Every finding on record at Cross Timbers Rehabilitation and Healthcare Center

Based on observation, interview, and record review, the facility failed to provide residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two (Resident #15 and Resident #65) of six residents reviewed for call lights. 1. The facility failed to ensure Resident #15's call light was not underneath her bed pillows so that she could contact staff for assistance to remove bed covers for her. 2. The facility failed to ensure Resident #65's call light was accessible so that she could request her catheter to be emptied. This failure could place the residents at risk of falling, further injury, and unnecessary pain from not being able to call for help. Findings included:1. Record review of Resident #15's Comprehensive MDS Assessment, dated 03/11/26, reflected [AGE] year-old female admitted to the facility on [DATE] with a BIMS of 10 indicating moderate cognitive impairment. Resident #15 had the following diagnoses: Stroke (sudden interruption of blood flow to the brain), Heart Failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs), unsteadiness on feet, lack of coordination. MDS further indicated Resident #15 was dependent on staff for toileting, showers, lower body dressing, putting on /talking off footwear and personal hygiene, rolling left to right, sitting to lying, lying to sitting, transferring, and substantial/maximal assistance with upper body dressing, and supervision or touching assistance with eating. Record review of Resident #15's Care Plan, initiated on 04/10/26, reflected the resident had an activities of daily living self-care performance deficit related to impaired balance, limited mobility, and musculoskeletal impairment. Goal: Resident will maintain current level of function in activities of daily living. Interventions included encouraging residents to use bell to call for assistance. Resident #15 is High risk for falls. Goal: The resident will be free from falls. Interventions included anticipate and meet the resident's needs. Place frequently used personal items within reach. Ensure resident is aware that they need to call for assistance before getting out of bed. Maintain call light within reach. Resident #15 has an alteration in musculoskeletal status to right upper extremity related to a contracture. Goal: The resident's mobility will be stabilized by use of wrist hand finger orthosis (externally applied device such as a brace or splint). Interventions included anticipating and meeting needs. Be sure call light is within reach and respond promptly to all requests for assistance. During an observation and interview on 04/14/26 11:03 a.m., revealed Resident #15 was lying in bed, and she began throwing items from her breakfast tray onto the floor from her bedside table. When Resident #15 was asked if she needed assistance. Resident #15 responded, Yes, I need to get help with removing my blankets, I am hot. I need to get help, and no one is coming in here to help me. Resident #15 was asked to use her call light to get assistance, and Resident #15 stated, I don't know where my call light is. Resident #15's call light was underneath her pillow, and not within her reach. Resident #15 only had use of her left hand, her right hand was contracted, and she was not able to move without assistance of her left hand. 2. Record review of Resident #65's Quarterly MDS Assessment, dated 04/04/26, reflected [AGE] year-old female admitted to the facility on [DATE] with a BIMS of 09 indicating moderate cognitive impairment. Resident #65 had the following diagnoses: Heart Failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs), high blood pressure (force of blood against the artery wall is consistently too high), Renal Insufficiency (kidney failure - kidneys lose their ability to function properly), Neurogenic Bladder (nerve damage disrupts communication between the brain and the brain, spinal cord, and bladder) and retention of urine (inability to completely empty bladder), Hip Fracture (break in the upper part of the thigh bone). The MDS further indicated Resident #65 was dependent on staff for toileting, showers, lower body dressing, putting on /talking off footwear and personal hygiene, rolling left to right, sit to lying, lying to sitting, transferring, and substantial/maximal assistance with toileting hygiene and transfers, showers, lower body dressing, and personal hygiene. Resident #65 utilized an indwelling catheter. Record review of Resident #65's Care Plan, initiated on 01/28/26, reflected the resident had a right hip fracture related to a fall. Goal: Resident will be free of complications related to hip fracture. Interventions included, anticipate and meet the resident's needs. Be sure call light is within reach and respond promptly to all request for assistance. The Care Plan also reflected Resident #65 had an indwelling catheter: Neurogenic bladder. Goal: Resident will be/remain free from catheter-related trauma. Interventions included check tubing for kinks and empty as needed per shift. Monitor and document intake and output as per facility policy. Monitor/document for pain/discomfort due to catheter. During an observation and interview on 04/14/26 11:04 a.m., revealed Resident #65 lying in bed. Resident #65 began pointing down to her catheter and stated, That bag seems to be full and needs to be emptied, and no one has come to empty the bag yet. During an observation revealed the catheter bag was full. Resident #65 was asked to initiate her call light and she replied, I would if I knew where it was. Resident #65 stated she could not reach the call light that was located behind her head and was tied to the corner of the bed. During an observation and interview on 04/14/26 11:30 a.m., LVN F stated she was the nurse assigned to 200 Hall. LVN F stated aides were waiting for the surveyor to exit the room so they could go in to assist residents. LVN F observed Resident #15's call light to be behind her head tucked underneath two pillows. LVN F observed Resident #65's call light to be tied to the left corner of the bed behind her head. LVN F began to unravel Resident #65's call light to place it within reach. LVN F stated she was not aware that residents were not able to reach their call light. LVN F stated resident call lights should be kept within reach of the resident to prevent accidents and emergencies, call lights should be available so that residents were able to communicate their needs to staff. LVN F stated all staff were responsible for ensuring call lights were within reach of the residents, and not doing so placed residents at risk of injury and not getting the care they need. During an observation and interview on 04/14/26 11:40 a.m. with DON revealed Resident #15's call light was underneath her two pillows. The DON pulled the call light chord from underneath the pillows and placed the call light within reach for Resident #15. The DON then asked Resident #15 if she could assist with anything and Resident #15 expressed that she was hot and would like to have the blankets removed from her body. Resident #15 further said that she had gotten upset and started throwing items because she needed someone to come into the room to help her. During an interview on 04/14/26 11:44 a.m., CNA G revealed she was not the aide working the hall, however, was pulled to come and assist Resident #15 and Resident #65. CNA G stated all residents should have call lights within reach so that they could contact staff when they were in need of care. CNA G stated all staff were responsible for ensuring call lights were within reach for residents, and not doing so placed residents in prolonged need of care and possible injury. During an interview on 04/16/2026 1:48 p.m., the DON revealed all staff were responsible for ensuring call lights were within reach for all residents. The DON stated not doing so placed residents at risk of possible injury and not getting adequate care. Review of the facility's Answering the Call Light policy, Revision date September 2022, reflected: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 19 resident (Resident #8) reviewed for foot care.The facility failed to ensure Resident #8's toenails were trimmed.This failure had the potential to affect place residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. Findings included:Record review of Resident #8's 5-day MDS assessment dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #8 had diagnoses which included metabolic encephalopathy (brain dysfunction), muscle wasting and atrophy (the loss or thinning of muscle tissue), depression (mood disorder), Non-Alzheimer's Dementia (problems with memory and thinking), hypertension (high blood pressure) and heart failure. Resident #8's BIMS score was 11, which indicated moderate cognitive impairment. The MDS further revealed Section GG - Functional Abilities indicated resident required partial/moderate/maximal assistances from staff to assist with getting personal hygiene. Record review of Resident #8's care plan, revised on 03/16/26, revealed Focus: The resident has an ADL self-care performance deficit muscle wasting and atrophy. Goal: The resident will maintain current level of function through the review date. Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.During an observation and interview on 04/15/26 at 8:50 a.m., Resident #8 was observed in her room, lying in bed watching television. Observed Resident #8's toenails for both feet, and the big toenails for both feet were approximately quarter of an inch past the tip of the toe curving to the side. The other toes nails were approximately a quarter of an inch past the tip of the toe. Resident #8 stated she would cut her own toenails because no one would ask to cut them. Resident #8 stated lately she had not been able to cut them due to not being able to bend over. Resident #8 stated no one had asked to trim them or been asked to see podiatry. Resident #8 stated she would like her toenails to be trimmed. During an interview on 04/16/26 at 12:18 p.m. CNA E revealed the nurses were responsible for trimming residents' fingernails and toenails. She stated if the resident was diabetic then podiatry would trim the nails but if they were not diabetic then the nurses would trim them. CNA E stated she was aware of Resident #8 toenails being long, and they needed to be trimmed. She stated she could not recall if she notified the nurse or therapy a few days ago about Resident #8 toenails. She stated she did not know if Resident #8 was seen by podiatry. She stated if a resident needed to be seen by podiatry the CNAs would notify the nurse and then the nurse would follow up. During an interview on 04/16/26 at 12:32 p.m., the Social Worker revealed Resident #8 was not being seen by podiatry. She stated she was waiting for family to sign a podiatry consent. She stated from her understanding if the resident was not being seen by podiatry, then the nurses were responsible for trimming toenails unless the resident was diabetic. During an interview on 04/16/26 at 12:34 p.m., RN D revealed Resident #8 was not diabetic and was not sure if she was being seen by podiatry. She stated since Resident #8 was not diabetic then it was the responsibility of the CNAs to trim the resident's toenails. Observed RN D enter Resident #8's room and observe her toenails. RN D stated they were long and needed to be trimmed by podiatry due to the thickness of the big toenails. RN D stated she was not aware of Resident #8's toenails being long and was never notified that they needed to be trimmed. She stated the potential risk of not trimming toenails could lead to infections. During an interview on 04/16/26 at 3:31 p.m., the ADON revealed the nurses were responsible for trimming residents' toenails unless the resident was diabetic then a podiatry referral needed to be completed. She stated Resident #8 was not receiving podiatry services. She stated the nurses were responsible for notifying her and the DON for any podiatry referral request. She stated her expectation was for the nurses to be checking residents' toenails and trim them if the resident was not diabetic. She stated the potential risk of not trimming toenails could lead to ingrowing toenails. During an interview on 04/16/26 at 4:29 p.m., the DON revealed the nurses were responsible for trimming residents' nails unless the residents were diabetic. She stated if a resident needed to be referred to podiatry, then the nurses were expected to notify the ADON or herself, they would notify the Social Worker, and the Social Worker would send a referral. She stated she was not sure if Resident #8 was being seen by podiatry. She stated the expectation was for the nurses to trim toenails unless the resident refuses. The DON stated the potential risk of not trimming toenails would be resident injuring herself or ingrowing toenails. Record review of facility Activities of Daily Living (ADL), Supporting; ADL Support policy, revised 04/2025, reflected the following: Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 1 of 3 residents (Residents #65) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #65's catheter urine collection bags were emptied in a timely manner. This failure could place residents with catheters at risk of infections and loss of dignity. Findings included: Record review of Resident #65's Quarterly MDS Assessment, dated 04/04/26, reflected [AGE] year-old female admitted to the facility on [DATE] with a BIMS of 09 indicating moderate cognitive impairment. Resident #15 had the following diagnoses: Heart Failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs), high blood pressure (force of blood against the artery wall is consistently too high), Renal Insufficiency (kidney failure - kidneys lose their ability to function properly), Neurogenic Bladder (nerve damage disrupts communication between the brain and the brain, spinal cord, and bladder) and retention of urine (inability to completely empty bladder), Hip Fracture (break in the upper part of the thigh bone). The MDS further indicated Resident #65 was dependent on staff for toileting and personal hygiene, rolling left to right, sitting to lying, lying to sitting, transferring, and substantial/maximal assistance with toileting hygiene and transfers. Resident #65 utilized an indwelling catheter. Record review of Resident #65's Care Plan, initiated on 01/28/26, reflected the resident had a right hip fracture related to fall. Goal: Resident will be free of complications related to hip fracture. Interventions included Interventions include Anticipate and meet the resident's needs. Be sure call light is within reach and respond promptly to all requests for assistance. Resident #65 has indwelling catheter: Neurogenic bladder. Goal: Resident will be/remain free from catheter-related trauma. Interventions included check tubing for kinks and empty as needed per shift. Monitor and document intake and output as per facility policy. Monitor/document for pain/discomfort due to catheter. Record review of Resident #65's physician orders dated 01/04/26 revealed:Foley Catheter 16 French 10 cubic centimeter bulb change as needed. Foley Catheter Care every shift and as needed. And Foley Catheter Output every shift dated 03/13/26. During an observation and interview on 04/14/26 11:04 a.m., revealed Resident #65 was lying in bed. Resident #65 began pointing down to her catheter and stated, That bag seems to be full and needs to be emptied, and no one has come to empty the bag yet. The catheter bag was full of urine. Resident #65 was asked to initiate her call light, and she replied, I would if I knew where it was. Resident #65 stated she could not reach the call light, which was behind her head and tied to the corner of the bed. During an observation and interview on 04/14/2026 11:30 a.m., LVN F stated she was the nurse assigned to 200 Hall. LVN F stated aides were waiting for the surveyor to exit the room so they could go in to assist residents. LVN F stated she was not aware that Resident #65's catheter bag was full and had not been emptied. LVN F stated Resident #65's was holding 800 cc's of urine, indicating that her catheter bag had not been emptied by the overnight shift. According to LVN F, the overnight shift should have made rounds and emptied Resident #65's catheter bag prior to the end of the shift. LVN F further stated when the aides came on the morning shift (6:00 AM - 2:00 PM) should have made rounds to ensure resident needs were met, not doing so placed residents at risk of infection, urine backing up and pain. During an interview on 04/14/26 11:44 a.m., CNA G revealed she was not the aide working the hall, however, was pulled to come and assist Resident #65 with emptying her catheter bag. CNA G stated aides were responsible for ensuring catheter bags were emptied in a timely manner, not doing so placed residents in prolonged need of care and possible injury. During an interview on 04/16/26 1:48 p.m., the DON revealed she noted Resident #65's catheter bag to be full, appearing that the bag had not been emptied. The DON stated the aide scheduled for the hall had gone home sick, and CNA G was pulled from another hall to cover resident needs. The DON stated aides were responsible to ensure catheter bags were emptied at least every shift. The DON stated not doing so placed residents at risk of possible infection, injury and not getting adequate care. Record review of the facility Catheter Care, Urinary policy, revised June 2025, reflecting the following: The purpose of this procedure is to prevent catheter-associated urinary tract infections.Empty the drainage bag regularly using a separate, clean collection container for each resident. Avoid splashing, and prevent contact of the drainage spigot with the nonsterile container. Empty the collection bag at least every eight (8) hours.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 (Resident #59 and Resident #61) of 3 residents reviewed for respiratory care. The facility failed to ensure that Resident #59 and Resident #61 received adequate oxygen to maintain their O2 sat above 92 % per physician's orders. This failure could place residents who receive oxygen therapy at risk of receiving inadequate oxygen support, which could result in serious harm. Findings included: 1.Record review of Resident #59's Quarterly MDS assessment dated [DATE], revealed at [AGE] year-old female who admitted to the facility on [DATE]. The resident's BIMS score was 14, which indicated intact cognition. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #4 required moderate assistance with most self-care ADLs. The MDS Assessment under Section I-Active Diagnoses, reflected Resident #59's active diagnoses included: COPD with acute exacerbation (lung disease with sudden worsening of symptoms), respiratory failure, and heart disease. The MDS Assessment under Section O-Special Treatments, Procedures, and Programs, reflected Resident #59 required oxygen therapy. The document did not specify if the oxygen therapy was continuous, intermittent, or high-concentration. Record review of Resident #59's Care Plan, revised 11/13/25, reflected the resident had shortness of breath related to COPD. Intervention included: encouraging sustained deep breaths, providing adequate rest periods with activities, and proper body alignment for optimal breathing. The document reflected that Resident #59 had asthma with episodes of wheezing. Interventions included: advising the resident to minimize contact with known allergens, assisting in identifying asthma triggers and strategies for prevention, education on how stress can cause asthma attacks, education on pursed-lip breathing, education regarding overuse of inhalers, elevating head of bed to help with breathing, and encouraging fluid intake. The document also reflected Resident #59 had altered respiratory status and difficulty breathing r/t COPD. Interventions included: administering medications as ordered, assisting the resident in learning signs of respiratory compromise, clearing airway with effective coughing, and monitoring and documenting changes in orientation, restlessness, anxiety, and air hunger. Further review of the document reflected it was not documented that the resident was non-compliant with care, including administration of oxygen therapy as needed or how smoking directly affected Resident #59's oxygen levels. Record review of Resident #59's active consolidated physician's orders, dated 04/16/26, reflected in part the following: -Check O2 SAT every shift for O2 SAT related to chronic obstructive pulmonary disease with acute exacerbation (sudden worsening of symptoms); Order date: 11/13/25. -Maintain O2 levels 1-5 (LPM) to keep O2 > 92 % every shift related to chronic obstructive pulmonary disease with acute exacerbation (sudden worsening of symptoms); Order date: 11/13/25. Record review of Resident #59's EHR under vitals reflected the following the following documented oxygen saturation rates for Resident #59: - 04/06/26 - 91% - 04/08/26 - 91% Further review revealed it was not documented that oxygen therapy was provided when oxygen sat was outside of normal limits. During an observation and interview on 04/15/26 at 10:45 a.m., revealed Resident #59 was sitting on the side of her bed. Resident #59 was breathing deeply and appeared to have shortness of breath; however, she was not wearing her nasal cannula to receive oxygen therapy. RN I was asked to check Resident #59's oxygen saturation rate, and the pulse oximeter initially measured at 85%. After approximately one minute, the resident's oxygen saturation rate went up to 90%. Resident #59 stated she was not feeling very well due to her breathing, but this was normal due to her diagnosis of chronic COPD. Resident #59 stated it was not bad because she was not wheezing. Resident #59 stated she knew when it was time to put on her oxygen, and she would do so when her O2 SAT was low. Resident #59 stated she knew when her O2 SAT was low when the nurses checked her vitals or when she felt shortness of breath and wheezing. Resident #59 stated she did not wear her oxygen continuously, but she would not refuse to wear it if she or the nurses felt she needed it. During an interview on 04/15/26 at 10:52 a.m., RN I stated the nurses followed the physician's orders when administering oxygen to residents. RN I stated Resident #59 had an order for her O2 SAT to be checked once each shift and administer oxygen to keep the resident's O2 SAT above 92 %. RN I stated Resident #59 was a former nurse and was very knowledgeable about her diagnosis. RN I stated Resident #59's O2 SAT at 90% indicated that she needed oxygen therapy. During an interview on 04/16/26 at 1:55 p.m., the DON stated Resident #59 was diagnosed with chronic COPD and should be on continuous oxygen therapy to maintain her O2 SAT above 92 %; however, the resident was not getting enough oxygen because she continued to smoke and would have to remove her oxygen to do so. The DON stated Resident #59 was good about wearing her oxygen when it was needed and was complaint with care in general. The DON stated not receiving adequate oxygen could place residents at risk of not having sufficient oxygen to oxygenate organs and affect overall health. During an interview on 04/16/26 at 2:28 p.m., the MD stated Resident #59 had an order in place to use oxygen therapy at 1-5 LPM to maintain her O2 SAT above 92 %, with the nurses checking her O2 SAT each shift. The MD stated the only way to truly ensure that Resident #59's O2 SAT remained above 92% was to use a continuous pulse oximeter and he was not sure if the nursing facility had the capability to do that. The MD stated Resident #59 was experiencing a decline in health due to chronic COPD but despite the decline and respiratory status, Resident #59 still refused to stop smoking. The MD stated Resident #59 required continuous oxygen therapy; however, she could not stay on oxygen while smoking. The MD stated Resident #59 would benefit more if she at least used the oxygen continuously while in the building. The MD asked the surveyor to tell him how his order should read to ensure that Resident #59 was receiving adequate oxygen and the surveyor explained that she could not offer advice. The MD stated Resident #59 was a retired intensive care nurse and liked to direct her own care; however, the resident was not exactly non-compliant. The MD stated his expectation was for the nurses to follow his orders as written and notify him of any issues with non-compliance or changes that need to be addressed in the resident's care plan. The MD stated the nurses would assess for changes such as increased shortness of breath and low O2 SAT and report to him as needed. The MD stated not receiving sufficient oxygen could place residents at risk of hypoxia (body tissue does not receive enough oxygen) and respiratory failure. 2. Record review of Resident #61's entry MDS Assessment, dated 03/9/26, reflected he was an [AGE] year-old male who admitted to the facility on [DATE]. The resident had moderate cognitive impairment with a BIMS score of 8, and his diagnoses included chronic obstructive pulmonary disease (COPD) (a progressive, incurable lung disease that restricts airflow, causing chronic breathing difficulties, coughing, and wheezing), and he was on continuous oxygen therapy. Record review of Resident #61's care plan dated 04/9/2026 reflected: Focus [Resident#61] has oxygen therapy rule out ineffective gas exchange, Respiratory illness COPD. Goals: Resident#61 residents will have no signs and symptoms of poor oxygen absorption through the review date. Interventions: Oxygen Settings: O2(Oxygen Monitor) via Oxygen via nasal cannula at 2-6liters continuous to keep spo2 (Peripheral Oxygen Saturation) measures the percentage of oxygen-carrying hemoglobin in the blood, with a normal, healthy reading typically between 95% and 100%)>90%. Record review of Resident #61's active physician's orders dated 03/14/26 revealed oxygen at 2-6 Liters by Nasal Canula continuous every Shift for shortness of breath. During an observation and interview on 04/14/26 at 11:00 a.m., revealed Resident #61 was lying in bed. She was not receiving oxygen from an oxygen concentrator. The oxygen tubing was covered with bedsheets, and the oxygen concentrator was marked at 5 liters per minute and was actively running. The resident stated he thought the tubing fell off during the day. The residents could not tell how long the oxygen had not been connected. During an observation on 04/14/26 at 2:24 p.m., revealed Resident #61 was lying in bed sleeping and not receiving oxygen. The oxygen tubing was folded and packed in plastic bags. During an observation on 04/15/26 at 7:15 a.m., revealed Resident #61 was lying in bed not receiving oxygen. The tubing was folded and packed in plastic bags. During an observation and interview on 04/15/26 at 8:37 a.m., RN D revealed she was the nurse assigned to Resident #61. Resident #61 was observed in bed without oxygen. She stated Resident #61 had oxygen orders for continuous oxygen. RN D checked the oxygen levels for Resident #61, and it was at 87%. She stated she was aware FResaident#61 oxygen was not on, and she said she checked his oxygen saturation at 6:45AM and it was at 90%, but she could not tell why she did not put the oxygen back on resident. She stated it was nurses' responsibility to be checking on residents on oxygen to ensure they were getting oxygen and maintained as per doctors' orders. She stated she was aware Resident #61 would remove his oxygen tubing. She stated she had notified the DON of Resident #61 of removing oxygen, and she was not sure of the actions taken. She stated the possible negative outcome for not receiving oxygen could be difficulty breathing. During an interview on 04/16/26 at 2:30 p.m., the DON revealed it was the responsibility of the charge nurse, to ensure physicians' orders were followed and ensure Resident #61's oxygen was always on and they checked oxygen every shift. She stated she was not aware Resident #61 was not always keeping oxygen on. She said if the nurses could have made her aware she could have contacted hospice, got new orders and updated care plans for noncompliance. The DON said the risk of not administering oxygen would be oxygen levels could drop, and organs not getting enough oxygen and shortness of breath. During an interview on 04/16/26 at 2:51 PM, the Doctor revealed his expectation was for Resident #61, who was on continuous oxygen, to be on oxygen at all times. He stated that if nurses were not ensuring oxygen was on, that could lead to an error of not following physicians' orders. He stated he expected nurses to follow physician orders as given and said he did not know Resident #61 was not using oxygen continuously. He said the risk of not administering oxygen continuously would make resident hypoxic (a dangerous condition where tissues receive inadequate oxygen, leading to symptoms like shortness of breath, confusion, headaches, and rapid heart rate). Record review of the facility's policy titled Oxygen Administration and Oxygen Safety, reviewed 03/03/26, reflected in part the following: Purpose- The purpose of this procedure is to provide guidelines for safe oxygen administration and oxygen safety guidelines. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident. 3. Assemble the equipment and supplies as needed. .12. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated (see Assessment) Assessment Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes); 2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); 3. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); 4. Vital signs; 5. Lung sounds; 6. Arterial blood gases and oxygen saturation, if applicable; and 7. Other laboratory results (hemoglobin, hematocrit, and complete blood count), if applicable.

Based on observation, interview, and record review, the facility failed to provide laboratory services to meet the needs of its residents for 1 of 5 residents (Resident #4) reviewed for laboratory services. The facility failed to provide proper monitoring of Resident #4's immunodeficiency disorder by not completing routine specialized laboratory services to ensure that treatment remained effective. This failure could place residents at risk of a delay in medical evaluation and treatment, which could result in worsening of conditions or serious harm. Findings included: Record review of Resident #4's Annual MDS Assessment, dated 03/20/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident's BIMS score was 15, which indicated intact cognition. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #4 was independent with all self-care ADLs. The MDS Assessment under Section I-Active Diagnoses, reflected Resident # 4's active diagnoses included: cerebrovascular accident (stroke-loss of blood flow to the brain), hypertension (high blood pressure), viral hepatitis (inflammation of the liver), and an immunodeficiency disorder (weakened immune system). Record review of Resident #4's Care Plan, revised 04/07/26, reflected the resident had impaired immunity and was at risk for dehydration and increased infections r/t to disease process. Interventions included: encouraging fluids and rest, administering medications as ordered, monitoring for signs of infection, monitoring for abnormal laboratory values, monitoring for changes in behavior and cognition, and keeping the environment clean. The document reflected Resident #4 experienced nausea and vomiting r/t disease process (initiated 05/07/25). Interventions included: monitoring for weakness and unsteadiness, administering medications as ordered, avoiding foods that cause overactive bowels, and keeping the resident clean, dry, and comfortable. Record review of Resident #4's laboratory results report, dated 04/12/26, reflected in part the following: Collection date: 04/07/26 Received date: 04/07/26 Reported date: 04/12/26 Order provider: [MD] -WBC (white blood count-measures the number of infection-fighting cells in the blood)- (L) 3.5; last comparison on 03/25/26- (L) 3.7 (reference range (3.8-11.8)) - [laboratory markers for immunodeficiency disorder]- Non Reactive (no detection of infection) . No comparison lab documented. -CD4- 375 (reference range [PHONE NUMBER]). No comparison lab documented Further review of this document reflected there was no evidence that these labs, specific for immunodeficiency disorder, were completed at any other times . Record review of Resident #4's consolidated physician's orders, dated 04/16/26, reflected in part the following: - Amylase (digestive enzyme), Lipase (digestive enzyme), CBC (analyzes cels in the blood to diagnose or monitor conditions like infections, anemia, or clotting issues), CMP (analyzes chemicals in blood for metabolism, organ function, and blood chemistry), UA with C&S; (analyzes urine for infections). Order date: 03/24/26. These were routine labs for general health monitoring and were completed as ordered.- CMP, CBC, UA in a.m.; Order date: 05/05/25 - lipid panel (measures cholesterol levels), vit B12 (measures vitamin B12 levels to diagnose deficiencies that could affect nerve health and red blood cell production), vitamin D (measures vit D levels to assess bone health), one time a day every 90 day (s) for quarterly labs. Order date:11/11/25. These were routine labs for general health monitoring and were completed as ordered. - vitamin B12, vit. d, lipid panel, CBC, CMP, HgA1c (measures average blood sugar levels), TSH (measures level of thyroid stimulating hormones in the blood), T4 (measures thyroid function), folic acid (measures vitamin B9 levels to diagnose deficiencies and anemia), ammonia (measures levels of ammonia in the blood to monitor for liver disorders), one time a day every 12 months starting on the 13th for 1 day(s) for annual labs; Order date: 11/11/25. These were routine labs for general health monitoring and were completed as ordered. - LABS: CBC, CMP, CD4 (measures the number of white blood cells to assess immune health, specific to an immunodeficiency disorder), [laboratory markers for immunodeficiency disorder] STAT for labs; Order date: 04/06/26; End date: 04/06/26. Completed. Further review reflected there were no prior orders for these labs, specific for immunodeficiency disorder, to be completed. During an observation and interview on 04/16/26 at 8:43 a.m., revealed Resident #4's body appeared to be thin and fragile. Resident #4 stated she still felt weak after returning to the facility from the local hospital due to nausea and vomiting caused by an issue with her esophagus. Resident #4 stated she resided at the facility for about 5 years and felt okay until last May 2025 when she had a stroke. Resident #4 stated since then, she had issues with vomiting off and on, and the vomiting increased and was more consistent about 2.5 weeks ago. Resident #4 stated prior to her admission to the facility she saw an infectious disease doctor about every 3 months for check-ups and lab work and was supposed to continue doing so; however, she had not seen one since her admission to the facility. Resident #4 stated she recalled speaking to a nurse about it a while ago but there was no follow-up. Resident #4 stated she was finally able to see an infectious disease doctor recently, after her vomiting got worse. During an interview on 04/16/26 at 1:11 p.m., the DON stated she worked at the facility for 2.5 years. She stated to her knowledge Resident #4 had not had any routine specialized labs regarding her immunodeficiency disorder. The DON stated there had never been an issue with care of Resident #4's disorder and it had never been a topic of discussion with the IDT. The DON stated all of Resident #4's medication was being managed by the MD, who also ordered the labs. The DON stated she was not the doctor and could not state if Resident #4 needed specialized labs to monitor her immunodeficiency disorder or how it could affect the resident if routine specialized monitoring was not completed. The DON stated she recalled speaking to Resident #4 about signing up with an immunodeficiency disorder program through the county hospital; however, she could not recall exactly when the conversation occurred or why Resident #59 never signed up. The DON stated it was possible that the resident did not want to, but she was unsure. The DON was unable to provide documentation of a referral to the program or a progress note to show that the program was discussed with Resident #4. During an interview on 04/16/26 at 2:28 p.m., the MD stated he was made aware that Resident #4 was vomiting and nauseous for over two weeks and that was found to be due to an esophageal issue. The MD stated as part of Resident #4's clinical workup to determine the cause of her nausea and vomiting, she was sent to an infectious disease doctor to see if it was related to her immunodeficiency disorder. The MD stated he had managed the care for Resident #4's immunodeficiency disorder. The MD stated Resident #4 was taking medication, but he had not ordered any routine specialized labs to monitor the effectiveness. The MD stated Resident #4 had routine foundational blood tests that he referred to for management of care, and that along with clinical assessments had been enough to detect any changes in the resident's immunodeficiency disorder. The MD stated Resident #4 had been stable on the same regimen for years, and he needed to check her previous clinical documentation prior to admission to see if there were any recommendations for labs. During an interview on 04/16/26 at 4:10 p.m., LVN H revealed she worked at the facility since May 2025. She stated she cared for Resident #4 and the resident had been well for the most part; however, she had random episodes of vomiting and had a long-standing order for Zofran as treatment. LVN H stated Resident #4 often complained of nausea and would only vomit sometimes; but it was never as bad as it was recently when the resident vomited consistently for two weeks. During an interview on 04/16/26 at 4:30 p.m., the DON stated there were no other residents in the facility diagnosed with an immunodeficiency disorder. Review of the facility's Laboratory Services policy, dated 03/03/26, reflected in part the following: POLICY/PROCEDURE It is the policy of this facility to ensure that laboratory services meet the needs of residents and that the results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, treatment, and that the facility has established policies and procedures. Review of the facility's policy titled Admission/readmission Orders revised April 2013, reflected in part the following: Policy Statement: Physicians shall provide appropriate admission and readmission orders. Outcomes: Residents/patients will receive appropriate treatments and services Residents and patients will not suffer complications because of incomplete, inaccurate, or delayed admission orders. The facility's care will be consistent with related standards and will comply with applicable laws and regulations. Review of the Center for Disease Control and Prevention website, https://www.cdc.gov/hivnexus/hcp/clinical-care/, updated 04/16/26, reflected in part the following: Clinical Care of [immunodeficiency disorder] In addition to supporting ART adherence, monitoring patients' [laboratory markers for immunodeficiency disorder] is important. A patient's plasma [immunodeficiency disorder] RNA [laboratory markers for immunodeficiency disorder] should be measured regularly to confirm initial and sustained response to ART. Most patients taking ART achieve viral suppression within 6 months The frequency of [laboratory markers for immunodeficiency disorder] testing depends on several factors. Current guidelines recommend [laboratory markers for immunodeficiency disorder] monitoring as follows.Stable Regimen. In patients on a stable, suppressive ART regimen (every 3-4 months, or every 6 months if virally suppressed for more than 2 years, to confirm durable viral suppression).

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 1 of 5 resident rooms (Resident #15's room) reviewed for infection control. The facility failed to remove and dispose of Resident #15's wound care trash and debris, which included a cup of gauze soaked with betadine and used wound care debris trash, from Resident #15's bedside table. This failure could place residents at risk of exposure to communicable diseases and infections.Findings included:Record review of Resident #15's Comprehensive MDS Assessment, dated 03/11/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a BIMS of 10 indicating moderate cognitive impairment. The MDS reflected Resident #15 had the following diagnoses: stroke (sudden interruption of blood flow to the brain), heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs), unsteadiness on feet, and lack of coordination. The MDS further indicated Resident #15 was at risk of developing pressure ulcers/injuries, and treatments included and applications of ointments/mediations. Record review of Resident #15's Care Plan, initiated on 04/10/26, reflected the resident had a deep tissue pressure injury/ulcer right lateral (the side of an object or body) foot, a deep tissue pressure injury to left heel, and deep tissue pressure injury/ulcer left lateral foot. Goal: Pressure injury/ulcer will show signs of healing and remain free from infection. With interventions that included Administer treatments as ordered and nominator for effectiveness. Clean right lateral foot with wound cleanser, pat dry, apply Betadine, cover with bordered dressing. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Weekly treatment documentation includes measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaks from blood vessels into nearby tissues, cuts, or area of inflammation).During an observation and interview on 04/14/26 11:03 a.m., revealed there was a cup with used gauze soaked with betadine next to the trash from wound care treatment supplies on Resident #15's bedside table next to her breakfast tray. Resident #15 stated the wound care items on her bedside table were left there by the wound care treatment nurse and the nurse practitioner when they came to complete treatment on her feet this morning. Resident #15 then pulled the blankets off her feet and pointed to her feet which revealed new gauze dated 04/14/26.During an observation and interview on 04/14/26 11:30 a.m., LVN F stated she was the nurse assigned to the 200 Hall. LVN F stated she observed Resident #15's tray table to have wound treatment debris remaining from morning rounds with the wound nurse and doctor next to Resident #15's breakfast tray. According to LVN F, she could not say whether the breakfast tray was delivered before or after wound care treatment was completed; however, the breakfast tray and wound treatment debris on the bedside table together posed a big risk for Resident #15. LVN F stated if the aide noticed the wound care debris on the tray table prior to delivering breakfast, the aide should have reported the concern or cleaned the tray table before leaving the breakfast for Resident #15. LVN F stated the Wound Care Nurse was responsible for cleaning after wound care treatment and not doing so placed residents at risk of infection and illness.During an interview on 04/14/26 at 11:34 a.m., the Treatment Nurse revealed she conducted rounds with the Wound Care Doctor early morning. The Treatment Nurse stated the Wound Care Doctor must have left the would care trash and debris on the bedside table. The Treatment Nurse stated, The doctor must have thought I was going to return back to clean after her. I was not aware there was trash and debris left on [Resident #15's] bedside table. The Treatment Nurse stated she was responsible for disposing of the trash and anything associated with treatment care after treatment was completed, and not doing so placed residents at risk of proper infection control practices and illnesses to the residents. During an interview on 04/16/26 at 1:48 p.m., the DON revealed she saw the wound care treatment debris and trash on the bedside table next to Resident #15's breakfast tray. The DON stated the Treatment Nurse was responsible for minimizing the spread of infections. The DON further stated the Treatment Nurse was expected to provide supplies for wound care on a tray with disposable paper, once treatment is completed all items should be disposed in the disposable paper in the trash, nothing should have been left on the tray table. The DON stated leaving wound treatment debris on Resident #15's bedside table left her at risk of infection. Record review of the facility's Infection Prevention and Control Program policy, revised 06/30/25, reflected the following: An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Record review of the facility's .Skin Integrity Prevention and Treatment Program policy, revised 06/30/25, reflecting the following: Wound Carea. Will follow the Non-Sterile Dressing Change Competency Protocolb. Emphasizes resident comfort, expectations, and pain management.c. Adheres to infection control best practices.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for care plans.The facility failed to develop a comprehensive person-centered care plan for Resident #1 that addressed her religious dietary restrictions.This failure could lead to the residents' personal choices and desires not being met. Findings included:Record review of Resident #1's quarterly MDS assessment, dated 12/18/25, reflected that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the resident's vision, Asperger's syndrome (form of Autism with social and communication issues), and diabetes. Her Functional Abilities assessment indicated she used a wheelchair for mobility, and she required staff assistance with her ADLs. Record review of Resident #1's care plan, dated 12/27/25, reflected she was PASRR positive and during an IDT meeting on 05/13/25, Resident #1's Kosher (Jewish) diet was discussed but there were no interventions addressing this specific issue. In an interview on 02/26/26 at 10:00 AM, Resident #1 stated she was blind in her left eye and had 15% vision in her right eye because of a stroke. She stated she had in the last few months begun to return to her religious roots and follow her religious teachings. Resident #1 stated she did not expect the facility to have a Kosher kitchen; she just asked them to try to accommodate her restrictions. She stated the Dietary Manager had met with her to go over the standard menu and she indicated what she could and could not have, and what she wanted for an alternative. Food service was much improved now. In an interview on 02/26/26 at 2:30 PM, the Dietary Manager stated Resident #1 just recently decided to follow a Kosher light diet in the last few months of no dairy on the same plate as meat. The Dietary Manager stated Resident #1 is the only resident with religious dietary restrictions, but she made accommodations. The Dietary Manager stated she had taken the facility's 5-week menu cycle to the resident and reviewed what was scheduled each day, allowing the resident to pick what she could and could not eat, and what she wanted as an alternative. In an interview on 02/26/26 at 2:50 PM, the Social Worker stated care plans were developed in a combination of care plan meetings and IDT meetings. She stated the MDS Coordinator created and maintained the care plan. She stated the facility did not currently have an MDS Coordinator, and she was not sure who was responsible for care plans until a new coordinator could be hired. The Social Worker was not aware of Resident #1's religious beliefs. In an interview and record review on 02/26/26 at 3:30 PM, the DON stated Resident #1 did not follow the Jewish lifestyle when she first admitted . She stated it had only been in the last few months that Resident #1 decided to return to the Jewish religion and lifestyle. After the DON reviewed Resident #1's care plan, she stated there were no dietary restrictions based on the resident's religious beliefs in the care plan. The DON stated during an IDT meeting on 05/13/25, documented in the care plan, Resident #1's religious and dietary restrictions were discussed but no interventions were documented. The DON agreed there were no specific interventions in place to address the resident's dietary needs, but staff could access the IDT meeting notes. She stated the Social Worker arranged the care plan meetings and notified the IDT team. She stated the risk of not respecting Resident #1's wishes and beliefs was the resident feeling isolated and belittled. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated January 2023, reflected: .1. The Interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident.8. Each resident's comprehensive person-centered care plan will:.b. Describe 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 ensure the interdisciplinary team determined if a resident was able to self-administer medications d for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility's interdisciplinary team failed to ensure Resident #1 was clinically appropriate to self-administer Systane ophthalmic eyedrops that were at the resident's bedside. The failure had the potential to place residents at risk for unsafe drug administration. Findings included:Record review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's BIMS score of 14, which indicated his cognition was intact. Resident #1's MDS was pending completion. Record review of Resident #1's Baseline Care Plan, admission date 10/04/25, reflected Section D. Medications revealed Resident #1 was not able to self-administer any medications. Record review of Resident #1's clinical records reflected no assessment was completed to indicate if Resident #1 was able to self-administer medication. Record review of Resident #1's order summary report reflected the following: Systane Ophthalmic Solution 0.4-0.3 % (Polyethylene Glycol-Propylene Glycol (Ophth)) Instill 2 drop in both eyes at bedtime for dry eyes Start date 10/04/25. Record review of Resident #1's order summary reflected Resident #1 had a new order for Systane Ophthalmic Solution 0.4-0.3 % (Polyethylene Glycol-Propylene Glycol [Ophth]) Instill 2 drop in both eyes at bedtime for dry eyes able to keep at bed side for self-administer and Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 2 drop in both eyes every 6 hours as needed for dry eyes able to keep at bed side and self administer Start Date: 10/08/25. Observation and interview on 10/08/25 at 10:21 AM, revealed Resident #1 had a bottle of Systane Ophthalmic Solution (eye drops) at his bedside table and an unopen bag with a box inside which contained Artificial Tears Ophthalmic Solution (eyedrops). Resident #1 stated she had the bottles since being admitted on [DATE], she stated staff had not mentioned anything about her eyedrops. Resident #1 stated she administered the eye drops at bedtime. She stated staff did not come by to ensure if she put them in. She stated she was not sure if staff knew she had them, but they never took them away from her bedside table, she stated I think they trust me. Interview on 10/08/25 at 10:40 AM, RN A revealed he was the nurse assigned to Resident #1. He stated he was not sure if he had residents who could self-administer eyedrops. RN A observed eyes drops at Resident #1's bedside table, he stated he did not observe the eye drops when he completed his rounds. RN A reviewed Resident #1's orders and stated the resident only had one order for eye drops to be administered at bedtime. He stated he was not aware Resident #1 had another bottle of artificial tear ophthalmic solution. RN A stated someone from the night shift might have left the eyedrop solution in the resident's room. Interview on 10/08/25 at 2:24 PM, ADON B revealed residents were able to self-administer eye-drop medications only if they were assessed and obtained a physician's order to self-administer and to keep medications at the bedside. She stated she was not aware of any residents who could self-administer eye drop medication. She stated expectations were for nurses to assess the residents to ensure residents were able to self-administer and obtain an order. ADON B stated there was no potential risk for the resident to self-administer and to keep eye drops at the bedside; however, the eye drops would need to be removed until the assessment was completed on the resident. Interview on 10/08/25 at 2:39 PM, LVN C revealed she was the 2:00 PM-10:00 PM nurse assigned to Resident #1 on 10/07/25. She stated she was not sure if she had any residents who could self-administer eye drops and keep them at the bedside. She stated the Medication Aides administered eye drops to residents, but she could not recall which Medication Aide was assigned to Resident #1. LVN C stated they had to first determine if a resident could self-administer eye drops. She stated she did not observe any eye drops at the resident's bedside during her shift for Resident #1. Interview on 10/08/25 at 2:45 PM, MA D revealed she was the 2:00 PM-10:00PM Medication Aide assigned to Resident #1 on 10/07/25. She stated Resident #1 kept her eye drops at her bedside and kept them at her bedside since admission. MA D stated Resident #1 had an order for the eyedrops, and the resident self-administered her own eye drops. She stated by the time she followed-up with Resident #1 at bedtime to ensure she administered the eyedrops the resident confirmed she had administered them. MA D stated no one had mentioned anything to her regarding whether Resident #1 could keep the eyedrops at her bedside or if she could self-administer them. She stated she assumed Resident #1 had an order to self-administer the eyedrops and to keep the eyedrops at her bedside. MA D stated she should had checked to ensure resident had orders to self-administer. She stated there was no potential risk to the resident because she was alert and knew when to administer. Interview on 10/08/25 at 3:13 PM, the DON revealed she had residents who could self-administer medications; however, she could not recall if Resident #1 was one who could self-administer. The DON stated the expectation was for the residents to be assessed first to ensure they were capable of self-administering, and then they would obtain a physician order. She stated the assessment was for them to know if the resident knew how to correctly administer medications and be aware of the times. The DON stated if the resident wanted to keep medications at her bedside a physician order had to be obtained. She stated the potential risk of keeping medications at the bedside would be someone else could get the medications or the residents not being able to self-administer. Record review of the facility Medication Administration policy, revised June 2025 reflected the following: .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 05/05/25. He was found down the street away from the facility and was brought back by the local police department. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 05/05/24 and ended on 05/06/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents who require supervision at risk of harm, severe injury, and possible death. Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated 09/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS (mental status assessment) score of 09 indicating he had moderate cognitive impairment. His active diagnoses included non-traumatic brain dysfunction (causes damage to the brain by internal factors such as lack of oxygen, exposure to toxins, or pressure from a tumor), non-Alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform activities of daily living), and Parkinson's disease (a brain disorder that affects movement and causes tremor, stiffness, and slowness). His MDS indicated he had behaviors of having delusions and had exhibiting wandering behavior for 1 to 3 days. Record review of Resident #1's Wander Data Collection, dated 12/23/24, reflected a score of 14 which was considered high. Record review of Resident #1's Wander Data Collection, dated 04/20/25, reflected a score of 24 which was considered high. Record review of Resident #1's Wander Data Collection, dated 05/06/25, reflected a score of 24 which was considered high.Record review of the facility's Provider Investigation Report, completed by the Former Administrator and dated 05/07/25, reflected on 05/05/25 at 7:00 PM Resident #1 wandered away from the facility, and he did not sustain any injuries. The Investigation Summary reflected the following:RE: [Resident #1].Age 71 Dx: Unspecified Dementia, Insomnia, PTSD, Parkinson's. BIMS 7.This is written follow-up to a previously reported incident for [the Facility] concerning a wandering event for [Resident #1].[Resident #1] walked out the front door of the facility following a couple out. [Resident #1]'s wander guard was operational. During the investigation, [Resident #1] claimed that he waited until someone exited and counted the clicks (the time before the door locks) and walked out after them around 7:00pm. [Resident #1] was seen less than a half mile from the facility at a [local business] and escorted back to the facility after he told the police where he lived which was [the Facility].[Resident #1] has a history of PTSD and gets very anxious when he cannot contact his wife. If this occurs, he paces the floor looking for her. This day, he was determined to go find her. Nurse [LVN A] saw [Resident #1] attempt to use the front door twice which triggered the wander guard alarm.Both times, she redirected him to his room. Around 7:00pm, he went to lunch and returned to pass medications to her residents. At 8:00pm, police returned [Resident #1] to the facility. [LVN A] performed an assessment to which there were no injuries to [Resident #1]. [LVN A] failed to put [Resident #1] on 1:1 at 6:45 or contact facility administration. [LVN A] failed to notify the facility administration upon his return until after because she was passing medication. She notified the DON at 11:19pm by text. Administrator began exhaustive investigation immediately.During staff interviews, staff state they heard the alarm and went to help get [Resident #1] away from the door the first two times but no one seems to recall the alarm at 7:00pm. Investigation shows [Resident #1] was wearing the wander guard and upon immediate inspection, the wander guard system worked properly with [Resident #1]s device.The Administrator immediately initiated the post elopement plan of action. Staff were immediately inserviced on the elopement policy and were not allowed to work their next shift until training and testing was completed. A wander guard check of the 4 individuals in the facility all functioned properly. An audit of wander guard maintenance checks and elopement drills were done and were done and recorded. The QAPI team along with Medical Director was immediately called to ADHOC QAPI meeting to discuss next steps and education. Witness statements from everyone present from 6:00pm to 8:00pm on 5/5/25 were interviewed and witness statements collected.In conclusion, [LVN A]'s failure to notify administration caused a situation that required a 1:1 assignment to be missed. Her failure to protect and monitor resident as the charge nurse ultimately led to her immediate dismissal for putting a client at risk of danger. Upon investigation, it was clear that this charge nurse decision put our system in jeopardy.Record review of Resident #1's Psychiatric Evaluation, dated 05/07/25, reflected the following: HPI: The resident is a [AGE] year-old married Caucasian male who was seen for psychiatric evaluation due to a recent episode of elopement from the building.He has no recollection of leaving the building. The resident has been on one-to-one supervision since he was brought by the police to the facility. The resident was found at [a local drug store] after he left this facility. Record review of Resident #1's Provider Notes, dated 06/04/25, reflected the following: Visit Date: 05/04/25.HPI: Staff report that patient has been trying to elope and is increasingly anxious. Family also concerned. Record review of Resident #1's Progress Notes reflected the following entries:- 05/05/25 at 10:42 PM, LVN A wrote: nurse did assessment and body check was done, no bruise or injury noted as at this time [sic]. respiration was even and unlabored. [sic] no pain noted. - 05/06/25 at 11:51 AM, LVN B wrote: resident is seated on the chair at this time, alert [sic] and oriented x2, all [sic] vitals are a stable, has [sic] a wander guard in place, continues [sic] on 1;1 supervision, assisted [sic] with all adls. - 05/06/25 at 12:22 PM, the SW wrote: SW called resident's wife regarding elopement last night. She is giving permission for Psych eval. She is agreeable to come in on 5/7/25 to meet with the Psychiatrist.remains on one-to-one supervision. - 05/08/25 at 7:47 AM, LVN B wrote: resident received resting in bed, on [sic] 1:1 supervision, wander [sic] guard to rt leg is in good working condition, all [sic] vitals are stable Record review of Resident #1's Physician's Orders reflected the following order: Wander Bracelet on right ankle r/t wandering/exit seeking behaviors. Nurse to check placement and function q shift including skin check under bracelet with a start date of 10/20/24. Record review of Resident #1's Medication Administration Record for May 2025 reflected his Wander Guard was checked on each of the three shifts from 05/01/25 to 05/08/25. Record review of Resident #1's 15 Minute Monitoring Sheets, dated 05/06/25 to 05/07/25, indicated where the resident was or what he was doing. Record review of Resident #1's 1 to 1 Monitoring sheets, dated 05/08/25, indicated where the resident was or what he was doing. A telephone interview with Resident #1's RP was attempted on 09/11/25 at 12:48 PM; however, the attempt was unsuccessful as she did not answer or call back. Interview via telephone on 09/11/25 at 12:26 PM with CNA E revealed she worked with Resident #1 on 05/05/25 when he eloped from the facility. CNA E said she was trying to redirect him from the front door, and keep him inside the facility. CNA E said Resident #1 was in an uproar that day about his wife coming to get him, and he was determined to get out. CNA E said other staff tried to calm him down, but nothing worked. CNA E said she had never seen Resident #1 near the front door before this day (05/05/25), but that was where he kept going towards. CNA E said Resident #1 was behaving this way because he wanted to leave and be with his wife. CNA E said when he supposedly got out through the front door, she was at the end of her hall giving a resident a shower so there was no way she would be able to hear the alarm or respond to it. CNA E said she was given report that he was acting this way even before lunch as well. CNA E said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. CNA E said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the nurse. Interview via telephone on 09/11/25 at 12:39 PM with [NAME] F revealed she was working the evening Resident #1 left the faciity on [DATE]. [NAME] F said she saw Resident #1 at the front door and was wondering why the police were there at the facility too. [NAME] F said she saw him earlier walking down the street by himself and wondered to herself how he got out of the facility without someone watching him. [NAME] F said she saw Resident #1 around 8 PM but he was already with the police who were bringing him back to the facility. [NAME] F said she saw him down the street near the grocery store. [NAME] F said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. [NAME] F said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the nurse. Interview via telephone on 09/11/25 at 12:44 PM with LVN B revealed she worked with Resident #1 during the morning shift of 05/05/25. LVN B said Resident #1 seemed to be his normal self, he used a walker to move around with, and she never saw him trying to go to the front door or making an attempt to leave. LVN B said she checked his Wander Guard during her shift and it was working as evidenced by him going near the door and setting the alarm off. LVN B said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. LVN B said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the DON. A telephone interview was attempted on 09/11/25 at 1:08 PM with CNA H; however, the attempt was unsuccessful as she did not answer or call back. Interview on 09/11/25 at 1:09 PM with RN I revealed he was not Resident #1's nurse on duty on 05/05/25. He stated prior to the incident he had seen the resident at the front door a lot, and the resident kept setting the alarm off. RN I said he saw the CNAs redirecting Resident #1 from the front door to his room or away from the exit door. RN I said he saw the CNAs had it handled and assumed his nurse knew about it as well. RN I said he had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. RN I said he also knew that if a resident was exhibiting exit-seeking or wandering behaviors or if they began to increase, he was supposed to report that to the DON. Interview on 09/11/25 at 1:14 PM with CNA J revealed she cared for Resident #1 while he was at the facility. CNA J said he talked about going to see his wife or going home, but staff would redirect him back to his room and let his nurse know he was trying to exit seek. CNA J said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. CNA J said she also knew that if a resident was exhibiting exit-seeking or wandering behaviors or if they began to increase, she was supposed to report that to the nurse. Interview on 09/11/25 at 1:33 PM with the SW revealed she knew Resident #1 could walk well but she did not recall him trying to get out of the facility. The SW said Resident #1 would walk and wander through the facility, but she never saw him having any exit seeking behavior. The SW said she did not remember anything about Resident #1 becoming agitated at not being able to see his wife. The SW said she had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. The SW said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the nurse. Interview on 09/11/25 at 2:17 PM with CNA C revealed he was working with Resident #1 on the night he eloped on 05/05/25. CNA C said he was working with other CNA's who had been trying to redirect Resident #1 away from the front door to his room or the dining room. CNA C said Resident #1 wanted to see his wife and he seemed determined to either talk to her or see her. CNA C said the last time he saw Resident #1 before he had eloped, he was in his room. CNA C said he had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. CNA C said he also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, he was supposed to report that to the DON. Interview on 09/11/25 at 2:24 PM with CNA L revealed Resident #1 had a habit of opening the front door and trying to get out. CNA L said Resident #1's wife would come pick him up and take him home often. CNA L said staff knew to monitor Resident #1 and his wandering behaviors because he walked up and down the hallways all the time. CNA L said it was normal for Resident #1 to sit near the front area and since he looked like a visitor, he could have followed someone out the front door without them realizing he was a resident. CNA L said Resident #1 would not have known how to open the door himself and his Wander Guard would have set the alarm off. CNA L said he had been in-serviced on the facility's procedures for an elopement and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. CNA L said he also knew that if a resident was exhibiting exit seeking or wandering behaviors, or if they began to increase, he was supposed to report that to the nurse. Interview on 09/11/25 at 2:46 PM with LVN M revealed she had been in-serviced on the facility's procedures for an elopement, and was able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. LVN M said she also knew that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, she was supposed to report that to the DON. Interview on 09/11/25 at 2:42 PM with ADON D revealed she was not there when Resident #1 eloped from the facility on 05/05/25, but she knew he would sit near the front door area. ADON D said Resident #1 not seeing his wife triggered him to want to leave the facility. ADON D said Resident #1's elopement happened around a time when his wife was not able to come and see him as often as she normally had, and he was trying to find her. ADON D said Resident #1 normally did not approach any exit doors, but would walk around the facility. ADON D said she only knew that Resident #1 left through the front door and was brought back by the police. ADON D said she was not sure how long Resident #1 was missing from the facility. ADON D said Resident #1's Wander Guard was checked every shift by the nurse for placement and functionality. ADON D said all staff knew to keep a close eye on Resident #1 and redirect him if he was to start to exit seek. ADON D said after Resident #1's elopement on 05/05/25, staff were in-serviced, Wander Guards were checked, and Resident #1 was placed on 1:1 monitoring by staff until he discharged . ADON D said all staff should know the facility's procedures for an elopement and should be able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. ADON D said all staff should also know that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, staff were supposed to report that to the DON or their nurse. Interview on 09/11/25 at 3:03 PM with the DON revealed she was surprised that Resident #1 had eloped from the facility. The DON said normally, Resident #1's wife came at a certain time in the evening so while he was not oriented to times, he had a routine he would follow. The DON said Resident #1 was constantly looking for his wife and she would come after dinner was over. The DON said the evening of 05/05/25, she got a call saying Resident #1 had gotten out of the facility, they thought behind a family member or someone leaving through the front door. The DON said Resident #1 was found up the street by the police and was brought back to the facility. The DON said when Resident #1 was brought back and assessed, he was placed on 1:1 monitoring until he was discharged to a different facility. The DON said Resident #1 had a Wander Guard on already and it was functioning as far as she knew. The DON said nurses checked a resident's Wander Guard for placement and functionality every shift. The DON said staff were in-serviced and should know the facility's procedures for an elopement and should be able to explain what to do if the alarm went off at a door or if a resident was noted to be missing. The DON said staff should also know that if a resident was exhibiting exit seeking or wandering behaviors or if they began to increase, they were supposed to report that to the nurse or herself. The DON said staff were expected to supervise residents at all times to make sure they did not elope from the facility. The DON said the purpose of supervising residents was to ensure they were safe. The DON said if residents were not supervised they could be injured in all kinds of ways by leaving the facility. The DON said she expected and staff had been trained to know what to do if a resident had exit seeking behaviors or had eloped. Interview through the phone on 09/12/25 at 10:27 AM with LVN A revealed she cared for Resident #1 the night of 05/05/25 when he eloped. LVN A said the incident happened a long time ago, and all she remembered was that she saw Resident #1 sitting in the front door area upset because his wife was not there to see him. LVN A said she asked Resident #1 to go back to his room because she was worried about him trying to leave the facility. LVN A said she was keeping an eye on Resident #1 and tried to redirect him. LVN A said she went on break and when she got off her break, the police had brought Resident #1 back to the facility. LVN A said she assessed Resident #1 and he did not have any injuries. LVN A said she checked Resident #1's Wander Guard and it was still working so she was not sure how he got out through the front door. LVN A said she stopped working for the facility shortly after the incident occurred. Record review of an undated witness statement reflected the following: Statement from [LVN A]: [LVN A] stated that [Resident #1] was pacing the lobby all day and around 6:30-6:45 had tried to exit the building and was redirected to his room by her and a CNA, [CNA C]. At this time, asked why she did not notify administration or place on 1:1 she responded that he was redirected. She stated she went to lunch around 7:00 PM and [Resident #1] was in his room. At 8:00pm [sic], [Resident #1] was returned to the building with [City Police Department]. He had exited the building. (When [Resident #1] was asked by [ADON D] what happened, he stated he was looking for his wife. He told police he lived at [Facility Name].) [LVN A] states she did not know that [Resident #1] had exited the building Upon [sic] his return, she failed to place [Resident #1] on 1:1 or contact the DON/Administrator timely. Record review of the facility's Wanderer Management, Monitoring System and Resident Elopement Protocol policy, dated 02/05/25, reflected: Purpose: To monitor safety of residents at risk for elopement. To provide a system to alert staff that a resident may be attempting to leave the facility. Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible.Responsibility: All staff is responsible to ensure resident safety.B. Interdisciplinary Interventions:.2. When a door alarm sounds, staff shall respond immediately and determine cause of the alarm. The staff member responding to the alarm clock shall check the outside of the building to determine if a resident has left the building. If upon investigation, no apparent cause is determined for the sounding of the alarm, the charge nurse shall immediately initiate an accounting of whereabouts of all residents at risk for elopement. The Administrator was notified on 09/11/25 at 4:50 PM that a past non-compliance IJ had been identified related to the facility's failure to provide adequate supervision to prevent an elopement. It was determined this failure placed Resident #1 in an IJ situation on 05/05/25. The facility had implemented the following corrective measures prior to the HHSC investigation: Observation on 09/11/25 at 1:55 PM of Resident #2 revealed she was wearing a Wander Guard and her nurse brought her near the front door, setting the alarm off which indicated the Wander Guard was working. Record review of an Elopement Drill Evaluation Form, dated 05/09/25, reflected the facility completed an elopement drill with staff. Record review of an in-service, dated 05/09/25, and titled Elopement Drill reflected 23 staff participated. Record review of an in-service, dated 05/05/25, and titled Elopement Policy reflected 76 staff were educated on the facility's elopement policy. Record review of an Elopement Policy Quiz, dated 05/06/25, reflected that 76 staff completed the quiz and passed. Record review of a QIPP QAPI Worksheet, dated 05/06/25, reflected a meeting was held to discuss Resident #1's elopement on 05/05/25. Record review of a sheet of paper, dated 05/06/25, and titled Wander guard Individual Checks reflected staff had ensured all 4 residents who used Wander Guards at the time were secured and operational. Record review of a sheet of paper, dated 05/06/25, and titled Exit Door Checks reflected all exit doors were locked and operational. Record review of a Logbook Report, dated 05/07/25, revealed the Maintenance Director had completed a check of residents with Wander Guards on 05/03/25. Record review of the facility's incident/accident log from 05/01/25 to 09/11/25 reflected there were no other elopement incidents that occurred. Record review of a Disciplinary Action Record, dated 05/06/25, reflected LVN A was terminated.

Based on interview and record review, the facility failed to ensure when the pharmacist reported any irregularities to the attending physician and the facility's medical director and director of nursing, these reports were acted upon for 3 of 5 residents (Residents #35, #44, and #39) reviewed for medication regimen review. 1. The facility's failed to ensure the Pharmacist Consultant recommendation for Residents #35's antipsychotic medication, Quetiapine Fumarate (Seroquel), were was reviewed by the physician for the identified irregularities. 2. The facility's failed to ensure the Pharmacist Consultant recommendation for Residents #44's antipsychotic medication, Quetiapine Fumarate (Seroquel), were was reviewed by the physician for the identified irregularities. 3. The facility failed to ensure the pharmacy consultant recommendation was sent to the physician for review for Resident #39's psychotropic medication, duloxetine (Cymbalta). These failures could place residents at risk for medication errors, unnecessary medications, and incorrect administration. Findings included: 1. Record review of Resident #35's Quarterly MDS Assessment, dated 01/03/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (mental health condition that can develop after someone experiences or witnesses a traumatic event). The resident had moderate cognitive impairment with a BIMS score of 09. Record review of Resident #35's care plan, dated 10/22/24, reflected Resident #35 had a mood problem had diagnosis of post-traumatic stress disorder. The goals: - Resident #35 will have improved mood state through the review date. Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #35's physician's orders dated 09/24/24 reflected an order for the resident to receive Quetiapine Fumarate Oral Tablet 25 MG Quetiapine Fumarate). Give 1 tablet by mouth every 24 hours as needed for agitation. Give medication at bedtime. Record review of Resident #35's Medication Regimen Record review, dated October 2024, reflected Please ensure there is an informed consent 3713 form provided by health and human services. Resident [has] an order for quetiapine, prn orders for antipsychotic drugs are limited to 14 days. [if]he briefs it need to be extended, [he] beyond 14 days patient must be seen and evaluated by provider and a new order written every 14 days. Recommendation of the Quetiapine for 14 days prn to be extended beyond 14 days. Resident to be reviewed and order written every 14 days.'' Record review of Resident #35's Medication Regimen Record review, dated November 2024, reflected Please ensure there [is] an informed consent 3713 form provided by health and human services. Resident [has] an order for quetiapine, prn orders for antipsychotic drugs are limited to 14 days. [if] [he] briefs it need to be extended, [he] beyond 14 days patient must be seen and evaluated by provider and a new order written every 14 days. Recommendation of the Quetiapine for 14 days prn to be extended beyond 14 days. Resident to be reviewed and order written every 14 days. Record review of Resident#35 Medication Regimen record review for October 2024 and November 2024 revealed that the Medication Regimen Records were not reviewed by the physician. There was no documentation reflecting the physician indicated he agreed with or declined with the recommendation. 2. Record review of Resident# 44's Quarterly MDS Assessment, dated 12/12/24, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included unspecified dementia, severe, with other behavioral. The resident had severe cognitive impairment with a BIMS score of 00. Record review of Resident #44's care plan, dated 11/30/24, reflected Resident #44 had a behavior problem rule out dementia (agitation including verbal and physical aggression, wandering, and hoarding), is verbally and physically aggressive at times. The goals: - Resident #44 will have fewer episodes of verbal and physical behaviors by review date. Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #44's physician's orders dated 11/19/24 reflected an order for the resident to receive Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate). Give 1 tablet by mouth at bedtime for sleep. Record review of Resident #44's Medication Regimen Record review, dated November 2024, reflected Please ensure there is an informed consent 3713 form provided by health and human services. Record review of Resident#44 Medication Regimen record review for November 2024 revealed that the Medication Regimen Records were not reviewed by the physician. There was no documentation reflecting the physician indicated he agreed with or declined with the recommendation. During an interview on 01/23/25 at 11:19AM with RN E she stated she was aware Resident#35 and #44 were receiving antipsychotic medication. She stated the doctor gives the orders, and the nurses were responsible of getting the consent form signed by either the patient or family member and the consent form is kept on residents' folders or scanned to electronic health records. During an interview on 01/24/25 at 10:12 AM the ADON acknowledged that there were orders for Resident #35's Quetiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) and Resident #44 Quetiapine Fumarate Oral Tablet 25 MG. The ADON stated Resident#35 and Resident#44 were supposed to have signed a form for antipsychotic medications. She stated the form was supposed to be filled by the DON and put in the file. She could not tell what form it was. She brought the company consent form and the 3713 form and stated the 3713 was the one recommended but both residents did not have one. She stated Resident #35 PRN Quetiapine orders was supposed to be addressed as per the pharmacist's recommendation. She stated it was the DON's responsibility to review the Pharmacist recommendation and ensure the doctor reviewed them and recommendations were taken care of. During an interview on 01/24/25 at 10:49AM with the Corporate RN, she stated pharmacist's recommendations were supposed to be reviewed by the DON and the attending physician. She stated she had contacted the DON who was admitted at the hospital, and she stated she could not find the physician review and recommendation forms. She stated she could find the consents, but they were the wrong forms that were used. She stated they were supposed to fill form 3713 as per the recommendation of the pharmacist and the physician was supposed to review the PRN orders for Resident#35 and either discontinue or write another order. She was asked of the risk and she stated it was not their facility policy to put residents on PRN antipsychotic. 3. Record review of Resident #39's MDS dated [DATE] reflected the resident was an an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, depression, bipolar disorder, and obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep). Resident #39 had a BIMS score of 14, indicating her cognition was intact. The MDS further indicated she was taking an antidepressant. Record review of Resident #39's care plan initiated on 06/20/24 reflected Resident #39 used anti-depression medication related to depression. Interventions included to administer the medication as ordered by the physician. Record review of Resident #39's pharmacy recommendation dated 11/25/24 reflected the following: .Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Duloxetine 60mg QDay --> Duloxetine 30mg QDay If dose reduction is contraindicated or resident failed previous reduction attempt please document below Record review of Resident #39's clinical record reflected the recommendation had not been acted on or reviewed by the physician. Interview on 01/24/25 at 1:52 PM with the ADON revealed the DON was responsible for the pharmacy recommendations and she was not sure why the recommendation has not been acted on and sent to the physician for review. The ADON said the DON was on medical leave at the time of the survey. Record review of the facility's Medication Regimen Record Review effective 10/01/18 reflected the following: Policy The consultant pharmacist performs a comprehensive of each resident's medication regimen (MRR) at least monthly. The MRR includes the evaluation of the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning while preventing or minimizing adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing, the attending practitioner, and the medical director. Record review of facility Psychotropic Management policy dated 01/11/22 reflected the following: .2.d. Consent should be obtained and documented on Texas Health and Human Services 3713, or most current form, as soon as possible. 3. PRN Antipsychotic and PRN Psychotropic medications- a. Any as needed use of an antipsychotic can only be authorized for 14 days. These orders cannot be renewed unless the attending physician or prescribing practitioner evaluate the resident for the appropriateness of that medication. A new order for prn anti-psychotic will be required to be written every 14 days. 42859

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 1 of 25 residents (Resident #45) and had acceptable labeling for 2 of 4 medication carts (medication cart for Halls 200 and 300) reviewed for labeling and storage. 1. The facility failed to ensure Resident #45's 1 bottle of thymus 300 capsules, 1 bottle of thyroid 130 capsules, 1 bottle of Advil 200 mg, and 1 bottle of Tylenol 500 mg stored at the resident's bedside table were locked in a lock box or secured in the medication cart or medication room. 2. The facility failed to ensure insulin vials were dated after they were opened. This failure could place residents at risk of not receiving the therapeutic dose of medication. Findings included: Record review of Resident# 45's Quarterly MDS Assessment, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included cancer (with or without metastasis) (when cancer spreads beyond the place where it started to other areas of your body). The resident had moderate cognitive impairment with a BIMS score of 10. Record review of Resident #45's care plan, dated [DATE], reflected Resident #45 was on pain medication therapy to rule out cancer, pathological fracture in neoplastic disease (abnormal growths of cells or tissues that can invade and spread to other parts of the body), or wedge compression fracture of third lumbar vertebrae. The goals: - Resident #45 will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions: - Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Record review of Resident #45's physician's orders dated [DATE] reflected an order for the resident tramadol HCl Oral tablet 50 mg (Tramadol HCl) Give 50 mg by mouth every 6 hours as needed for Pain. Record review of Resident #45's physician's orders dated [DATE] reflected an order for the resident to Acetaminophen tablet 325 mg give 2 tablet by mouth every 4 hours as needed for general discomfort/pain. Observation and interview on [DATE] at 12:23 PM revealed Resident #45 with 1 bottle of thymus 300 capsules, 1 bottle of thyroid 130 capsule, 1 bottle of Advil 200mgs, and 1 bottle of Tylenol 500 mg stored at the resident's bedside table. Resident #45 stated, he used the thymus and thyroid capsules before meals and Advil and Tylenol he took when in pain. Observation and interview with RN E on [DATE] at 12:48 PM, who was the charge nurse for Hall 500, revealed she was aware the medications were in the room. She stated when the resident was admitted he was assessed for self-administration and was doing it but recently his cognitive status had changed. RN E stated she had checked on Resident#45's records and there was no assessment of self-administration and he had not been care planed for self-administration. RN E stated they did not have a resident who self-administered medications at the facility. RN E stated Resident #45 did not have an order for thymus 300 capsule, thyroid 130 capsule, Advil 200mgs, and Tylenol 500mgs and having the medication in his possession placed him at risk of overuse of the medication or adverse reactions and other residents could get them. RN E stated it was the responsibility of all nursing staff to remove any medications from the resident's bedside. She stated she had done training on medication in rooms, but she could not tell when. Observation on [DATE] at 1:57 PM of the medication cart for Hall 200, with LVN A revealed 1 insulin pen,(basaglar is a long-acting insulin used to control high blood sugar) was opened, partially used, and not labeled with the open date. Interview on [DATE] at 2:05 PM with LVN A, who was the charge nurse for Hall 200, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated but she did not check that morning. She stated the risk of administering insulin when not dated was they might have expired and would not be effective. She stated she had done training on labeling and dating the insulins. Observation on [DATE] at 2:23 PM of the medication cart for Hall 300 with LVN C revealed 2 insulin pens, glargine flex pen insulin injection and insulin Tresiba flex pen, were opened, partially used, and not labeled with the open date. Interview on [DATE] at 2:28 PM with LVN C, who was the charge nurse for Hall 300, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated but she had checked and missed the 2 vials. She stated the risk of administering insulin when not dated was they might have expired and would not be effective. She stated she had done training on labeling and dating the insulins. Interview on [DATE] at 3:45 PM with the ADON revealed it was her expectation that staff date the insulin pens once they pulled them from the refrigerator. She stated it was also the responsibility of the staff to check daily on the expiration dates and labelling. She stated if the staff were not putting the opened dates on the insulin pens and vials that required an open date it placed residents at risk of not getting required therapy. The ADON stated it was her responsibility to audit the carts and the last time she audited was in December. She also stated she expected the nurse to sign off narcotics on the narcotic administration log once they were administered. She stated the risk would be overdose and drug diversion. She stated she was supposed to check the narcotic logs every day and the last time she had checked was [DATE]. Interview on [DATE] at 3:51 PM with the ADON revealed it was all nursing staff's responsibility to ensure there were no medications in the residents' rooms. They were supposed to notify the ADON and the DON. She stated at one-point there was confusion on Resident#45 because at first, he was care planned for self-administration and when his cognition status changed, he was not able to self-administer. She stated that was one year ago when the previous DON was in the facility. She stated it was an oversight because when he started declining the medications were supposed to be removed from his room. She stated an assessment of self-administration was supposed to be done for him to have medications in the room but at this time they could not do the assessment, he could not pass. She stated the risk for Resident#45 having medications in the room was he could overdose, the roommate could take them and other wandering residents. She stated she was not sure whether facility had done training on medications in residents' rooms. Interview on [DATE] at 11:38 AM with the Cooperate RN revealed residents were not supposed to have medication of any kind in their rooms unless they were assessed and were found to be safe with self-administration and there was a doctor's order to self-administer. She stated her expectation was staff were to remove medications from the rooms. The Corporate RN stated residents having medications in their rooms put them at risk of over medicating and other residents could get ahold of them. She stated she also expected staff to label insulin with an opening date once they opened and to check carts for dates and labeling every shift. She stated the risk was they could be expired and if administered they would not be effective. She stated she was not sure whether the facility had done training on labeling and putting an opening date. The Corporate RN stated her expectation was if nurse administered narcotics, they should sign off on the narcotic administration log. She stated the risk of not signing off was an overdose and effect on resident's management. She stated the ADON and the DON were responsible for auditing the carts for labeling and opening dates and on narcotic logging of after administration. Record review of the facility's Administering Medication policy, dated [DATE], reflected: .12 .when opening a multi-dose container, the date opened is recorded on the container . Record review of the facility's policy Storage of Medication, dated [DATE], reflected: Medications and biologicals used in the facility are stored in locked compartments under proper temperatures, lights, and humidity controls.

Based on observation, interview, and record review, the facility failed to ensure the facility provided food that was palatable, for 1 of 3 observed meals (the lunch meal on 01/22/25) reviewed for dietary services. The facility failed to serve food that had a smooth, puddling like texture during the lunch meal on 01/22/25. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Observation on 01/22/25 at 10:00 AM of the kitchen revealed [NAME] F was boiling spaghetti pasta on the stove and after being fully cooked, she added them to the machine to puree the food. [NAME] F pureed the cooked pasta, but it still had bits of pasta in it and was not smooth or pudding like. A sample tray was requested and tasted on 01/22/25 at 1:45 PM with three state surveyors and the DM. The tray that was tasted included pureed spaghetti meat sauce, pureed bread, pureed vegetables, and pureed pasta. The pureed pasta was chunky with pieces of cooked pasta chunks in it; it did not have a smooth or pudding like texture . Interview on 01/22/25 at 1:47 PM with the DM revealed the noodles were very chunky and had pieces of pasta leaving it not smooth or puddling like. The DM said [NAME] F was responsible for making the pureed pasta today for the lunch meal and she should have used a different type of pasta. The DM said [NAME] F was nervous and used regular spaghetti pasta instead of egg noodle pasta that she would normally use for pureed pasta since they were easier to puree. The DM said she did not check the texture of the pureed pasta and normally did not check the texture of pureed food items. The DM said residents could choke if the pureed food item was not the right texture. The DM said each pureed food item should be smooth and puddling like. Record review of a list of residents who were ordered a pureed diet revealed nine total residents. Record review of a menu, dated 01/14/25, and titled Diet Extension: Wednesday, Week 4 [Facility Name] [City Initials] 2024 5Wk [sic] reflected for the Regular/Puree Lunch meal was: Meatballs w/Spaghetti Sc, Spaghetti Noodles, Italian Bld Veg, Herb Butter Roll, Cheesecake Bar. Record review of the facility's Food and Nutrition Services policy, dated 06/12/24, reflected: .7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature .

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 each resident on one of three medication carts (200) and 2 of 19 residents (Residents #1, #3, and #190) reviewed for pharmacy services. 1. The facility failed to ensure the 200 Hall nurses' medication cart contained accurate narcotic logs for Resident #1 and #3. 2. The facility failed to ensure Resident #190's physician order for Lomotil was followed when Hospice Nurse G faxed the order on 01/20/25 to the facility, and it was not put in the system until 01/22/25. These failures could place residents at risk for medication errors, drug diversion, and delay in medication administration. Findings included: 1. Record review of Resident# 1's Quarterly MDS Assessment, dated 01/08/25, reflected the resident was [AGE] year-old female readmitted to the facility on [DATE] with original admission on 02/18/2020, with diagnoses that included anxiety disorder (excessive and uncontrollable feelings of fear and anxiety). The resident had intact cognition with a BIMS score of 15. Record review of Resident #1's physician's orders undated reflected an order for the resident to receive Xanax Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 8 hours related to anxiety disorder, (administer only at 2am, 10am, and 6pm as per resident request). Record review of Resident# 3's Quarterly MDS assessment, dated 10/21/24, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included pain. The resident had intact cognition with a BIMS score of 14. Record review of Resident #3's physician orders dated 06/04/24 reflected an order for the resident to receive Tylenol with Codeine #3 Oral Tablet 300-30 mg (Acetaminophen w/Codeine) Give 1 tablet by mouth every 4 hours, as needed for pain. Observation and record review on 01/22/25 at 01:57 PM of 200 Hall nurses' medication cart and the Narcotic Administration Record, with LVN A, revealed Resident #1's Narcotic Administration Record for Xanax 0.25 mg reflected a total of 18 pills remaining, while the blister pack count was 19 pills. It was last administered on 01/22/25 at 10:00 AM. It also revealed Resident#3's Narcotic Administration record Tylenol with Codeine #3 Oral Tablet 300-30 mg reflected a total of 15 pills remaining, while the blister pack count was 17 pills. Last administered on 01/22/25 at 1:28 PM. Interview with LVN A on 01/22/25 at 2:17 PM revealed she administered Xanax 0.25 mg 1 tablet to Resident #1 at 10:00 AM, Tylenol with codeine 300-30 mg2 tablets to Resident #3 as needed every 4 hours, and she had not signed off on the narcotic administration record log. She stated she gave the residents the medication, but she forgot to sign off on the narcotic administration log. She stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the Medication Administration Record, but she did not. LVN A stated the failure to log off could lead to overdose since the person that came after her would not be able to tell when the narcotic was administered. She stated she had done an in-service on Medication administration. In an interview on 01/22/25 at 3:48 PM, the ADON stated her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. The ADON stated failure to document could lead to drug diversion and overdose. She stated it was her responsibility to audit the medication carts daily. Interview on 01/24/25 at 11:38 AM, the Corporate RN revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. The Corporate RN stated failure to document could lead to overdose and effect on resident management. She stated it was the responsibility of the DON and the ADONs to audit the medication carts. She stated she will check on facility training records and none was provided. Record review of facility policy entitled Medication Administration , dated 07/08/24, reflected the following: did not address the narcotic administration record. 2. Record review of Resident #190's Admission Record, dated 01/24/25, reflected she was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #190's Annual MDS Assessment, dated 12/28/24, reflected she had a BIMS score of 5 indicating severe cognitive impairment. Her diagnoses included heart failure (where the heart cannot keep up with its workload), hypertension (high blood pressure), and Alzheimer's disease (a neurological disorder that causes irreversible changes in memory, thinking, and behavior). Record review of Resident #190's January Order Summary Report reflected an order of Lomotil Tablet 2.5-0.025 MG (Diphenoxylate-Atropine), Give 2 tablet by mouth every 6 hours for diarrhea give 2 tablet until diarrhea resolve [sic] with an order date of 01/22/25. There was no evidence of a PRN order for the Lomotil as of 01/20/25. Record review of Resident #190's Medication Administration Record for January 2025 reflected Resident #190 received the Lomotil medication starting in the afternoon on 01/22/25. There was no additional orders or administrations for Lomotil. Record review of a faxed order, dated 01/20/25, for Resident #190 from Hospice Agency H reflected: Lomotil; 2 Tablet ORAL 4 times a day As Needed for Diarrhea (2.5-0.025 MG Tablet); 2 tablets orally every 6 hours as needed for diarrhea. The order was signed by Hospice Nurse G. Observation and interview on 01/22/25 at 11:00 AM with Resident #190 revealed she was in her bed in her room, dressed and groomed. Resident #190 said she had not been having any diarrhea and was doing great. Resident #190 said she was getting all her medications as far as she knew. Interview on 01/22/25 at 3:43 PM with Hospice Nurse G revealed she was told on Monday that Resident #190 had been having diarrhea for four days. Hospice Nurse G said the facility was not giving Resident #190 her anti-diarrhea medicine as it was ordered so she changed the order. Hospice Nurse G said she had faxed an order on Monday to the facility that was PRN, but it was changed today (01/22/25) to be given on a routine basis instead. Interview on 01/23/25 at 10:28 AM with RN H revealed Resident #190 did have some diarrhea but it was getting better. RN H said she thought the order for the anti-diarrhea medicine came on Monday, but she was not sure. RN H said the anti-diarrhea medicine was supposed to be PRN but was changed to be routine . Interview on 01/24/25 at 10:17 AM with the ADON revealed she was told Resident #190's Hospice Nurse had faxed orders over for Lomotil instead of giving the order directly to the nurse to treat Resident #190's diarrhea. The ADON said she would have to check to see if anyone ever saw the order or not and would follow-up once she found out what happened. Interview and record review on 01/24/25 at 11:40 AM with the ADON revealed she saw the order for Resident #190 still sitting on top of the fax machine. The ADON brought the faxed order for the Lomotil which showed an order date of 01/20/25.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #26 and #245) reviewed for dialysis. The facility failed to ensure dialysis communication forms for Residents #26 and Resident #245 were received back after returning from dialysis treatment. This failure could place residents at risk of inadequate communication between the facility and dialysis center. Findings included: 1. Record review of Resident #26's admission MDS assessment, dated 01/12/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #26 had a diagnosis of end stage renal disease (a chronic condition that occurs when the kidneys can no longer filter waste from the blood and requires long-term dialysis). She had a BIMS score of 13, which indicated her cognition was intact. The MDS reflected Resident #26 received dialysis. Record review of Resident #26's care plan, dated 01/07/25, reflected Resident #26 needed hemodialysis (medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly) rule out renal failure. The care plan reflected the following goals: [Resident #26] would have no signs of complication from dialysis through next review date. The resident will have immediate intervention should any s/sx of complications from dialysis occurs through the review date. The care plan interventions reflected: Encourage resident to go for the scheduled dialysis appointments Tuesday's, Thursday's, and Saturday's. Resident receives dialysis. Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Record review of Resident #26's January 2025 physician's order reflected to monitor permcath (flexible tube that's inserted into a blood vessel to provide long-term access to the bloodstream) pressure dressing to rule out chest for excessive bleeding every shift. Record review of Resident #26's EHR reflected nursing documentation regarding Resident #26's pre- and post-dialysis vital signs but missed any communication from dialysis center. Record review of Resident #26's dialysis communication forms for 01/07/25 to 01/24/25 reflected dialysis communication form dated 01/18/25 and 01/23/25, all the other dialysis dates of the month of January 2025 were missing communication forms totaling to 6 days in January 2025 on the following days: 01/09/25, 01/11/25, 01/14/25, 01/16/25, 01/18/25, and 01/21/25. 2. Record review of Resident #245's admission MDS assessment, dated 01/11/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #245 had a diagnosis of end stage renal disease (a chronic condition that occurs when the kidneys can no longer filter waste from the blood and requires long-term dialysis). She had a BIMS score of 14, which indicated her cognition was intact. The MDS reflected Resident #245 received dialysis. Record review of Resident #245's care plan, dated 01/07/25, reflected Resident #245 needed hemodialysis (medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly) rule out renal failure. The goals reflected Resident #245 would have no signs of complication from dialysis through next review date. The care plan interventions included: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis. Check and change dressing daily at access site. Record review of Resident #245's January 2025 physician's order reflected Check Bruit &Thrill every Shift, notify provider if not palpable every shift for dialysis site Tuesday, Thursday, and Saturday every shift. Record review of Resident #245's EHR reflected nursing documentation regarding Resident #245's pre- and post-dialysis vital signs but missed any communication from dialysis center. Record review of Resident #245's dialysis communication forms for 01/07/25 to 01/24/25 reflected dialysis communication form dated 01/07/25, 01/11/25, 1/16/25 and 01/18/25 all the other dialysis dates of the month of January 2025 were missing communication forms totaling to 4 days in January 2025 on the following days: 01/09/25, 01/14/25, 01/21/25, and 01/23/25. Interview on 01/21/25 at 12:35 PM with Resident #26 revealed she went for dialysis Tuesday, Thursday, and Saturday. She stated she got a form that she took to dialysis and brought back to the facility, but she stated she was not sure whether she brought the form back to the facility after dialysis. She stated she got checked for her vital signs when she left for dialysis and when she came back from dialysis. Interview on 01/22/25 at 8:29 AM with Resident #245 revealed she went for dialysis Tuesday, Thursday, and Saturday. She stated she got a form that she took to dialysis and brought back to the facility in her bag, but she stated she was not sure whether the staff took the communication form from her bag. She stated her vital signs were checked when she left for dialysis and when she came back from dialysis. Interview on 01/22/25 at 3:03 PM with RN E revealed she was aware she was supposed to send Resident #26 and Resident #245 with the dialysis communication form when they left for dialysis and then collect the form when the resident's returned from dialysis. RN E stated she knew she was supposed to monitor the dialysis access site for the bruit thrill (a vibration caused by blood flowing through the fistula and can be felt by placing fingers just above incision line), dressing for bleeding and vital signs when Residents #26 and Resident #245 were back from dialysis which she does and document in the progress notes. She stated it was all nurse's responsibility to collect the dialysis communication forms when Resident #26 and Resident #245 came back and filed them. RN E stated they were supposed to call the dialysis clinic and follow up if communication forms were not sent back with residents. She stated failure to follow up on the communication form after dialysis was completed could cause them to miss the orders and recommendations from dialysis center. She stated she had done trainings on dialysis communication form, but she could not recall when. Interview on 01/23/25 at 12:40 PM with the ADON revealed the nurses were supposed to fill out the forms with the residents' pre-dialysis vitals, and the form would be taken to dialysis by Resident #26 and Resident #245. She stated she expected the nurses to collect the form after dialysis, perform vital signs, and document on electronic health records and put the communication forms on the binders. She stated the importance of the communication form was communication between the facility and dialysis center on new orders, treatment given, and any change of condition. She stated she had checked on the binders and had noticed the communication forms were missing after the surveyor brought it to her attention. She stated she talked to Resident #26 and Resident #245, and they told her they turned the communication forms into the dialysis center, and they do not bring them back. She stated she was responsible on ensuring nurses were completing the forms, monitoring vitals pre and post dialysis. She stated she could not recall the last time she checked the binders, but she checked on 01/23/25 after she was notified the communication forms were missing. She stated she checked on health records and the nurses were documenting the vitals pre and post dialysis. She stated admitting nurses were responsible of putting orders for monitoring pre and post-dialysis, and it was her responsibility and the DON to go through the orders and ensure none were missing. She stated the risk of not having the communication form brought back from dialysis was omission of orders. Interview on 01/24/25 at 11:23 AM with the Corporate Nurse revealed her expectation was for the nurses to send Resident #26 and Resident #245 with a communication form and get it when back from dialysis. She stated post-dialysis assessments should be documented in electronic health records. She stated she also expected the facility to have orders for pre and post dialysis. She stated the failure to collect the forms back from dialysis were they could miss important orders from dialysis. She stated the DON was responsible of following up to ensure all orders were in place and the staff were getting the communication forms back from dialysis. She stated she would check whether the facility had done training with staff and provided a record dated 01/23/25 on dialysis protocol that addressed dialysis communication forms and monitoring before and after dialysis. Record review of the facility's Dialysis Protocol policy, dated 05/17/24, reflected the following: .2. Implement dialysis communication regarding plan of care. 3. Auscultate shunt site for presence or absence of thrill and bruit-if absent notify doctor immediately. 4. Monitor site for s/s of infection

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services, based on the comprehensive assessment, to prevent urinary tract infections for 1 of 3 residents (Resident #68) reviewed for urinary catheters. The facility failed to keep Resident #68's catheter tubing off the floor while the resident was in her wheelchair causing it to drag on the floor and be stepped on while she was being pushed down the hall. This failure could affect residents with catheters by placing them at risk for the development and/or worsening of urinary tract infections and injury. Findings included: Record review of Resident #68's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included depression, bipolar disorder, dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling), disorder of kidney and ureter. Resident #82 has a BIMS of 5 indicating she had severe cognitive impairment. Record review of Resident #68's January 2025 monthly orders reflected she had a catheter 18 French 10 cc bulb. Observation on 01/21/25 at 11:18 AM of Resident #68 revealed she was being pushed in her wheelchair from her room to the dining room by the Activity Director. The resident's catheter tubing was dragging on the floor and the Activity Director stepped on the tubing. When the Activity Director stepped on the tubing, she moved her foot and continued to push the resident. The resident did not appear to be in distress or noticed her tubing had been stepped on. Interview on 01/24/25 at 11:53 AM with the Activity Director revealed she recalled stepping on Resident #68's catheter tubing when she was pushing the resident in her wheelchair. The Activity Director said she was not aware the catheter tubing was not supposed to be dragging on the floor and did not know she had to tell someone so they could lift it off the ground. Interview on 01/24/25 at 1:27 PM with LVN A revealed Resident #68's catheter tubing should not drag on the floor because it could introduce bacteria and was an infection control issue and if the Activity Director stepped on the tubing it could pull the catheter or hurt the resident. LVN A said if non-nursing staff were to see a catheter tube dragging, they should let the nursing staff know so they could fix the issue. Interview on 01/24/25 at 2:33 PM with the ADON revealed if non-nursing staff saw catheter tubing dragging on the floor, they could pick it up themselves or ask nursing staff for assistance. When the Activity Director stepped on the tubing, the ADON stated it could have pulled the catheter causing discomfort to the resident. She stated it was also an infection control issue. Record review of the facility's Catheter Care, Urinary policy, revised January 2023, reflected the following: Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections. .Infection Control . .b. Be sure the catheter tubing and drainage bags are kept off the floor

Based on interview and record review, the facility failed to ensure, based on a resident's comprehensive assessment, residents maintained acceptable parameters of nutritional status for 1 of 19 residents (Resident #68) reviewed for nutrition. The facility failed to obtain Resident #68's weight upon her admission to the facility on [DATE] and failed to obtain weekly weights for the resident for four weeks, which resulted in the resident's weight loss not being identified. This failure placed residents at-risk for loss of weight and inadequate nutrition. Findings included: Record review of Resident #68's admission MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included depression, bipolar disorder, dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling), disorder of kidney and ureter, cognitive impairment, and malnutrition. Resident #82 has a BIMS of 5 indicating she had severe cognitive impairment. The MDS further reflected Resident #68's weight was 127 pounds. Record review of Resident #68's care plan revised on 01/07/25 did not reflect there were any weight concerns. Record review of Resident #68's hospital records dated 12/30/24 reflected the resident weighed 127 pounds. Record review of Resident #68's facility weights reflected the following: 01/15/25 - 128.6 pounds 01/21/25 - 119.4 pounds 01/23/25 - 119 pounds - surveyor witnessed weight being taken Record review of Resident #68's meal intake from 01/01/25-01/21/25 reflected there were 4 meals where the resident ate 26%-50%, 23 meals where she ate 51%-75%, and 3 days where she ate 75%-100%. Record review of Resident #68's admit evaluation initiated by LVN D dated 12/31/24 reflected there was not a weight entered for the resident. Observation and interview on 01/23/25 at 1:44 PM revealed Resident #68 was in her room, in her wheelchair, eating lunch. The resident said she was full, and it appeared she had eaten about 50% of her meal. Resident #68 was asked if she had been having decreased appetite, and the resident was not able to answer yes or no to the question and just said she was full. Interview on 01/23/25 at 12:35 PM with CNA B revealed she worked at the facility Monday through Friday and worked with Resident #68. CNA B said the resident was able to eat on her own with no issues and described her a good eater for breakfast and lunch. CNA B also said Resident #68 had never not eaten or said she was not hungry. Interview on 01/24/25 at 2:26 PM with LVN D revealed she had just started working at the facility when Resident #68 was admitted and there was another nurse assisting her as it was her first new admit. LVN D said that nurse no longer worked at the facility. LVN D stated she did not get a weight on Resident #68 and was unsure if the other nurse had gotten an initial weight on the resident. Interview on 01/23/25 at 12:20 PM with Resident #68's family revealed she visited the resident frequently, and she had not noticed any weight loss. The family said Resident #68's weight usually fluctuated anywhere from 120 pounds to 135 pounds. The family said Resident #68 normally ate well, and the resident had not said anything to her about not being hungry or that she was not eating well. Interview on 01/23/25 at 12:16 PM with the ADON revealed she was not aware that new admits needed to be weighed weekly per their policy and did not know Resident #68's weight had not been taken when she first admitted . The ADON said some of the resident weights also might have been missed because of the recent ice storm that hit the area and staff calling in. The ADON further stated the DON had been on medical leave since the holiday break, and she (ADON) was trying to keep her head above water. She stated this is why the weight had been missed possibly. The ADON said if she would have noted the variance in weights, she should have called the doctor for further orders. Interview on 01/23/25 at 1:53 PM with the Registered Dietitian revealed she saw Resident #68 on 01/07/25 and noted there was not a weight in the system for Resident #68 and she had sent an email to the DON and ADON along with other department heads to obtain a weight for the resident. The Registered Dietitian said she had planned on following up with the resident the week of the survey to see if the staff had obtained the weights. The Registered Dietitian stated if she would have been made aware of the resident's weight loss, she would have put some measures in place such as adding fortified foods to her meal or a supplement if the resident was not eating at least 75% during her meals. She said that based on the resident's current weight and height, the resident was slightly below her BMI, but she was not concerned about it. Interview on 01/24/25 at 11:21 AM with the Physician revealed he had seen Resident #68, and she did not appear to be grossly underweight. The Physician said the staff were normally pretty good about letting him know when residents were experiencing weight loss and he or someone from his office was at the facility at least 5 times a week. The Physician further stated if he would have been told about Resident #68's weight loss he would have put some measures in place as well as trying to find out what was causing the weight loss. Record review of the facility's Weight Management policy dated January 2021 reflected the following: Procedure 1. Residents will be weighed on Admission and readmission. 2. New admits will be weighed weekly for the first 4 weeks to establish baseline weights, after which they will be weighted monthly .5. Any weight change (loss or gain) of 5lbs or more since the last weight assessment will be retaken Additionally, the Interdisciplinary Team will assure the below tasks are accomplished: Physician notification of weight loss and documentation

Based on interview and record review, the facility failed to ensure that PRN orders for antipsychotic drugs were limited to 14 days and could not be renewed, unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication and resident's drug regimen was free from unnecessary drugs, to include adequate indications for its use for 2 of 2 residents (Residents #35 and #44) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #35's PRN order for Seroquel (Quetiapine Fumarate) , an antipsychotic medication, did not extend beyond 14 days without an identified end date. 2. The facility failed to ensure Resident #44 did not receive the antipsychotic medication Seroquel (Quetiapine Fumarate) for sleep. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. Findings included: 1. Record review of Resident# 35's Quarterly MDS Assessment, dated 01/03/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder (mental health condition that can develop after someone experiences or witnesses a traumatic event). The resident had moderate cognitive impairment with a BIMS score of 09. Record review of Resident #35's care plan, dated 10/22/24, reflected Resident #35 had a mood problem and had a diagnosis of post-traumatic stress disorder. The care plan reflected the goals were [Resident #35] will have improved mood state through the review date. Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #35's physician's orders dated 09/24/24 reflected an order for the resident to receive Quetiapine Fumarate Oral Tablet 25 mg (Seroquel). Give 1 tablet by mouth every 24 hours as needed for agitation. Give medication at bedtime. Record review of Resident #35's September 2024 MAR revealed he received it on 09/25/24. Record review of Resident #35's November 2024 MAR revealed he received it on 11/10/24. In an interview on 01/24/25 at 10:12 AM the ADON acknowledged that the order for Resident #35's Quetiapine Fumarate Oral Tablet 25 mg PRN had been in the MAR since September 2024. The ADON stated Resident#35 was supposed to be on prn antipsychotic medication for 14 days and then discontinued or the doctor to review and decide whether to continue. She stated it seemed the resident admitted with the prn medication. She stated the admitting nurses put the orders in the electronic records and it was the DON and the ADON's responsibility to follow up the following day and she thought they missed the orders to make sure the residents who were on PRN antipsychotic medications were assessed every 14 days for the resident to continue with the medication. The ADON stated they have already called the resident's primary care provider to inform them of the need for the medication to be reviewed. She stated the doctor issued an order to reduce the order to 12.5mgs and then discontinue . She was not asked how the failure would affect the resident. In an interview on 01/24/25 at 10:49 AM with the Corporate RN, she stated all PRN Psychotropic medications were supposed to be re-evaluated every 14 days by the resident's primary care provider and determine if the resident was to continue with the medication . She was asked but she could not answer. She stated it was not facility policy to put resident on antipsychotic medication. In an interview on 01/24/25 at 12:18 PM with the NP, she stated Resident #35 was not supposed to be on PRN antipsychotic medication. She was not aware he was on PRN medication, and she did not prescribe the antipsychotic medications, but the doctor did. She could not say the effect unless she saw the file for the resident. Interview on 01/24/25 at 12:19 PM with doctor was attempted by phone with no response and voice mail was left. 2. Record review of Resident# 44's Quarterly MDS Assessment, dated 12/12/24, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included unspecified dementia, severe, with other behaviors. The resident had severe cognitive impairment with a BIMS score of 00. Record review of Resident #44's care plan, dated 11/30/24, reflected Resident #44 used the antipsychotic medication, Seroquel. The care plan reflected the goals were: [Resident #35] will reduce the use of psychotropic medication through the review date. Interventions: - Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. Record review of Resident #44's physician's orders dated 11/19/24 reflected an order for the resident to receive Quetiapine Fumarate Oral Tablet 50 mg (Seroquel). Give 1 tablet by mouth at bedtime for sleep. In an interview on 01/23/25 at 1:03 PM with the MDS Coordinator, she stated she prepared the care plan for Resident#44, and she was not supposed to be on an antipsychotic Quetiapine Fumarate for sleep. She stated Resident #44 had a diagnosis of Alzheimer disease and dementia , but the resident was not supposed to be on an antipsychotic. She stated she did not know of the risk associated with Resident #44 receiving these medications. Interview on 01/24/25 at 10:12 AM with the ADON revealed she acknowledged the order for Resident #44's Quetiapine Fumarate Oral Tablet 50 mg for sleep. She stated the nurses put the orders in the electronic records and it was the DON and the ADON's responsibility to follow up the following day and she thought they missed the order to make sure the residents who were on antipsychotic medications were for the right diagnosis. The ADON stated they had already called the resident's primary care provider to inform them of the need for the medication to be reviewed. She stated the the resident would be sleeping alot. Interview on 01/24/25 at 10:49 AM with the Corporate RN revealed her expectation was the facility could have used other alternative medication for sleep rather than Quetiapine Fumarate. She stated the ADON, and the DON could have caught it and notified the doctor for an alternative. She stated Quetiapine Fumarate was for resident with schizophrenia and not a choice for Resident #44 who had dementia and Alzheimer. She stated the risk of Resident#44 using Quetiapine Fumarate would be fatigue. She was not asked how the failure would affect the Resident #44 Interview on 01/24/25 at 12:14 PM with the NP revealed Resident #44 was not supposed to be on antipsychotic medication for sleep. She was aware she had diagnosis of dementia with behaviors, and she did not prescribe the antipsychotic medications, and if they admit with an antipsychotic, she did refer residents to be evaluated by a psychiatrist. She stated she did not belief it was meant for sleep since she had a diagnosis of dementia with behaviors. She was not asked on how the medication would affect the resident. Interview on 01/24/25 at 12:43 PM with the Physician was attempted; however, the attempt was unsuccessful with no return call. Record review of the facility's Psychotropic/Psychoactive Medication policy dated 12/09/24 reflected the following: .1. Resident will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . Record review of the facility's Psychotropic Management policy dated 01/11/22 reflected the following: .3. PRN Antipsychotic and PRN Psychotropic medications- a. Any as needed use of an antipsychotic can only be authorized for 14 days. These orders cannot be renewed unless the attending physician or prescribing practitioner evaluate the resident for the appropriateness of that medication. A new order for prn anti-psychotic will be required to be written every 14 days . Record review of the Seroquel: Package Insert/Prescribing Info last updated 01/30/24 reflected the following: Highlights of Prescribing Information . Warning: Increased Mortality in Elderly Patients with Dementia-Related Psychosis; and Suicidal Thoughts and Behaviors .Indications and Usage for Seroquel Seroquel is an atypical antipsychotic indicated for the treatment of: - Schizophrenia - Bipolar I disorder mania episodes - Bipolar disorder, depressive episodes .5. Warnings and Precautions 5.1 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death .Seroquel is not approved for the treatment of patients with dementia-related psychosis .

Based on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 19 residents (Resident #39) reviewed for resident call system. The facility failed to ensure Resident #39 had a working call light. This failure could have placed residents at risk of being unable to obtain assistance when needed. Findings included: Record review of Resident #39's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, depression, bipolar disorder, and obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep). Resident #39 had a BIMS score of 14, indicating her cognition was intact. Record review of Resident #39's care plan initiated on 10/25/24 reflected the resident had an ADL self-care performance deficit related impaired balance. Interventions included to encourage the resident to use bell to call for assistance. Observation and interview on 01/21/25 at 2:14 PM of Resident #39 revealed she was lying in bed and had just finished breakfast. The resident said she had recently been moved to that room the night prior and she said she did not think her call light was working because she had pushed it for someone to pick up her lunch tray and no one had been in yet. The resident was asked to push the call light again and the light did not turn on outside of the room. Resident #39 further stated she would like her call light to work in case she needed something or assistance. Interview on 01/21/25 at 2:17 PM with the Maintenance Director revealed he was not aware the call light was not working. The Maintenance Director pushed the call light himself and it did not work. He said it appeared he needed to replace the cord. Record review of the facility's Resident Call System policy, dated October 2022, reflected the following: Policy Residents are provided with means to call staff for assistance through communication system that directly calls a staff member or a centralized workstation .3. The resident call system remains functional at all times

Based on interview and record review, the facility failed to report the results of all investigations to the State Survey Agency (HHSC), within 5 working days of the incident for 1 of 3 facility self-reported incidents (Incident Intake ID: 483847)reviewed for reporting to HHSC. The facility failed to submit a Provider Investigation Report to HHSC within 5 working days of reporting an incident involving allegations of quality of care, administration/personnel, and resident rights regarding Resident #1 on 02/12/24. This failure could place the residents at risk for not having investigations reported within the timeframe as required. Findings included: Record review of the face sheet printed on 02/28/24 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses including vascular dementia severe with agitation (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), cerebral atherosclerosis (build-up of plaque in the blood vessels of the brain), and high blood pressure. Record review of the admission MDS dated [DATE] indicated Resident #1's cognition was severely impaired with a BIMS score of 00. Record review of Resident#1 care plan, dated 02/05/24, indicated Resident #1 had impaired thought process due to dementia and had behaviors. Resident #1 was noted to have behavior problems due to being physically aggressive and resistive to care as evidenced by refusal for staff to provide incontinence care and activities of daily living rule out dementia. The care plan reflected: Intervention: Allow Resident #1 to make decisions about treatment regime, to provide sense of control. Review of TULIP reflected the DON reported an incident (Incident Intake ID: 483847) on 02/12/24 at 5:00 PM. The incident involved Resident #1 and CNA A with allegations of administration/personnel, quality of care, and resident rights. Further review of the TULIP record reflected no evidence a Provider Investigation Report had been submitted for this incident as of 02/28/24. Interview on 02/28/24 at 2:27 PM with the DON revealed she was notified by a family member on 02/12/24 that they heard CNA A walking down the hall with other staff stating she could not wait to get out of the facility because the residents were mean. CNA A was then observed pointing towards Resident #1's room. The DON stated after learning of the incident she notified the Administrator, called the intake in to the State Survey Agency, and CNA A was suspended. She stated she was aware the Provider Investigation Report was supposed to be completed within 5 days. Interview on 02/28/24 at 3:35 PM with the Administrator revealed the family member reported the incident happened on the hallway on 02/10/24, and they notified the DON on 02/12/24. The DON notified him, since he was out of the office, and he told the DON to report to the State Survey Agency and suspend the CNA. The Administrator stated he was aware of the regulations he was supposed to submit the investigation report within 5 days, but he did not because he could not get ahold of CNA A for an interview. He stated there was no abuse, and he felt it was not reportable because this was unprofessional behavior on the hallway. CNA A was suspended, although she had already given her resignation letter to the facility, and that week was her last working at the facility. The Administrator stated he had not seen CNA A since that day. He stated failure to submit the investigation report could have caused the problem to continue or reoccur. He stated he did in-service training on abuse and neglect on 02/17/24, and he did safe surveys with interviewable residents, which resulted in no issues or concerns being reported. Review of the in-service record, dated 02/17/24, on the topic of Abuse and Neglect revealed the staff were trained on the types of abuse, reporting of allegations of abuse to the Administrator, who was the facility's Abuse Coordinator, immediately. The training also reflected if an allegation was reported to a supervisor, it should also be reported to the Administrator. Record review of the facility's current Abuse policy, dated 11/07/23, reflected: .3. The facility will report the results of the investigations to the enforcement agency in accordance with state law, including the stated survey and certification agency. .5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions

Based on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen for food storage. The facility failed to: 1. date, label, and seal food items in the dry storage area of the facility's kitchen. 2. Cook J, Dietary Aide K and Maintenance Director washed their hands and put on hair restraints prior to entering or directly after entering the kitchen. 3. keep the kitchen clean and sanitary and free from dirt and food debris and well maintained equipment and exit barrier. These failures could affect residents by placing them at risk of cross contamination and food-borne illness which could cause gastro-intestinal illnesses and increase in pests. Findings included: Observation on [DATE] at 11:04 am of the facility's kitchen revealed: -Two 32 ounce bags of clear unlabeled Spaghetti noodles were opened with no open on date . -1 very large 64 ounce bag of clear unlabeled spiral noodles were opened without a received and open on date . -1 very large 64 ounce bag of clear unlabeled Spaghetti noodles were opened with no received and open on date . -1 large white 25 pound bag of Dry black beans was opened with no open on date . -1 32 ounce bag of Mexican seasoning with a received date of ,d+[DATE] and no open on date . -1 Small bag of gravy with a receive date ,d+[DATE] and brownie mix received date ,d+[DATE] were both open and had no open dates . -There was a 15 ounce bag of clear unlabeled cake mix and 10 ounce bag of clear unlabeled corn flakes dated ,d+[DATE] without open dates . -There was one 20 ounce bag clear unlabeled of cheerios with a receive date of ,d+[DATE] . -There was a large clear bag of clear unlabeled rice crispies dated ,d+[DATE] . - 1 Gallon bottle of liquid browning seasoning had 7 dried up brown rings inside of it and dried up sauce was all around the top of the bottle and it did not have an open date . -The flooring in the dry pantry room had a torn piece of cardboard, paper and pieces of debris and there were several areas of blackish colored dirt on each side of the entrance of the storage room . -1 white foot pedal trash can had a greasy layer of film on it and the sink had a greasy dusty texture on it. -There was dried brownish stained splash marks on the counter next to the tea maker, -2 white wooden planks holding up the food steam had 2 inches of blackish discoloration on them . -Inside of the utility room in the kitchen, a yellow mop bucket had dried brownish blackish stains around the sides of it and a small amount of brownish water in it .the floor mop sink was covered with dried blackish and browns .the floor had several layers of dried blackish dirt around the base board and a paper towel was on the floor and there was several areas of the door frame had brownish rust stains on it . -The flooring next to the large, grey and metal ice machine in the kitchen had very large dried whitish stains. -The black swing top trash can had a lot of whitish and brownish dried food and drink stains on it. -The small greyish ice machine on the countertop of the dining room with leaking water from the dispenser into a tray that was full and the grey tray had brownish and whitish splash stains on it . -The south door of the dining had sunlight shining through a large size hole approximately 3 inches in diameter at the bottom corner of the door .and next to the door the base board and door frame had broken blackish particles which appeared crumbled. Interview on [DATE] at 11:25 am, the Dietary Director stated she was not sure why these food items identified in the storage room did not have opened on dates and was not sure when they needed to be used by. She stated the staff knew better and she would do an Inservice training today ([DATE]) to make sure everyone labeled the food items properly. She stated when food items was not labeled correctly she was not sure how it could affect the residents. She stated her expectations was for the kitchen staff to put the received and open on dates on all food items opened and rotate them on the shelf. Interview and Observation on [DATE] at 11:30 am, Cook J walked into the kitchen without a hairnet or face mask on and she did not wash her hands. She walked straight to the supply room on the other side from the sink and to where the residents cups were stored. She stated she had just started her shift and was going to put her purse up then put a hairnet and face mask on and wash her hands. Interview and observation on [DATE] at 11:33 am, Dietary Aide K walked into the kitchen directly to the supply room where the resident's cups were stored, and he did not wash his hands or had on a hair net he stated he just started working at this facility and should have washed his hands and have on a hairnet when once intering the kitchen. Interview and observation on [DATE] at 11:46 am, Maintenance Director walked into the kitchen from the back door to the Dietary Directors office without washing his hands or having on a hairnet and began talking to her about something. He stated he just came to the kitchen to tell the Dietary Director the plumber was at the facility to fix something. He stated he was supposed to have on a hair net and wash his hands in the kitchen to prevent from getting any hair on the food and equipment, to not get anything dirty and said he was not sure where the hairnets were kept. Interview on [DATE] at 11:55 am, the Dietary Director stated they did not have any hairnets by the front entrance doors because they box was taken down after they remodeled and she was not sure why it was not put back up. She stated she was not sure why the Cook J, Dietary Aide K and the Maintenance Director did not wash their hands and have on hairnets in the kitchen. She stated Cook J and dietary aide K wanted to put their stuff down first then they were going to wash their hands. She stated she was not aware there was whitish colored splash stains next to the ice machine, the dirty sink, dirty trash can, dirty countertops by the coffee maker and dirty floor drain. She stated she was unaware the small ice machine on the counter in the dining room was leaking and the drain was full of water but stated she would notify the Maintenance Director to repair. Interview on [DATE] at 12:13 am, the Administrator stated he was not aware of the kitchen being dirty and unsanitary or the food not being labeled correctly. He stated he was not aware of the drink dispenser leaking water and was not aware of the chipped exit door with the hole in the corner area in the dining room. He stated would talk to the Maintenance Director about repairing. Interview on [DATE] at [DATE] at 2:28 pm, Cook L stated she cleaned the stove, the fryer and freezer once a week and the other cook cleaned the fryer oven and food steamer. She stated normally the dishwasher and dietary aide cleaned the trash cans and added she swept and mopped after every meal. She stated whoever was the dietary aide that day, cleaned the kitchen and signed off on the cleaning schedule what was cleaneed. She stated not having an unsanitary kitchen could make people sick. She stated they needed more staff, 1 dishwasher and a weekend cook. She stated everybody was responsible for ensuring the kitchen was cleaned and ultimately the Dietary Director was responsible. She stated there were no issues with the storage area and was not aware of spaghetti and other items not labeled correctly. She stated once the food and drinks were delivered to the facilty, they dated when they were received and when something was opened they had to put an open date on it. She stated it was important to date food because it could get old and expire. She stated if food was expired, the residents could get sick and maybe get food poisoning. She stated the last time she had a label and storage inservice training was a few months ago. Interview on [DATE] at 6:48 pm, the Administrator stated the Dietary Director was responsible for ensuring the kitchen was clean and sanitary and handwashing and hairnets are on. He stated he would start doing weekly checks of the kitchen and was pending having a professional cleaning service do a deep clean of the whole kitchen. Record review of the facility's Kitchen Equipment Cleaning and Sanitation policy revised 12.2020 revealed, Policy: The kitchen and dining equipment and food contact surfaces shall be maintained in a clean and sanitized condition .Procedure: Dining Services staff should be trained on cleaning and sanitizing processes .The Dietary Manager shall provide cleaning assignments to indicate the time and task to be completed by dining services staff. The Dietary Manager is responsible to ensure that cleaning assignments have been timely completed .Equipment food contact surfaces and utensils shall be kept free of encrusted grease deposits and other accumulations .Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . Record review of the facility's Food Receiving and Storage policy dated [DATE] revealed, Policy Statement: Food shall be stored in a manner that complies with safe food handling practices .Policy Interpretation and implementation: 1. Food services, or other designated staff will maintain clean food storage areas at all times .14.e other opened containers must be dated and sealed or covered during storage. Review of the Food and Drug Administration Food Code, dated 2022, reflected: ,d+[DATE].11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under S ,d+[DATE].122. (C) Pressurized BEVERAGE containers, cased FOOD in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture XXX,d+[DATE].11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (Resident #9) of 19 residents reviewed for pain/comfort. 1. Staff failed to premedicate Resident #9 prior to wound care. The resident was medicated during the care, after surveyor intervention. 2. PT G failed to stop the wound care when the resident was in pain and allow the pain medication to work. 3. LVN F failed to ensure Resident #9 swallowed all of the pain medication that was in her mouth. These failures resulted in Resident #9 screaming, yelling, and crying out during the wound care. These failures could affect the other 39 residents, who were on a pain management program, by placing them at risk for unrelieved pain, discomfort, and anxiety. Findings included: Resident #9's Face Sheet dated 10/19/12 reflected the resident was a [AGE] year-old female, who was originally admitted to the facility on [DATE] and then readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #9's Pain Evaluation dated 10/01/12 reflected using the PAINAD scale that she had "Repeated troubled calling out. Loud moaning or groaning. Crying...Sad, Frightened, Frowning...Rigid. Fists clenched, Knees pulled up. Pulling or pushing away. Striking out...Unable to console, distract or reassure." The Evaluation also reflected she demonstrated the following non-verbal/Noncognitive Signs of Pain: grimacing/distorted face, frowning/scowling, glazed eyes/tearing, wrinkled brow, moaning, crying/whimpering, screaming, fidgeting/irritability, clenched fists, wringing of hands, and increased hand/finger movements. Resident #9's Pain Evaluation reflected she received [MEDICATION NAME] 5/325 mg two tablets every six hours as needed for pain. Resident #9's Admission Nursing assessment dated [DATE] reflected a [DIAGNOSES REDACTED]. Further review of the Nursing Assessment revealed she needed assistance with transfers, bathing, eating, and personal hygiene. The Assessment reflected Resident #9 had a Foley catheter and was incontinent of bowel. The Assessment also reflected Resident #9 was alert but unable to understand. Resident #9's Pain Evaluation dated 10/10/12 reflected the resident was not in pain. Resident #9's Wound/Skin Healing Record dated 10/10/12 reflected an unstageable wound which measured 2.1 cm x 1.5 cm x 1.9 cm with 2.9 cm tunneling at 12 o'clock. The Record also reflected Resident #9 was unable to communicate, but she demonstrated the following non-verbal communication of moaning/crying, being tense, and restlessness. Resident #9's Admission Care Plan dated 10/10/12 reflected the goal for the resident's pain was for the resident to be as comfortable as possible. The interventions were to "Monitor pain, Non-drug interventions, Administer pain medications as ordered, and Establish causative factors and ways to alleviate them." The Care Plan also reflected to use the Wong Pain Scale and the interventions included, "Assess location, frequency, duration, and intensity of pain. Document assessment...Administer pain medications as ordered and requested. Document effectiveness...." Resident #9's admission orders [REDACTED]. Resident #9's Physician's Telephone Order, dated 10/10/12 and signed by PT G, reflected PT to evaluate the wound and treat as indicated. Resident #9's Physician's Telephone Order, dated 10/10/12 and signed by PT G, reflected PT to clean the sacral/coccyx wound with wound cleaner, apply Santyl, pack with [MEDICATION NAME] rope and cover with foam and bordered gauze or adhesive tape to secure. Resident #9's Physician's Telephone Order, dated 10/12/12 and signed by PT G, "Effective 10/10/12... PT wound clarification - Skilled wound care to include removal of devitalized tissue (with) scissors, tweezers and scalpel PRN." Resident #9's PT Evaluation and Plan of Treatment dated 10/10/12 and electronically signed by PT G reflected the reason for the referral was "Patient exhibits exacerbation of decreased skin integrity, decreased judgment and reduced ADL participation indicating the need for PT to assess abilities, decrease complaints of pain and facilitate wound healing." The Evaluation also reflected the wound to her sacrum/coccyx measured: "Length = 2.1 centimeters; Width = 1.5 centimeters; Depth Measure = 1.9 centimeters; Edge + Rolled & thickened; Tunneling = 2.9 centimeters; Skin Surrounding Wound = White/Gray; Odor = Strong; Drainage = Moderate amounts." Further review of the Evaluation revealed Resident #9's pain was "Pain = 7/10 (Pt is very tender to light touch)." An observation on 10/16/12 at 9:55 AM, during the initial tour, revealed the resident was on a low bed with a mat on the floor next to the bed and the side rails were raised. LVN E stated Resident #9 was alert to her name only, was incontinent of bowel, and had a Foley catheter. LVN E revealed Resident #9 was a fall risk, required two staff for transfers and was total care for her activities of daily living. LVN E, the wound nurse, stated Resident #9 had thin skin, her legs were purple, and she had an unstageable wound on her coccyx that she was admitted with. LVN E also said Resident #9 had the behavior of yelling out, and the staff had to determine what she wanted. An observation on 10/16/12 at 1:20 PM revealed OT I assisting Resident #9 to eat. The resident had a mouth full of food and OT I stated Resident #9 tended to pocket her food or chew it and then let it fall out of her mouth. An observation on 10/17/12 at 9:15 AM revealed LVN E and CNA K were in Resident #9's room. LVN E stated, at that time, they had just completed the treatments to Resident #9's legs, arms and trunk, and PT G would provide the treatment to the resident's unstageable wound on her coccyx. An observation on 10/17/12 at 10:20 AM revealed PT G, PTA H, and LVN E were in Resident #9's room for the wound care. Resident #9 was lying on her right side facing the wall with LVN E on that side of the bed to assist PT G. PTA H was beside PT G to assist. Resident #9 cried out when PT G began touching her wound. PT G told Resident #9 she would be ok. The surveyor asked if Resident #9 was medicated for pain, and LVN E said she did not know. PT G was taking sterile Q-tips and poking and wiping inside the wound, and Resident #9 was crying out. After Resident #9 continued crying out, LVN E said she would check to see if Resident #9 was medicated and left the room. PT G told Resident #9 again "You will be ok..." and continued with the treatment. The wound to Resident #9's coccyx was dark brown to black in color, had a very foul odor to it and per PT G, the wound was tunneling at the 12 o'clock position. The surveyor observed the wound while PT G was putting Q-tips in and it appeared to be undermining around the rest of the edges. Resident #9 had quieted but as soon as PT G continued to poke and prod in certain areas of the wound, the resident cried out as the areas were probed. PT G continued to poke and prod with Resident #9 crying out. At 10:28 AM, LVN E returned and informed PT G Resident #9 was not medicated for pain prior to the wound care. PT G washed her hands, put on fresh gloves and retrieved a 4 by 4 inch gauge pad, which she sprayed with wound cleanser, then used her finger and poked it inside the wound. Resident #9 cried out and PT G grabbed a Q-tip and pushed the 4x4 pad in and moved it about. She stated, "I use wet 4x4s to clean more of the dead tissue out." She removed the first one, wet and poked a second one in the wound with Resident #9 screaming out. LVN E then said "Oh, I need to go get her pain medication" and left the room. PT G continued to clean the wound with the resident crying out periodically. She stated she was going to continue this treatment for a few more weeks and if no improvement was made, she would see about a wound vac. PT G washed her hands, put new gloves on and said now she was going to place Santyl all over the wound. Resident #9 cried out when the Q-tip with Santyl touched the wound. PT G said next she was going to pack the wound with Aqua-cell. At approximately 10:33 AM LVN F came in the room with pain medication for Resident #9, which was crushed and mixed in applesauce. PTA H went around to the other side of Resident #9's bed at her head and LVN F raised the head of the bed. Resident #9 was still on her right side, so LVN F got on the side of the bed with PTA H. LVN F used a wooden spoon, after he finally got the resident to open her mouth, got the applesauce with a crushed [MEDICATION NAME] mixed in and placed it into Resident #9's mouth. Resident #9 did not swallow and had a mouth full of [MEDICATION NAME] crushed and mixed in applesauce. LVN F and PTA H kept trying to get her to swallow the medication by stroking her cheek and talking to her. PT G stated, "She just pockets it...." LVN F got some thickened juice and began to try and spoon some of it into her mouth. PTA H and PT G used the draw sheet and turned Resident #9 more onto her back while the resident hollered "Oh my legs!" LVN F finally got Resident #9 to swallow once around 10:40 AM and he then spooned more of the thickened juice in her mouth and went to get tissues. LVN F came back to the bed and wiped Resident #9's mouth. LVN F said the medication aide was on break so he had to bring the pain medicine. LVN F then left the room. Resident #9 was back on her right side and PTA H was on the side with the resident's head facing her and she talked to the resident. At 10:42 AM, PT G began to pack the Aqua-cell into Resident #9's wound, and the resident cried out. PTA H began talking to the resident, and PT G continued to pack the wound with Resident #9 crying out periodically. PT G completed packing the wound at 10:45 AM and then completed the treatment at 10:50 AM. There was a pool of a pale, yellow, liquid substance with white particles in it on Resident #9's pillow, by her mouth where the pain medicine with applesauce and thickened liquid had flowed out of her mouth. An interview on 10/18/12 at 12:30 PM with LVN E revealed she sometimes assisted PT G with Resident #9's wound care, but not every time. LVN E said Resident #9 had not cried out like that, but would mostly cry out when they turned her and especially on her right side. LVN E stated they had looked at her pain when she was first admitted and tried to put her on a routine pain medication, but her family member told them her crying out was a behavior. LVN E said the family member did not want a routine pain medication given. She revealed the family member had agreed with an as-needed pain medication. LVN E stated she had never given Resident #9 anything for pain, since she was sent to the emergency roiagnom on [DATE]. LVN E revealed she had never seen Resident #9 have that kind of pain, and she had seen her flinching in pain yesterday. She said she wanted to be there to assess Resident #9 for pain before wound care with PT G. When asked how she assessed a non-verbal resident for pain during treatments, LVN E replied she would assess the resident by his/her behavior, observing the resident's face, and seeing if the resident cried out or teared. LVN E revealed if the pain was intense enough she would stop the treatment, request pain medication be administered and wait 30-45 minutes before resuming the treatment. LVN E stated, if she had been providing the wound care to Resident #9 on 10/17/12, "I would've covered it (wound) up and come back in 30 minutes and let the [MEDICATION NAME] kick in." She said PT G and PTA H were the only other ones who provided wound care. When asked what the criteria was for the PT to provide wound care, LVN E replied if she had been doing a treatment for one month and there was no improvement or if the wound needed mechanical debridement, then the PT department or PT G and PTA H would provide it. LVN E stated the Charge Nurses were responsible for their residents' wound care on the weekends. An interview with PT G on 10/18/12 at 12:46 PM revealed she provided wound care to Resident #9 and one other resident. When asked if she ever checked them for pain, she replied she asked them if they were in pain. PT G stated Resident #9 always has "disturbances," little sounds. She stated some days she slept through the treatment, and some days she was more "disturbed." When asked what disturbed meant several times, PT G did not answer. She explained about the tunneling and when she checked the depth of the tunneling, Resident #9 became "disturbed," but she had an assistant to calm the resident. PT G revealed Resident #9 made a little more noise the previous day during her treatment and she got the pain medication. She stated Resident #9 normally received pain medication and she waited 45 minutes to an hour before she provided the wound care. PT G said she checked with the Medication Aide "Every time I do it..." to ensure the resident was medicated with the [MEDICATION NAME] and then she waited 45 minutes to an hour to do the treatment. When asked if she had waited yesterday for the [MEDICATION NAME] to take affect, she replied she waited a few minutes maybe five to seven minutes. PT G revealed normally Resident #9 was pre-medicated before the treatment. She stated she thought the medication was given because State was there and ready to observe the wound care. PT G said she talked to Resident #9's family member during the Care Plan Meeting when the resident's pain was addressed. She said she explained to the family member the treatment to the resident's coccyx was very painful and required pain medication. PT G revealed the family member said the resident's crying out was a behavior, and she did not believe it was pain. PT G stated she informed the family member it was a very painful procedure, and Resident #9 needed pain medication, so the family member agreed to the resident receiving [MEDICATION NAME] as needed for treatments. An observation on 10/18/12 at 8:25 AM revealed CNA J attempting to feed Resident #9 her breakfast. CNA J stated Resident #9 was not swallowing well. The resident's bottom lip was hanging loosely and CNA J said if she held the resident's lip up, then she swallowed a little better. Resident #9's breakfast was pureed, and CNA J said her diet was changed. The surveyor observed Resident #9 appeared to be miserable and asked her if she was. Resident #9 replied "UN-huh." An interview on 10/18/12 at 9:30 AM with CNA K revealed Resident #9 had always moaned since she was admitted . She stated Resident #9 moaned any time they moved her or touched her. On 10/18/12 at 1:20 PM the Director of Therapy, PT G and PTA H spoke with the surveyor. The Director of Therapy stated she thought Resident #9's pain was not a routine event and wanted to clarify what was witnessed during the wound care by PT G on 10/17/12 with the assistance of PTA H and LVN E. PTA H revealed she felt Resident #9 was having anxiety, and once she engaged the resident, the resident felt more relaxed. The Director of Therapy said Resident #9 had exhibited anxiety. The surveyor notified the Director of Therapy of the observations of the wound care on 10/17/12. PTA H stated Resident #9 was moaning, but there were no tears. PT G said Resident #9's family member said it was a behavior the resident had been exhibiting for years. PT G replied yes, when asked if she was able to differentiate between pain and tactile behaviors. PT G stated Resident #9's family member did not think Resident #9 had any pain from her [MEDICAL CONDITION] either. PT G revealed the family member thought it was a behavior. PTA H again said she did not know if Resident #9 was premedicated for pain prior to her treatment. PTA H stated Resident #9 made sounds or noises, but she did not have any tears during the wound care. At that time, PT G stated Resident #9 "doesn't like anyone to touch her...when you touch her she is very loud...." PT G also stated "...if a patient is always in pain, they would always be screaming out and (Resident #9) doesn't do that." The Director of Therapy stated they were going to in-service their staff on pain. PT G was asked to point out which MA she was referring to and PT G pointed to MA L. An interview with MA L on 10/18/12 at 1:40 PM revealed she was the 6:00 AM to 2:00 PM MA for Resident #9. MA L stated she had given Resident #9 [MEDICATION NAME] (pain medication) about two weeks prior because "she was hurting/screaming...." She stated Resident #9 could not tell her she was in pain. MA L said she went to her Charge Nurse that day and he went to Resident #9's room, touched her, agreed she was in pain and gave permission to give the resident the pain medication. MA L stated she had never given Resident #9 any pain medication since then. MA L also stated PT G never came to her and asked if she had medicated Resident #9 or asked her to medicate Resident #9 for pain. She thought maybe they have asked the next shift to medicate the resident. MA L stated even if she had been asked by PT G, she would still have to get the permission from her Charge Nurse. An interview with MA M on 10/18/12 at 1:47 PM revealed she was the 2:00 PM to 10:00 PM MA for Resident #9. When asked if PT G ever checked if Resident #9 was medicated for pain or if PT G had ever asked her to medicate her for pain, so they could do her dressing change, MA M replied, "No. Never." Resident #9's Controlled Drug Record for [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg reflected she received one tablet on 10/17/12 at 2:20 PM, since her readmission on 10/10/12. On 10/18/12 at 3:53 PM the DON and Administrator discussed Resident #9's pain with the surveyor. The DON stated she addressed the issue of pain with Resident #9's family member during the Care Plan Meeting and her family member, who was a Psychiatric RN, informed the DON, he/she did not think Resident #9 was in pain. He/she stated the resident's crying out was a behavior. The surveyor discussed the observation of the wound care provided by PT G to Resident #9. The surveyor informed them PT G said she always ensured the resident was premedicated. On 10/19/12 at 10:07 AM, Physician N stated he had cared for Resident #9 in another facility before she came to this facility. He revealed her crying out was and had been addressed over and over throughout his time of caring for her, with her family member, who was a Geriatric or Psychiatric nurse. Dr. N said Resident #9's family member informed him Resident #9 had cried out for years, and it was like anxiety, and he/she wanted it treated with antianxiety medications. On 10/18/12 at 7:17 PM, the DON stated PT G was suspended until further investigation. The DON revealed PT G told her and the Administrator, she ensured Resident #9 was premedicated prior to treatments every time. The DON stated she reviewed Resident #9's two Controlled Drug Records for [MEDICATION NAME]/[MEDICATION NAME] and confirmed the resident did not receive any medication, since her readmission on 10/10/12, until surveyor intervention on 10/17/12. On 10/18/12 at 8:27 PM, the DON stated she spoke to Resident #9's physician, and he suggested trying a [MEDICATION NAME] again to help with the pain. She also stated they would be ordered. On 10/19/12 at 10:50 AM, the Regional Director of Operations, Administrator and DON discussed the situation with Resident #9. The surveyor informed them of the observations of PT G's wound care provided to Resident #9 on 10/17/12. They stated they understood. The facility's current undated Pain Management Program "How To" reflected, "...If a resident is assessed as experiencing pain during the shift, then pain medication and or alternative therapies should be administered." The facility's current Pain Management Program, revised 01/21/08, reflected, "Qualified staff will recognize that pain is a co-existing condition with a number of diseases and injuries, and will require explicit attention...Qualified staff will recognize that unrelieved pain has an enormous physiological and psychological effect on patients/residents, therefore, will effectively manage pain as an integral component of their care...Myth #2: Sleep or sedation = pain relief. Reality: Pain is exhausting, and it depletes all of the body's energies...Sleep or sedation is not the same as pain relief, which brings down the level of pain so that the resident enjoys some level of function and the best quality of life possible under the circumstances...ADVOCATE for the resident in pain....OBSERVE residents carefully for signs of pain. Some residents may not verbalize pain; you may have to observe for behavioral symptoms. REPORT resident's...along with any signs of pain you have observed. MONITOR and continually reassess the resident's pain as treatment proceeds. ANTICIPATE activities that might cause the resident some pain. If the resident has a PRN prescription for pain medication, suggest taking the medication prior to these activities. Example- therapy, wound care...." The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 10/16/12 and signed by the DON, reflected 40 residents were on a pain management program.

Based on observation, interview and record review, the facility failed to ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for one (Resident #10) of seven residents assessed for pressure ulcers. 1. Staff failed to place a pressure relieving mattress/overlay on Resident #10's bed, when she became bed bound. 2. Staff failed to turn and reposition Resident #10 every two hours. These failures resulted in Resident #10 having three pressure ulcers, including one that was unstageable. These failures could affect one resident in the facility identified as being bedfast all or most of the time. Findings included: Resident #10 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected she was at risk for developing pressure ulcers, but she currently did not have any pressure ulcers. The assessment also reflected she had not any pressure uclers prior to admission, and she did not have any skin conditions present during the observation period. Resident #10's Care Plan, dated 07/18/12, reflected she was at risk for skin breakdown and she would remain free of skin breakdown. The Care Plan also reflected, "Place my pressure reducing device/product on bed/chair...I need two persons to assist with repositioning to avoid skin friction/shearing." Further review of the Care Plan revealed, "I need a daily observation of skin with routine care...Use my pillows or other supportive/protective devices to assist with positioning." Resident #10's nursing Weekly Skin Assessments beginning with the week of 07/25/12 through 10/10/12 did not reflect a wound on her buttocks. The Facility's Weekly Pressure Ulcer QI Logs for September and October 2012, with the last one dated 10/12/12, reflected Resident #10 was not listed with a pressure ulcer. An observation on 10/16/12 at 9:39 AM, during the initial tour, revealed Resident #10 on her back in a low bed with a scoop mattress, to prevent the resident from rolling out of bed, with her eyes closed. There was not a pressure relieving mattress on her bed. There was a strong, pungent odor in the room. On 10/16/12 at 10:09 AM, LVN O described Resident #10 as alert and oriented to self and family with confusion, was incontinent of bowel and bladder, had behaviors and would resist or fight caregivers at times. LVN O said the resident was on a low bed due to a fall which resulted in the development of a large hematoma on her right lower leg along with a [MEDICAL CONDITION]. LVN O stated the resident was bed bound, since the development of the [MEDICAL CONDITION], but she would get up in her WC for meals at times. An observation on 10/16/12 at 12:16 PM revealed Resident #10 in the shower with CNA B, who was attempting to assist her to dress. Resident #10 had a large hematoma on her right lower lateral leg which had three large scabbed areas on it. CNA B called for help as Resident #10 was fighting him. LVN O entered the shower room and assisted Resident #10 to get her gown on. LVN O stated Resident #10 was sent to the hospital after a fall and had a fractured pelvis, but was not a candidate for surgery. She said her leg swelled after she came back from the hospital, and they found a hematoma. LVN O stated the resident returned to the hospital, and it was drained, which was all they could do. LVN O said Resident #10 was sent back from the hospital on [MEDICATION NAME] injections and [MEDICATION NAME]. LVN O took Resident #10 back to her room and informed CNA B she would send another CNA to help transfer Resident #10 to her bed. In a few minutes, CNA P entered the room and assisted CNA B to transfer Resident #10 to her bed. The CNAs placed the resident in bed and turned her on her right side to place a brief under her. CNA B was about to put skin barrier cream on the resident's buttocks. Resident #10 had a large opened area in the middle of her right buttock . CNA B and CNA P were asked about the area. CNA B started to rub the cream on the resident, but CNA P stopped him and told him to go get the nurse. LVN O entered the room, saw Resident #10's right buttock, and gasped. LVN O stated she would wash her hands, so she could measure the opened areas. When asked, LVN O replied the areas had not been there before and were new areas. LVN O measured the wounds and the results length 3.5 cm and width 4.3 cm. The other wound measured 1.0 cm by 1.0 cm. On 10/16/12 at 12:42 PM LVN E, the wound nurse, entered the room and stated the areas were unstageable. She took her own measurements, and after surveyor intervention measured the area of slough within wound one. Her measurements were 3.5 cm by 3.5 cm and the area of slough in the wound bed measured 3.0 cm by 1.7 cm. The second wound measured 1.0 cm by 0.6 cm and the wound bed was almost 100% slough. A third area, which was very tiny, was not measured by LVN O or LVN E. LVN E revealed she would do a temporary foam and [MEDICATION NAME] dressing until she could contact the physician. She stated she would plan on using Santyl (a [MEDICATION NAME] agent). LVN E then dressed each wound after cleaning with wound cleanser and covered wound one with a foam dressing and wound two with a circular [MEDICATION NAME] dressing, which also covered the third area. After the wound care was completed the surveyor asked LVN E who was responsible for skin assessments, and she replied the Charge Nurses for each hall were responsible for weekly skin assessments. On 10/16/12 at 1:05 PM when LVN E had stepped out of the room to retrieve more dressings, CNA P explained to Resident #10's family member, who was in the room during the wound care, since the wounds had developed they would now leave Resident #10's incontinent brief off and start turning her every two hours to help relieve the pressure on her buttocks. An observation on 10/16/12 at 2:28 PM revealed a CNA put an air overlay mattress, pressure relieving, on Resident #10's bed and the scoop mattress was gone. On 10/16/12 at 4:25 PM, the DON stated she and the NP assessed Resident #10's wounds on her right buttocks and thought they were caused by shear, not pressure. Two surveyors, the DON, LVN E and the NP went to Resident #10's room to observe the wounds. The NP revealed the wound beds were clean looking. The surveyor informed her they looked like they had slough in them. LVN E stood at the head of Resident #10's bed, the NP was next, and then the DON and the surveyor were at the foot of the bed. The NP took the foam dressing off of wound one and said, "See it looks like something just sheared it off." She then took the [MEDICATION NAME] off of wound number two and said, "Oh it has a center in it...." The NP was asked what the yellowish colored part in the wound bed was. The surveyor stated LVN E measured the area of slough earlier. The NP turned on the overbed light and revealed, "Oh! Yes there are centers in both of them..." The NP then agreed there was slough in both wounds and it appeared another area had occurred due to pulling the tape off, as she pointed to the third wound. The surveyor informed the NP the wound was there earlier. The NP said, "Well, [MEDICATION NAME] will still take care of them all." She stated they would get some labs, put the resident on vitamins and zinc. The NP also stated, "...since her leg got bad she hasn't been moving as much or as well..." The NP revealed Resident #10 "doesn't eat well...If this is all she has, she's doing pretty good." The DON asked the surveyors if the wound was unstageable. During an interview with CNA B on 10/17/12 at 10:07 AM, he stated if he found a new area on a resident's skin, he was supposed to inform the Charge Nurse. He said he and CNA Q usually took care of Resident #10 and CNA Q was her CNA on 10/15/12. CNA B revealed he had assisted CNA Q with Resident #10's care and had not noticed the opened areas. During an interview with CNA Q on 10/17/12 at 10:09 AM, she revealed she and CNA B changed Resident #10 on 10/15/12 and she did not notice the opened areas. On 10/18/12 at 8:38 AM during Resident #10's wound care to her right buttocks, LVN E stated she "pushed for the Santyl and was glad they (NP) agreed." During an interview on 10/18/12 at 5:20 PM with MDS R, when asked who should observe the resident's skin daily during routine care, she replied the CNAs. MDS R said she did not know if they documented it anywhere. She stated there were shower sheets for the CNAs to use. She revealed, "To me that's just part of nursing practice. You see something. You bring it to someone's attention." Resident #10's Nurse's Note, dated 10/16/12 at 1:00 PM and signed by the LVN E, reflected she was informed by the nurse that Resident #10 had an opened area to her buttocks. The Note reflected the wound (wound two) on her right upper buttock measured 1.0 cm x 0.6 cm and was "covered with slough...." The Note also reflected the wound (wound one) on her lower right buttock measured 3.5 cm x 3.5 cm x 0 and the slough area measured 3.0 cm x 1.7 cm, and the wound bed was "75% slough. " Resident #10's Nurse's Note, dated 10/16/12 at 4:00 PM and signed by LVN E , reflected a new order to discontinue the previous treatment order for Resident #10's right buttock, and a new order to clean the three areas, apply Santyl, cover with Combiderm and secure with tape every day. Resident #10's Progress Note, dated 10/16/12 and signed by the NP, reflected, "3 Open areas (R) buttock round 3.5 x 3.5 cm, 1 cm x 1/2 cm, 1 mm x 1 mm." The Note also reflected to monitor the hematoma on Resident #10's right leg and forehead. The Note reflected, "treat (with) Santyl and cover (with) [MEDICATION NAME]." Resident #10's Progress Note also reflected to plan for an air mattress, stress tab with Zinc and E'elemental. Review of the web site; <http://www.santyl.com/about> retrieved on 11/01/12 revealed "Santyl Ointment is a continuous, Active Micro-Debridement" it further reflected, "Santyl Ointment is indicated for the debridement of: Pressure ulcers, Diabetic ulcers, Venous leg ulcers, severely burned areas...." The facility's current Policy and procedure for Pressure Ulcers, dated October 2010, reflected, "Measurements for pressure ulcers: ...Unstageable Pressure Ulcers Document and describe greatest length and width. Depth should not be measureable due to unable to determine base of wound due to necrotic tissue/Eschar present...Unstageble as full thickness tissue loss in which the base of the ulcer is covered in slough (yellow, tan, gray, green or brown)...." The facility's undated policy and procedure, Pressure Ulcer Prevention, reflected, "Repositioning should occur at least eveery 2 hours, but more frequent positioning may be warranted for individuals who are at higher risk for pressure ulcer development...." The facility's undated policy and procedure, Pressure Ulcers Differentiation, reflected an "avoidable" pressure ulcer was if a "resident developed a pressure ulcer and the facility did not do one or more of the following:..defined and implemented interventions that are consistent with residents' needs, goals and recognized standards of practice...." The Form CMS-672, Resident Census and Conditions of Residents, signed by the the DON on 10/16/12 identified one resident as being bedfast all or most of the time.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who enters the facility without pressure sores did not develop pressure sores and a resident having pressure sores received the necessary treatment and services to promote healing and prevent new pressure sores from developing for three (Residents #2, #4 and #10) of ten residents reviewed with pressure sores. 1. Resident #10 was admitted to the facility on [DATE] with a [MEDICATION NAME] dressing on the left buttock for a Stage II pressure sore. The resident's admission assessment did not identify the pressure sore. On [DATE], the dressing on the resident's left buttock, which was dated [DATE] was changed. This was 7 days since the previous dressing change instead of the physician-ordered three days. There was no evidence a dressing change was done from [DATE] until [DATE], a period of eight days. The pressure sore never had more of a description than being 1 cm in size ([DATE]), a Stage III and/or a Stage II. There was no description of the surrounding skin or the wound base, increases/decreases in size, odor and/or drainage. LVN C and LVN D initialed treatments and/or assessments as being done for Resident #10, which they did not do. 2. Resident #2 did not have a pressure ulcer when first admitted to the facility. Resident #2's skin assessments did not include a description of the resident's pressure ulcer. There was no measurement, no description of the wound base or surrounding skin, and nothing about odor or drainage. The resident's care plan did not address the pressure ulcer. The Weekly Pressure Ulcer QI Log did not accurately identify whether the resident had a pressure ulcer or the site of the pressure ulcer. 3. Resident #4 had a pressure sore on the left heel, unidentified by the facility, which was found on [DATE] to be 1 cm x 1 cm and covered with eschar (unstageable). A [MEDICATION NAME] agent was used and on [DATE], the pressure sore no longer had eschar. LVN R continued to use the [MEDICATION NAME] agent on the pressure sore, because it was "the order," risking damage to the skin, instead of updating the physician on the change in the pressure sore. These failures could affect Residents #2, #4 and #10; the seven residents identified by the facility with pressure sores; the 69 residents, who were in a chair all or most of the time; one resident, who was physically restrained; 58 residents, who were occasionally or frequently incontinent of bladder; and 48 residents, who were occasionally or frequently incontinent of bowel, placing them at risk for the development of pressure sores, having unidentified pressure sores and a decline in current pressure sores resulting in the loss of nutritional stores, pain, infection, decreased socialization, unintended weight loss, a decline in their range of motion and the potential need for debridement and/or hospitalization . Findings included: 1. Resident #10's Admission Nursing assessment dated [DATE] reflected no wound or skin problems. Review of the initial nurses' notes dated [DATE] revealed Resident #10 was admitted with numerous bruises, skin scabs and sutures due to a fall prior to hospitalization . The nurses' notes reflected Resident #10 had "[MEDICATION NAME] to left buttock removed, 1 cm open area, cleansed with normal saline, [MEDICATION NAME] placed." Resident #10's MDS assessment dated [DATE] reflected [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #10 was at risk for developing a pressure sore and had one Stage II "ongoing" pressure sore. Resident #10 was observed during initial tour on [DATE] at 9:35 a.m. sitting in a wheelchair and self-propelling himself about the facility. Interview with the facility's only ADON at that time revealed Resident #10 had a pressure sore on his left buttock. The ADON added Resident #10 required the assistance of one person for transfers and ADLs. On [DATE] at 3:00 p.m., when queried regarding Resident #10's pressure sore, LVN R stated the resident's wound care was provided by PT. The ADON was present during the interview and stated she would verify PT was providing the care. On [DATE] at approximately 3:25 p.m., RN A approached the surveyor and stated PT was not responsible for Resident #10's wound care. She stated, "I do his (Resident #10) wound care. The nurses always have." RN A was observed on [DATE] at 3:15 p.m. providing treatment to Resident #10's pressure ulcer. Resident #10 was rolled onto his right side to reveal a [MEDICATION NAME] dressing on his left buttock. The dressing was clearly dated ",[DATE]" (which meant the dressing had been changed on [DATE]). When queried about the date, RN A revealed she was "the last one to do (change) the dressing" and she had done it on [DATE] and dated the dressing accordingly. Review of Resident #10's physician's orders [REDACTED]." Review of Resident #10's consolidated physician orders [REDACTED]. Monitor drsg (dressing) to Left buttock Q shift." An order clarification dated [DATE] reflected Resident #10's pressure sore was a Stage II and was never a Stage III. The order reflected to "Start [MEDICATION NAME] to Left buttock change every three days and prn til healed Stage II." Review of the FNP Progress Note dated for [DATE] revealed documentation the pressure sore to the buttock was "healed." During an interview on [DATE] at 3:55 p.m., RN A was again queried about Resident #10's pressure sore. RN A said she replaced the resident's [MEDICATION NAME] dressing on [DATE], after his shower. When asked if the dressing had been on for seven days, RN A stated, "Yeah." Review of Resident #10's Treatment Sheet for [DATE] revealed the pressure sore treatment was done on [DATE] (day of admission). No other treatments were documented as done. (According to the physician's orders [REDACTED].) Review of Resident #10's Treatment Sheet for [DATE] revealed the pressure sore treatment was documented as done on [DATE] and on [DATE]. The treatment done on [DATE], as indicated by the dressing, was not documented. Review of Resident #10's weekly skin report revealed on [DATE], [DATE] and [DATE], the treatments were documented as done per the physician's orders [REDACTED]. The pressure sore was never staged. "Progress" was documented "cont (continue) Tx." A Weekly Pressure Ulcer QI Log was provided by facility administration. The information dated [DATE] reflected Resident #10 had a Stage II pressure sore, size 0.5 cm x 0.5 cm with a depth of 0.1 cm. The pressure sore had no drainage or odor, and no culture was done. The information on the Log for [DATE] had the identical information. During an interview on [DATE] at 9:20 a.m., LVN B revealed although she was not sure of the date, she thought she did Resident #10's pressure sore treatment on [DATE], but did not document the treatment or any description of the pressure sore. She was asked if she remembered what the pressure sore looked like on [DATE]. She responded, it was "small," and the wound bed was "pink." During an interview on [DATE] at 9:58 a.m., LVN C stated she changed Resident #10's [MEDICATION NAME] on [DATE]. LVN C stated she wrote the date (,[DATE]) on the dressing when she changed it. When informed the date on the [MEDICATION NAME] removed on [DATE] was ",[DATE]," LVN C had no explanation. When asked if she documented any assessment or description of the pressure sore, LVN C stated she initialed the Treatment Sheet; which was the only place to document. LVN C stated Physical Therapy did the measurements on all pressure sores. On [DATE] at 10:30 a.m., LVN D revealed she had seen Resident #10's pressure sore. She stated the pressure sore was "unstageable...was necrotic...couldn't see inside of it." LVN D was unsure when or if she ever changed the dressing. Resident #10's weekly skin assessment sheet was reviewed with LVN D. She said she initialed the assessment as done on [DATE], but she stated she did not actually do the assessment. She stated RN A did the assessment and documented the findings. LVN D stated she also initialed the assessment as done on [DATE], but did not do the treatment. LVN D added she did not work on that day. LVN D was asked for an explanation, but she did not respond. On [DATE] at approximately 10:55 a.m., LVN W said every Thursday the Weekly Pressure Ulcer QI Log was completed and turned in to the ADON for a meeting on Fridays. She stated the Log was completed from the resident's assessments. If the resident did not have a treatment on Thursday, the most recent assessment was used. LVN W stated she did not assess Resident #10. She stated the nurse working on Resident #10's hall gave her the information on [DATE] and [DATE]. During an interview on [DATE] at 11:20 a.m., the ADON was queried about the process for the identification and treatment of [REDACTED]. The ADON said the residents with multiple Stage II pressure sores and residents with pressure sores, which were Stage III or greater were monitored and treated by physical therapy, including weekly measurements. She added the charge nurses were responsible for the other residents. The ADON stated "they" get the information from physical therapy and put in on the weekly report, and the reports are reviewed in the weekly QA meeting. The ADON explained the nurses shared the responsibility of skin assessment according to the shift they worked. The day shift assessed the residents in the A-beds, and the evening shift assessed the residents in the B-beds. The ADON also stated, "We chart by exception." She explained the nurse documented the treatments. When asked about the staging of Resident #10's pressure ulcer, she responded she had mistakenly identified it as a Stage III on the order, and then did a clarification order. When asked if the process for assessing, documenting and monitoring pressure sores was effective, she stated, "It is a huge problem. We need to re-do the way we do assessments. We need to look at the system and revise forms...Things have to be changed." During an interview on [DATE] at approximately 5:00 p.m., RN A stated she was not aware LVN B was doing the pressure sore treatment on Resident #10. She explained Resident #10 was in a B-bed and the 2 p.m. - 10 p.m. nurses provided the treatments to the residents in all the B beds. RN A stated LVN B worked the 6 a.m. - 2 p.m. shift and the day shift provided the treatments for all the residents in the A beds. Review of Resident #10's undated care plan for a Stage II pressure sore revealed approaches included: "wound care as ordered... weekly evaluation of wound healing... daily observation of skin... monitor for changes in my skin status that may indicate worsening of my pressure ulcer...." 2. Resident #2, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 2's MDS assessment further reflected the resident was totally dependent on staff for ADLs and required two-person physical assist for bed mobility and transfers. The MDS assessment reflected Resident #2 was at risk for developing a pressure sore and was not admitted to the facility with a pressure sore. Observation on [DATE] at 2:00 PM revealed Resident #2 had a large [MEDICATION NAME] dressing across the top of both buttocks with a handwritten date of [DATE] (the date of the dressing change). Resident #2's Nurse's Notes dated [DATE] reflected "2 cm open area to L (left) buttocks, cleansed c (with) N/S (Normal Saline), patted dry + (and) [MEDICATION NAME] placed." Review of Resident #2's care plan dated [DATE] and last updated on [DATE] revealed it did not address the pressure ulcer. It only indicated the resident was "At risk for skin breakdown." Review of the Weekly Pressure Ulcer QI Log dated [DATE], [DATE] and [DATE], revealed Resident #2 was not identified as having a pressure ulcer. The Weekly Pressure Ulcer QI Log identified Resident #2 as having one pressure ulcer to the left thigh. On [DATE] at 2:00 p.m., observation revealed [MEDICATION NAME] on both of Resident #2's buttocks. There was no dressing on Resident #2's thigh. Resident #2's weekly skin assessment sheet dated [DATE] documented the resident's treatment as being done, but there was no description, measurement, or staging for the pressure sore on the resident's left buttock. None of the weekly skin assessments documented more than Resident #2's treatment being done. 3. Resident #4's [DATE] Physician order [REDACTED]. Resident #4's Admission Nursing assessment dated [DATE] reflected the resident was admitted with a sacral pressure sore, which measured 1.7 cm x 0.7 cm. Review of the [DATE] Treatment sheet and consolidated orders for Resident #4 revealed a treatment order dated [DATE] for the left heel. The order reflected to clean the left heel with normal saline, pat dry, and apply Derma Prep twice daily. Another physician's orders [REDACTED]. An order dated [DATE] reflected to discontinue treatment to Resident #4's left heel and left great toe due to the skin being intact and treatment was completed. On [DATE] a physician's orders [REDACTED]. The weekly skin assessment sheet was reviewed and revealed documentation for Resident #4 on [DATE] as follows: open area to left heel. See treatment orders, continue with treatment. Resident #4's Nurse's Notes dated [DATE] reflected "Noted resident has open area to left outer heel. ...NP was notified and she gave order clean (symbol for with) N/S wound cleanser. Apply Santyl cover (symbol for with) dry dressing...." Resident #4's Physician's telephone order dated [DATE] reflected, "Clean left heel (with) wound cleanser pat dry. Apply Santyl dry dressing...." Review of the Weekly Pressure Ulcer QI Log dated [DATE] and documented by the Corporate Nurse revealed Resident #4 had a facility-acquired pressure sore on her right heel. The pressure sore was covered with eschar (had, dry dead tissue) and measured 1 cm x 1 cm with no depth and was unstageable. There was no odor or drainage. The pressure sore was being treated with Santyl. On [DATE] at 10:09 a.m., LVN R was observed providing a dressing change to Resident #4's left heel pressure sore. Observation revealed Resident #4's right heel had no pressure sore. When queried, LVN R verified it was the resident's left heel, which had the pressure sore. At that time, LVN R measured the pressure sore on Resident #4's left heel. The measurements were 0.8 cm x 1.0 cm. The depth was 0.1 cm. LVN R cleansed the pressure sore, patted it with dry gauze, applied Santyl and a non-adhesive dressing. The pressure sore was open and had no odor or drainage. On [DATE] at 10:25 a.m., following the observation of the treatment, LVN R stated, "Today the wound is a Stage III. It's open with a dark spot in the middle. Yesterday it was a Stage II. I don't know who did what to it, but it looks great. It changed a lot. I don't know. It's like magic." The surveyor informed LVN R the Weekly Pressure Ulcer QI Log dated [DATE] had reflected the pressure sore was unstageable. LVN R verified "the whole area was dark when it was found and not open. It was open yesterday." LVN R was asked why Santyl, a [MEDICATION NAME] agent (removal of dead tissue) was still being used on the Stage III pressure sore. LVN R replied, "That's the order." Resident #4's Treatment Administration Record for [DATE] reflected the resident received the following treatment on [DATE] and [DATE]: "Clean left heel (symbol for with) wound cleanser, pat dry. Apply Santyl & dry dressing ...." 4. The MAR indicated [REDACTED]. In the front pocket of the notebook, an undated reference sheet entitled "Pressure Ulcer Assessment Section M: Skin Conditions" was found, which reflected: "A complete assessment of skin is essential to an effective wound prevention and management program. Follow steps 1 through 5 to assess a pressure ulcer and complete Section M of the MDS 3.0." There were 15 colored pictures to help identify pressure sores from Stage I through Stage IV and included unstageable pressure sores. Terms used were identified. Review of the facility's Policy for "Pressure Ulcer Prevention Program" provided as current and dated [DATE] revealed: "All residents will be assessed for the risk of pressure ulcer development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to prevent the development of avoidable pressure ulcers, or, to treat existing pressure ulcers." Under "Procedure..4. All residents will have a head to toe assessment completed on a weekly basis by a licensed nurse to identify any skin breakdown. The results of this assessment will be documented in the resident's medical record." Further review of the facility's Policy under the title "Section M. Skin Condition" and subtitle "Process" revealed "Review the resident's record and consult with the nurse assistant about the presence of an ulcer. Examine the resident and determine the stage and number of any ulcers present. Without a full body check, an ulcer can be missed." 5. According to the Pressure Ulcer Treatment Quick Reference Guide developed by European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) in 2009, under the section entitled International NPUAP/EPUAP Pressure Ulcer Classification System: A Stage I Pressure Ulcer is one with Non-blanchable [DIAGNOSES REDACTED] of intact skin. A Suspected Deep Tissue Injury is a purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 6. Retrieved at [DATE] from the National Library of Medicine at www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A5393PressureUlcers [DATE] <http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A5393PressureUlcers[DATE]> " Pressure ulcers should be uniformly described to facilitate communication among staff and to ensure adequate monitoring of the progress toward healing. The system developed by the National Pressure Ulcer Advisory Panel (NPUAP, 1989) <http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A6343> is a synthesis of the most commonly used staging methods. Necrotic tissue must be removed before the stage of the ulcer can be determined. To monitor progress or deterioration of the lesion, the examiner must accurately measure the length, width, and depth of the ulcer and describe sinus tracts, tunneling, undermining, necrotic tissue, exudate, and the presence or absence of granulation tissue and [MEDICATION NAME] (Yarkony, Kirk, Carlson, et al., 1990). <http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A6343> Color photographs, taken on initial assessment and reevaluation, are very helpful in monitoring ulcer healing. " " Reassess pressure ulcers at least weekly (as shown in Attachment A). If the condition of the patient or of the wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted. (Strength of Evidence = C.) ... " " ... To determine the adequacy of the treatment plan, it is essential to monitor pressure ulcers at consistent intervals. Assessment and documentation should be carried out at least weekly, unless there is evidence of deterioration, in which case both the pressure ulcer and the patient's overall management must be reassessed immediately. In the home setting, this may require the assistance of the patient and family, because weekly assessment by health care providers is not always feasible. Indicators of a deteriorating pressure ulcer include increases in exudate and wound [MEDICAL CONDITION], loss of granulation tissue, and a purulent discharge. The onset of impaired mental status, fever, [MEDICAL CONDITION], and [MEDICAL CONDITION] indicate sudden deterioration of the patient's physical status. ... " " A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. (Strength of Evidence = C.) A pressure ulcer with adequate innervation and vascular supply should show evidence of healing within 2 to 4 weeks (Robson, Phillips, Thomason, et al., 1992b; <http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A6343> van Rijswijk, 1993). <http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A6343> Suboptimal healing may be attributed to inadequacies of the treatment plan or failure to adhere to the treatment plan (e.g., failure to alleviate the pressure, to apply proper dressings, or to correct nutritional deficiencies). These contributing factors can be influenced by psychosocial or economic variables. Although healing is always the preferred goal, maintenance of comfort may be an appropriate goal for a terminally ill patient. " 7. The Form CMS-672, Resident Census and Conditions of Residents, dated [DATE] and signed by the Regional Nurse reflected seven residents had pressure sores (excluding Stage I), 109 residents were receiving preventive skin care, 69 residents were in a chair all or most of the time, one resident was physically restrained, 58 residents were occasionally or frequently incontinent of bladder, 48 residents were occasionally or frequently incontinent of bowel and the census was 109 residents.