that Resident #1 was given the Pfizer vaccine on 01/16/21 during a vaccination clinic performed by [local pharmacy] at the nursing facility. Record review of the facility policy entitled Resident Rights dated 11/28/16 revealed the following: Exercise of Rights The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States Planning and implementing care .5. The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive

Based on interview and record review, the facility failed to notify the physician to alter treatment for 1 of 3 residents (Resident #2) reviewed for notification. The facility failed to Notify Physician A as ordered when Resident #2's blood sugar was noted to be less than 60 mg/dl. This failure could affect residents by placing them at risk for not receiving appropriate care and interventions. Findings included: Record review of Resident #2's electronic Face Sheet dated 10/28/21 indicated she was a [AGE] year-old female with an admitted [DATE]. Resident #2 's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Admission MDS dated [DATE] indicated she was severely impaired in her cognitive skills for daily decision making and never/rarely made decisions. Section I Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #2's Care Plan dated 06/11/2021 and revised on 06/22/21 revealed the following: Focus: The resident has Diabetes. Goal: The resident will have no complications related to diabetes through review date .Interventions/tasks .Monitor compliance with diet and document any problems . Record review of Resident #2's electronic physician orders, signed, dated 07/01/2021 revealed an order that started on 06/17/2021 for the following: Accucheck AC (before meals) and HS (at bedtime) before meals and at bedtime, notify MD if FSBS (fasting blood sugar) is < (less than) 60 or > (greater than) 400. signed, Physician A. Record review of Resident #2's electronic Medication Administration Record (MAR) for June 2021 and July 2021 revealed the following: Accucheck AC and HS before meals and at bedtime NOTIFY MD IF FSBS <60 or >400 . 06/15/21 - FSBS of 58mg/dl at 6:00am by LVN B 06/24/21 - FSBS of 56mg/dl at 6:00am by RN A 06/29/21 - FSBS of 54mg/dl at 6:00am by LVN B 07/03/21 - FSBS of 51 mg/dl at 6:00am by LVN C 07/05/21 - FSBS of 46 mg/dl at 6:00am by RN A Record review of Resident #2's electronic progress notes from 06/18/21 to 07/06/21 did not reveal any entries by nursing staff or any documentation in Resident #2's electronic health record that indicated Physician A was notified of a low blood sugar less than 60mg/dl. In an interview on 10/28/21 at 3:30pm, Physician A reviewed documentation on his cell phone and verified in his electronic faxes, text messages and phone log that he was not notified of Resident #2's low blood sugar on 07/05/21; Physician A said that he had been notified for some of the low blood sugars but could not at the time of the interview verify that he had been notified for all of them that were below his parameters of 60mg/dl. Physician A said that he should have been notified and depending on the glucose level he would have either told the staff to administer orange juice and recheck blood sugar in one hour or he would have given an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician A said it also depended on the level of consciousness the resident had but that having a blood sugar below 60 could lead to serious health issues and even death if not addressed. In a telephone interview on 10/28/21 at 8:30pm, RN A said that she recalled Resident #2 having a low blood sugar on several occasions and that she felt certain she would have called or texted Physician A for Resident #2's blood sugar being less than 60mg/dl. RN A said she was aware of the parameters on the MAR and felt sure that Resident #2 was given orange juice with sugar in it and that she rechecked the blood sugar within the hour. RN A verified that there was not any documentation in the chart for 06/24/21 and 07/05/21 indicating that the physician had been notified. RN A said that she had been trained on the electronic charting software and that there was no reason to have not documented it in the electronic health record. RN A said that she recalled both instances of Resident #2 having low blood sugars and was certain that she was alert and responsive. RN A said that she recalled being in-serviced recently regarding accuchecks and the need to have parameters on the order and when to notify the physician. In an interview on 10/29/21 at 10:11am, LVN A said that she recalled Resident #2 having a low blood sugar of 46mg/dl on 07/05/21, LVN A said that she received shift change report from RN A. LVN A verified and said that there was not an entry in a progress note that Resident #2's blood sugar was rechecked on 07/05/21 and that she should have charted in a progress note that the blood sugar had been rechecked. LVN A said that she recalled being in-serviced recently regarding accuchecks and the need to have parameters on the order and when to notify the physician. LVN A said that a blood sugar of less than 60mg/dl could lead to serious health issues, clammy skin, diaphoresis, the resident can become unresponsive and go into a comatose state and potentially even death if not given glucose. In a telephone interview on 10/29/21 at 11:23am, LVN B said that she did not recall obtaining low blood sugars for Resident #2 on 06/15/21 or 06/29/21. LVN B said that she did not recall notifying Physician A regarding the low blood sugars but stated she knew there were parameters to follow for blood sugar levels and there were located on the MAR where the blood sugar is documented. LVN B said that if she notified Physician A it would be located in the progress notes or a fax would be scanned into the electronic health record. LVN B said that she recalled being in-serviced recently regarding accuchecks and the need to have parameters on the order and when to notify the physician. Record review on 10/29/21 at 11:30am of facility in-service revealed the following: Inservice .Subject: Accuchecks Date 6/25/21 Instructor: [DON] .All diabetic residents with accuchecks need to have parameters on when to notify the MD, please pay close attention to residents FSBS parameters. You must call MD and document notification in progress notes if FSBS is out of parameters. Thank you . Signatures [RN A], [LVN A] and [LVN B]. In an interview on 10/29/21 at 11:50am, the DON said that nurses should be documenting in a progress note when they notify physicians or retake blood sugars. The DON said that the diabetic residents all had parameters for low and high blood glucose values and that the physician should be notified if the nurses take the blood sugar and it is outside of these parameters. The DON said her expectation is for the nurses to document the blood sugars, notification and reassessment of the resident in the resident's electronic health record. The DON said that she had conducted an in-service in June that educated nursing staff about the importance of the parameters, notification to doctors and documentation. The DON said that the nurses should have followed the physician orders and documented in the chart. Record review of the facility policy entitled Notifying the Physician of Change in Status dated 03/11/2013, revealed the following: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in condition when to notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician and interventions that were implemented in the resident's clinical record. 6. The nurse will monitor and reassess the resident's status and response to interventions