Every finding on record at Cypress Woods Care Center

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 resident (Resident #38 and Resident #7) reviewed for infection control andthe facility failed to maintain an effective system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for 11 of 12 staff (Staff E, F, G, H, I, J, K, L, M, N, O) reviewed for TB testing. 1. The facility failed to ensure LVN A wore proper PPE when providing wound care for Resident #38 and failed to ensure LVN A did not exhibit multiple failures to maintain effective infection control while providing wound care for Resident #38. 2. The facility failed to ensure CNA B wore proper PPE while providing indwelling catheter care for Resident #7 and failed to ensure CNA B did not exhibit multiple failures to maintain effective infection control while providing wound care for Resident #7. 3. The facility failed to ensure ADON B and LVN D read TB skin tests in the required 72 hours for 11 employees. These failures could place residents at risk for acquiring infections. Findings include: Record review of Resident #38's admission Record (04/02/2026) revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included cerebral infarction (stroke), muscle weakness, and stage 4 pressure ulcer on her sacral area. Record review of Resident #38's Quarterly MDS assessment, dated 02/26/2026, revealed she scored 14 on the BIMS, indicative of intact cognition. Resident #38 had limited range of motion of one upper and one lower extremity. Record review of Resident #38's Care Plan (PS CP updated 10/30/24) revealed she had a PS on her sacrum. The CP did not address wound care technique or PPE use. Record review of Resident #38's Physician Order, dated 03/31/2026, revealed the wound was to be treated daily. The order read, in part, .Wound care orders cleanse pressure wound to sacral with wound cleanser, pack calcium alginate and collagen, cover with foam dressing every day. Record review of Resident #38's Physician's Order, dated 02/21/2025, revealed she was to be on EBP due to having the pressure sore. Observation and interview on 03/31/2026 at 2:57 p.m. revealed LVN A provided wound care for Resident #38. LVN A sanitized her hands and donned a mask and gloves. She sanitized Resident #38's overbed table. LVN A placed non permeable craft paper as a barrier on the overbed table. She then placed several 4 x 4 inch gauze into a transparent plastic cup. LVN A then sprayed wound cleanser on the gauze. LVN A placed one single-use NS container, gauze, and a bordered gauze on the craft paper barrier. Observation on 04/01/2026 at 1:11 p.m. revealed CNA C provided indwelling catheter care for Resident #7. Observation revealed there was a sign on the wall outside the entrance to the room that the revealed the resident was on EBP. He had no roommate. There were gowns and gloves available at the doorway. Resident #7 was sitting in his wheelchair. Continued observation revealed LVN A retrieved a previously opened/unsealed package of Calcium Alginate from the wound care cart drawer. One corner of the sheet of Calcium Alginate had already been cut from it. LVN A picked up scissors from a drawer in the cart and motioned towards cutting the Calcium Alginate. The State Surveyor stopped LVN A and asked her to sanitize the scissors. LVN A sanitized the scissors and again motioned towards cutting a piece of Calcium Alginate from the previously opened package. The Surveyor State Surveyor stopped LVN A and asked her to use Calcium Alginate from an unopened package. LVN A discarded the previously opened package, as well as two additional opened/unsealed packages of Calcium Alginate from the cart. LVN A sanitized her hands, donned new gloves and opened a new package of Calcium Alginate. She cut a small piece of Calcium Alginate from the new package. LVN A did not place any Collagen on the over bed table. LVN A entered Resident #38's room and closed the door. She washed her hands and donned gloves. She did not don a gown. Resident #38 was able to turn onto her right side. The old dressing on her sacral area was intact. There was no date or initials on the dressing. LVN A discarded the dressing and washed her hands and donned new gloves. LVN A cleaned the wound with wound cleanser/gauze three times. LVN A then sprayed the NS onto the wound. LVN A patted the wound dry with clean gauze. LVN A changed her gloves and placed the Calcium Alginate on the wound. She then covered the wound with the bordered gauze. All used supplies were placed in the trash. Resident #38 repositioned herself to where she was lying flat on her back. LVN A adjusted the resident's linens prior to discarding her gloves. LVN discarded her gloves and washed her hands. LVN A positioned the over bed table over Resident #38's midsection without sanitizing it. LVN A left the room. The State Surveyor asked Resident #38 to not touch the over bed table until it was sanitized. Observation and interview immediately following the wound care treatment revealed LVN A was at her cart in the hallway. She verbalized she was finished with the treatment. The State Surveyor asked her to sanitize Resident #38's over bed table. She did. LVN A said she should have sanitized the over bed table after the treatment and should have worn a gown during the wound care treatment. 2. Record review of Resident #7's admission Record revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included type 2 diabetes, chronic kidney disease, and muscle weakness. Record review of Resident #7's Quarterly MDS assessment, dated 02/27/2026, revealed he scored 15 on the BIMS, indicative of intact cognition. Resident #7 had an indwelling urinary catheter. Record review of Resident #7's Care Plan, dated 10/30/2024, revealed the resident was on EBP due to having an indwelling catheter. The Care Plan read, in part, .Don gown and gloves during high contact resident care activities. Observation and interview on 04/01/2026 at 1:11 p.m. revealed CNA C provided indwelling catheter care for Resident #7. Observation revealed there was a sign on the wall outside the entrance to the room that revealed the resident was on EBP. He had no roommate. There were gowns and gloves available at the doorway. Resident #7 was sitting in his wheelchair. CNA C sanitized her hands and donned gloves. She did not don a gown. She assisted Resident #7 to stand and pivot by placing her arms around his upper chest. The resident appeared to need moderate assist. CNA C then removed Resident #7's shoes and pants. She pulled the catheter collection bag through one pant leg. She emptied the catheter collection bag into a plastic container. She drained the container and rinsed it. CNA C said, We never wear PPE for him. He doesn't have anything. We never wear a gown with him. The State Surveyor asked CNA C to wash her hands and don a gown and gloves. She wore her mask under her chin. Observation of the catheter care revealed no concerns. After the catheter care was completed, CNA C motioned towards adjusting the resident's linens with the same gloves. The State Surveyor stopped her and asked her to wash her hands. CNA C washed her hands and donned new gloves. She adjusted the linens. CNA C said the EBP sign on the outside of the door was for the catheter and wound care (the wound has been resolved). CNA C said wearing PPE was important So we, me and the residents, won't catch anything from it. In an interview on 04/01/2026 at 3:00 p.m., the DON said Resident #7 was on EBP for having an indwelling catheter. She said during contact the staff must wear gown and gloves. She said the PPE from protected them from becoming infected. She said without wearing PPE, the staff could contract an infection herself. She said she and the ADON (LVN B) were responsible for overseeing the staff wore PPE when needed. In an interview on 04/02/2026 at 1:51 p.m., LVN B, the facility Infection Preventionist, said if a resident on was on EBP, the staff should wash their hands when they in went in the room, and must have a gown and gloves on. She said [NAME] has provided in-services. She said if the protocol was not followed, it could result in infections for staff and residents. She said for Resident #38's wound care, the Calcium Alginate should have been in a sealed bag. If the package was not re-sealable it could have been placed in a zip-lock bag. She said bacteria could have entered the opened bag. 3. Record review of the facility Employee Immunization and TB Testing records revealed the following: * indicates read greater than 72 hours after given mployee Hire Date Date PPd given Date test read Read by Staff E 03/18/2026 03/25/2026 03/30/2026 * LVN B Staff E 03/30/2026 04/01/2026 LVN B Staff F 09/29/25 09/29/2025 10/03/2025 * LVN B 10/11/2025 10/14/2025 LVN B Staff G 10/08/2025 11/07/2025 11/13/2025 * LVN D 11/13/2025 11/17/2025 LVN D Staff H 09/15/2025 11/18/2025 11/21/2025 LVN B 12/04/2025 12/08/2025 * LVN B Staff I 05/19/2025 07/03/2025 07/06/2025 LVN B 07/04/2025 07/14/2025 * LVN B Staff J 11/24/2025 11/25/2025 12/01/2025 * LVN B 12/02/2025 12/02/2025 LVN B (same day) Staff K 02/02/2026 02/09/2026 02/11/2026 LVN D 02/13/2026 02/18/2026 * LVN D Staff L 01/05/2026 02/10/2026 02/12/2026 unidentified 02/12/2026 02/18/2026 * LVN D Staff M 12/18/2025 01/14/2026 01/17/2026 LVN B 02/02/2026 02/06/2026 * LVN B Staff N 11/18/2025 11/18/2025 11/24/2025 * unknown 11/25/2025 12/04/2025 * LVN B Staff O 03/11/2026 03/11/2026 03/18/2026 * LVN B 03/25/2026 03/28/2026 LVN B In an interview on 04/02/2026 at 3:45 p.m., the DON said the TB skin test should be given, then read between 48-72 hours later. She added Three days is greater than 72 hours, so usually would do a repeat. She was shown the Employee Immunization and TB Testing record for Staff E. She said the signature was ADON B. She said ADON B was responsible for the TB testing. The Administrator was present but did not say anything at that time. In an interview 04/02/2026 at 3:49 p.m. with ADON B, the facility Infection Preventionist, she said staff were given a 2-step TB test when hired. ADON B said Staff E's TB test was read three days after given. When ADON B was shown the Employee Immunization and TB Testing record for Staff E, she acknowledged the date given was written as 03/25/2026 and the date read as 03/30/2026. She said, I may not have been able to sign. She said sometimes other staff would take photos of the staff's arm and send them to her. She named HR Coordinator as a person who would take photos. an interview on 04/02/2026 at 3:56 p.m., the HR Coordinator said she did not look at TB tests. She said sometimes staff would send pictures, but she did not take photos. In an interview on 04/02/2026 at 4:03 p.m., ADON B said she read the tests on time, but signed them late. She said she did not read Staff E's test on 04/01/2026, but her signature was on the form. In an interview on 04/02/2026 at 4:08 p.m., LVN D said if she was available when it was time to read the TB test result, she would read it then report to whomever had the paper. She said the most recent time she read one, it was two weeks prior. She said she did not take pictures of anyone's arm. She added, If I read it, I'll put that I read it. Whoever reads it has to sign the form. She said normal time to read test results was 72 hours. Observation and interview on 04/02/2026 at 4:12 p.m., revealed Staff E appeared to have reddened areas on both arms. The red area on the right arm was greater in diameter than the left. Staff E said LVN P read the result on her left arm on the previous day. Observation and interview on 04/02/2026 at 4:15 p.m. revealed ADON B looked at Staff E's left arm and said It looks like she's having a reaction. At that time the DON said Staff E should go to the hospital for a chest x-ray. Record review of an email, dated 04/02/2026 at 7:23 p.m., revealed Staff E had a chest x-ray. The result was 'negative.' Record review of the facility policy Administration and Interpretation of Tuberculin Skin Tests (revised 04/03/20250 read, in part, .4. Procedure for reading the skin test: a. Read the test between 48 and 72 hours after the test was administered.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #9) reviewed for comprehensive care plans. The facility failed to ensure Resident #9 had a comprehensive care plan in place with interventions to address the use of insulin. This deficient practice could place residents at risk of their needs not being monitored and cared for at the facility. Findings include: Record review of Resident #9's facility admission record, dated 4/1/26, revealed a 68-year- old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #9 had diagnoses which included Type II Diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar [glucose] levels) and mild protein-calorie malnutrition (a nutritional deficiency resulting from inadequate intake of calories and protein). Record review of Resident #9's Quarterly MDS, dated [DATE], revealed Resident #9 had a BIMS score of 13 out of 15, which indicated Resident #9 was cognitively intact. Section N-Medications revealed Resident #9 received insulin injections. Record review of Resident #9's, undated, care plan revealed there was no comprehensive care plan in place with interventions to address the use of insulin. Record review of Resident #9's physician orders, dated March 2026, revealed orders to administer HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 3 unit subcutaneously three times a day for glucose control hold if <100 call provider if >300 with a start date of 3/08/26. An order to administer Toujeo SoloStar Subcutaneous Solution Pen-injector 300 UNIT/ML (Insulin Glargine) Inject 34 unit subcutaneously one time a day for insulin hold for fsbs below 100 with a start date of 1/12/26. An interview on 4/1/26 at 12:31 PM with the DON, she said Resident #9 should have a care plan for insulin, and they would add it now. She said the RAI manual was used to complete assessments and care plans. She said the MDS Coordinator was responsible for completing the care plans. An interview on 4/1/26 at 3:09 PM with the DON, she said a comprehensive care plan for Resident #9's insulin was important and should be there. The importance of comprehensive care plans was making sure residents received proper care. A negative outcome of not having a comprehensive care plan could result in the resident not receiving the right care. During an interview on 4/2/26 at 9:13 AM with the MDS Coordinator, she said Resident #9 should have a comprehensive care plan for insulin and she added it yesterday (4/1/26). She said she was the only staff responsible for the care plans and she used the RAI manual. She said the care plan was important to provide care and not having one could cause a lot of negative outcomes. An interview on 4/2/26 at 6:00 PM with the Administrator, he said he was aware of the missing comprehensive care plan, the care plans should be done, his expectation was care was provided for the resident. Record review of the facility's policy and procedure entitled Care Plans, Comprehensive Person-Centered, dated revised December 2016, read in part .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive-person-centered care plan will.incorporate identified problem areas.incorporate risk factors associated with identified problems.aid in preventing or reducing decline.

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of 1 resident (Resident #38) of 4 residents reviewed for skin integrity, received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection.-The facility failed to ensure LVN A followed wound care orders by omitting collagen while providing wound care for Resident #38.The failure placed the resident at risk for infection and delayed resolving of the pressure sore.Findings include: Record review of Resident #38's admission Record (04/02/2026) revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included cerebral infarction (stroke), muscle weakness, and stage 4 pressure ulcer on her sacral area. Record review of Resident #38's Quarterly MDS assessment, dated 02/26/2026, revealed she scored 14 on the BIMS, indicative of intact cognition. Resident #38 had limited range of motion of one upper and one lower extremity. Record review of Resident #38's Care Plan (PS CP updated 10/30/24) revealed she had a PS on her sacrum. The CP did not address wound care technique or PPE use.Record review of Resident #38's Physician Order, dated 03/31/2026, revealed the wound was to be treated daily. The order read, in part, .Wound care orders cleanse pressure wound to sacral with wound cleanser, pack calcium alginate and collagen, cover with foam dressing every day. Observation and interview on 03/31/2026 at 2:57 p.m. revealed LVN A provided wound care for Resident #38. LVN A sanitized her hands and donned a mask and gloves. She sanitized Resident #38's overbed table. LVN A placed non permeable craft paper as a barrier on the overbed table. She then placed several 4 x 4 inch gauze into a transparent plastic cup. LVN A then sprayed wound cleanser on the gauze. LVN A placed one single-use NS container, gauze, and a bordered gauze on the craft paper barrier. Continued observation revealed LVN A retrieved a previously opened/unsealed package of Calcium Alginate from the wound care cart drawer. One corner of the sheet of Calcium Alginate had already been cut from it. LVN A picked up scissors from a drawer in the cart and motioned towards cutting the Calcium Alginate. The State Surveyor stopped LVN A and asked her to sanitize the scissors. LVN A sanitized the scissors and again motioned towards cutting a piece of Calcium Alginate from the previously opened package. The Surveyor State Surveyor stopped LVN A and asked her to use Calcium Alginate from an unopened package. LVN A discarded the previously opened package, as well as two additional opened/unsealed packages of Calcium Alginate from the cart. LVN A sanitized her hands, donned new gloves and opened a new package of Calcium Alginate. She cut a small piece of Calcium Alginate from the new package. LVN A did not place any Collagen on the over bed table. LVN A entered Resident #38's room and closed the door. She washed her hands and donned gloves. She did not don a gown. Resident #38 was able to turn onto her right side. The old dressing on her sacral area was intact. There was no date or initials on the dressing. LVN A discarded the dressing and washed her hands and donned new gloves. LVN A cleaned the wound with wound cleanser/gauze three times. LVN A then sprayed the NS onto the wound. LVN A patted the wound dry with clean gauze. LVN A changed her gloves and placed the Calcium Alginate on the wound. LVN A did not apply Collagen. She then covered the wound with the bordered gauze. All used supplies were placed in the trash. Interview immediately following the wound care treatment revealed LVN A verbalized she was finished with the treatment. The facility policy Wound Treatment Management (revised 05/15/2025) read, in part, .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes

Based on observation, interviews, and record review the facility failed to ensure a safe, clean, and sanitary environment for residents when staff allowed four residents' toothbrushes to be stored together in a single cup, resulting in direct contact between the toothbrush heads for Residents #1, #2, #3 and #4. The facility failed to separate residents personal toothbrushes and store them in separate toothbrush cup holders or zip lock bags per DON. This practice created an unsanitary and non homelike environment and failed to protect residents from potential cross contamination. This failure could place residents at risk of cross-contamination.Record review on 01/11/2026 revealed a statement made by the Residents #1 After witnessing horrible conditions such as pest, dirty and unsanitary conditions, such as all residents' toothbrushes kept together in a cup. During an observation on 01/13/2026 at 9:10 a.m. revealed a plastic cup on the bathroom countertop shared by Residents #1, # 2, #3, and #4. Observation further revealed four toothbrushes, all visibly used, stored together in a single cup with the bristle heads touching. During an observation on 01/13/2026 at 9:15 a.m revealed residents #1, # 2, #3 and #4 toothbrushes were dirty and the bristles from one of toothbrushes appeared to be worn down to the handle of the toothbrush. During an interview with CNA #1 on 01/13/2026 at 9:25 a.m., CNA#1 stated the toothbrushes belonged to four different residents and that they store them together to keep them in one place. CNA #1 stated that residents' toothbrushes should be in a plastic zip lock bag with toothbrush, toothpaste with resident's name on zip lock bag. CNA #1 stated by storing residents' toothbrushes together in one cup can cause them to get sick and possible infected. During an interview on 01/13/2026 at 10:00 a.m., LVN stated residents in this room shared the bathroom, but should each have individual, sanitary storage for personal hygiene items. LVN stated toothbrushes stored together in one cup could cause them to get infected or sick. During an interview on 01/13/2026 at 11:30 a.m., the DON stated by storing four residents' toothbrushes in one cup with bristle to bristle contact, the facility failed to ensure a sanitary environment and increased the risk of bacterial transfer among residents. The DON stated the CNAs were to store the residents' toothbrush and toothpaste in a plastic bag with each resident's name on them. I The DON stated she would in-service staff on the practice and monitor daily to assure this did not happen again. The DON stated there was no policy or procedure for storing residents' personal hygiene.

Based on interview, and record review the facility failed to obtain laboratory services to meet the needs of 1 of 5 residents (Resident #31) reviewed for laboratory services. The facility failed to ensure Resident #31 received lab test that were ordered for lipid panel and thyroid panel to know if the medications of atorvastatin and levothyroxine were at correct levels for administration to resident. This failure could place residents at risk for adverse effects of pain, discomfort, increase side effects, not receiving the therapeutic effects of the medication, and a decline in health. Findings included: Record review of Resident #31's face sheet revealed a [AGE] year-old female admitted on [DATE]. Diagnosis were Cerebral Infarction (occurs when blood flow to the brain was blocked), Hypothyroidism (condition which the thyroid gland does not produce enough thyroid hormone), and Hypertensive Heart Disease (complications from high blood pressure). Record review of Resident #31's Quarterly MDS dated [DATE] revealed a BIMS score of 14 indicating cognition was intact. Record review of Resident #31's Medication Record for September 2024 revealed: Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime for Hypercholesterolemia And Levothyroxine Sodium Tablet 125 MCG Give 1 tablet by mouth in the morning for low thyroid hormone were being given to resident as ordered. Record review of Resident #31's pharmacist communication to her physician dated 9/4/24 revealed a suggestion to have a lipid panels new and yearly and thyroid panel now one time. This was signed as agreed by physician on 9/23/24. Record review of physician orders reviewed on 1/7/25 for active orders revealed no orders for the labs requested on 9/23/24. Interview on 1/7/24 at 3:45 PM with DON and she stated that the order had not been ordered and not followed through from the pharmacist suggestion. Attempted interview with physician on 1/8/24 at 12:20 PM. Left a message with answering service because the physician was at lunch. The physician never returned the call. Interview on 1/8/25 at 1:05 PM with DON and she stated that the process begins with the pharmacist review and suggestion. This was then emailed or given to the MDS nurse. The MDS nurse sends to medical records. The person there ensures to get the form signed by the physician on if the physician agrees or disagrees. Once signed, she sends it back to the MDS nurse to order. After ordered, Medical Records scans into PCC and files away the form. She was not sure what happened and where the breakdown was. This order was never placed. The signed form was an order and should be followed up on and completed. These were not urgent labs but should have been done since it was an order. The physician would be looking for levels of the medication. There were no recent labs, and it was important to know what the medication levels were to ensure correct medication was being given. Interview on 1/8/24 at 1:10 PM with MDS nurse and she stated that she was to follow up on what is required after the papers are signed. The physician signed form from the pharmacist was an order. She did not know what happened with this order. She said it was possible for it to be uploaded into the system before she received it. This should have been completed. It was important to do what the physician ordered. Interview on 1/8/24 at 1:20 PM with Medical Records and she stated she did not know anything that was done on the medical side. She said she received the pharmacist form and she either put them out for the physician to sign or sent them to the physician to sign. After I receive the form back, I give them to the MDS nurse. She was then responsible for doing what was needed medically. They then were returned, and she would upload and file away. Record review of facility policy titled, Lab and Diagnostic test Results - Clinical Protocol revised November 2018 read in part, .The physician will identify and order diagnostic and lab testing .The staff will process test requisitions and arrange for tests

Based on observation, interview and record review the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 8 of 59 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #8 and Resident #9) reviewed for accidents and supervision. 1. The facility failed to ensure 8 residents were able to evacuate in the event of an emergency due to plywood bolted down to the exterior door that barricaded the exit on Hall A. 2. The facility failed to ensure 8 residents on Hall A had two exits available in an event of an emergency due to the dead-end corridor. An immediate jeopardy (IJ) was identified on 6/4/2024 at 5:37 p.m. The IJ template was provided to the facility on [DATE] at 5:37p.m. While the IJ was removed on 6/5/2024 at 12:01p.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of physical and psychological harm, and possible death, due to the exit door creating a dead-end corridor in an emergency. Findings Included : Resident #1 Record review of Resident #1's face sheet dated 6/5/2024 revealed a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of Emphysema (type of lung disease), unspecified, unspecified abnormalities of gait and mobility (change in walking pattern), other lack of coordination, and cognitive impairment (a condition in which there is a decline in memory and thinking). Record review of Resident #1's MDS dated [DATE] revealed Section C0500 had a brief interview of mental status score of 00, which indicated severe cognitive impairment. Section GG- Functional Abilities and Goals -Roll left and right, sit to lying, lying to sitting side of bed, sit to stand, transfer (toilet/shower) and walk 10, 50 and 150 feet were all scored a6 which represented he was independent. Record review of Resident #1's care plan revised on 4/28/2023 revealed Resident #1 had a slightly limited physical mobility r/t use of cane when ambulating, goal- Resident #1 will demonstrate the appropriate use of adaptive device to increase mobility. Resident #2 Record review of Resident #2's face sheet dated 6/5/2024 revealed a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of dementia (a loss of thinking, remembering and reasoning), hypertensive heart disease (a change in left ventricle, atrial and arteries as a result of chronic blood pressure), unspecified abnormalities of gait and mobility (change in walking pattern), unspecified lack of coordination and cognitive communication deficit. Record review of Resident #2's MDS dated [DATE] revealed Section C-0500 brief interview of mental status was unscored (00), which indicated severe cognitive impairment. Section C-1310 Onset of mental status change (B) Inattention and (C) Disorganized thinking were coded as a 1 for behavior continuously present and did not fluctuate. Section GG Functional abilities GG-0115 notated Upper extremity (shoulder, elbow, wrist and hand) coded as a 2 which indicated impairment on both sides. Section GG-0170 reflected lying to sitting on side of bed was coded as a 03 which indicated partial assistance needed by staff. Sit to stand, chair to bed, toilet transfer and tub/shower transfers were coded as (02) which represented substantial assistance needed by staff. Walk 10 feet was coded an88 which indicated not attempted due to safety concerns. Record Review of Resident #2's care plan dated 5/26/2021 and revised on 9/29/2023 revealed Resident #2 had impaired cognitive function r/t forgetfulness, diagnoses of dementia, BIMs indicated severe impairment. Resident #2 had a communication problem r/t/ hearing loss, he was HOH. Resident #3 Record review of Resident #3's face sheet 6/7/2024 revealed an [AGE] year-old female that was admitted to the facility on [DATE] and with diagnoses of cerebral infarction(stroke caused by disrupted blood flow to the brain), other lack of coordination, unspecified abnormality of gait (change in walking pattern), hypertensive heart disease (a change in left ventricle, atrial and arteries as a result of chronic blood pressure), unspecified dementia, and cognitive communication deficit. Record review of Resident #3's quarterly MDS dated [DATE] revealed C0500- brief interview of mental status was unscored (00) which indicated severe impairment. Section GG Functional Abilities indicated Upper Extremities and lower extremities (1) indicated impairment on one side. Mobility Devices reflected (C) Wheelchair was used. Roll left and right, sit to lying, lying to sitting on side of bed was coded a 03 which indicated partial/moderate staff assistance was needed. Sit to stand, chair/bed to chair transfer, tub/shower and toilet transfers were coded a 02 which indicated substantial assistance required by staff. Record review of Resident #3's care plan dated 9/21/2023 revealed the resident had a physical functioning deficit. Goal: Resident will maintain current ROM through next review. Interventions: Monitor for safety. Resident #4 Record review of Resident #4's face sheet dated 6/7/2024 revealed a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Cognitive communication deficit, cerebral infarction, difficulty in walking, unspecified osteoarthritis, and Type 2 diabetes. Record review of Resident #4's annual MDS dated [DATE] revealed Section C0500- Brief interview of mental status was codes as 13, which indicated cognitively intact. Section GG Functional abilities and goals indicated sit to stand, chair/bed-to chair transfers were coded as a (01) which indicated the resident was dependent on staff for assistance. Walk 10 feet was coded as an (88) which indicated not attempted due to safety concerns. Record review of Resident #4's care plan dated 8/22/2023 revealed Resident #4 was at risk for falls. Goal: Resident #4 will demonstrate the appropriate use of adaptive device to increase mobility, and free from minor injury. Intervention: Remind Resident #4 to call for assistance when trying to transfer. Resident #5 Record review of Resident #5's face sheet dated 6/5/2024 revealed a [AGE] year-old female that was admitted on [DATE] with diagnoses of Hypertensive heart disease without heart failure (a change in left ventricle, atrial and arteries as a result of chronic blood pressure), falls, attention and concentration deficits, senile (degeneration of brain), Dementia, and cognitive communication deficit and altered mental status. Record review of Resident #5's MDS dated [DATE] revealed section C500- BIMS was unscored (00) indicating severe impairment. Section GG- Functional Abilities and Goals indicated roll left and right, sit to lying, lying to sitting were coded (2) for substantial assistance required by staff. Sit to stand, chair/bed-to-chair transfer, toilet and shower transfer were coded as (1) Dependent- helper did all of the effort. Mobility device was coded a 1 which indicated a manual wheelchair was used. Record review of Resident #5's care plan dated 4/5/2021 and revised on 4/24/2024 revealed Resident #5 self-care deficit needed total assistance of one staff with ADL's. Interventions: Resident #5 transfers with one-person total assist. Resident #6 Record review of Resident #6's face sheet dated 6/7/2024 revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, hypertensive heart disease without heart failure (a change in left ventricle, atrial and arteries as a result of chronic blood pressure), atherosclerosis of native arteries of right leg with ulceration of ankle and peripheral vascular disease. Record review of Resident #6's annual MDS dated [DATE] revealed section C0500- brief interview of mental status was not coded(blank). Section C1000- Cognitive skills for daily decisions was coded as (3)- which meant severely impaired (never made decisions). Section GG- Functional Mobility checked C. Wheelchair was used for mobility. GG0170- Roll left and right and lying to sitting on side of bed were coded a 02 which indicated substantial/maximal assistance. Sit to stand and chair/bed-to-chair transfer were coded a 01 which indicated dependent- helper did all effort. Record review of Resident #6's care plan dated 9/26/2023 revealed Resident #6 had impaired cognitive function/Alzheimer. Goal: Resident #6 will maintain current level of cognitive function. Resident #6 required assistance with her ADL's. Intervention: Resident requires max 2 staff participation with transfers. Resident #8 Record review of Resident #8 face sheet dated 6/7/2024 revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (progressive disease that destroys memory), unspecified dementia without behavioral disturbance, hypertensive heart disease a change in left ventricle, atrial and arteries as a result of chronic blood pressure), muscle weakness and other lack of coordination. Record review of Resident #8's MDS dated [DATE] revealed Section C0500 brief interview of mental status score was 05 indicating severe cognitive impairment. Section GG- Functional Abilities and goals reflected roll left and right, sit to lying, chair/bed-to-chair transfer, walk 10 feet were all coded as a 6 which indicated the resident was independent. Record review of Resident #6's care plan dated 8/21/2023 revealed she had cognitive impairment. Goal: Resident #8 will maintain current cognitive function. Resident #9 Record review of Resident #9's face sheet dated 6/7/2024 revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (a change in left ventricle, atrial and arteries because of chronic blood pressure), muscle weakness, and Type 2 Diabetes and unsteady on feet. Record review of Resident #9's MDS dated [DATE] revealed Section C0500-brief interview of mental status was 15, which indicated cognitively intact. The MDS reflected for GG0120-mobility devices (C) Wheelchair is used for mobility. Record review of Resident #9's care plan dated 12/8/2023 revealed she had physical functioning deficit related to: Mobility impairment. Goal: Resident will maintain current level of physical functioning through next review. Interventions: Use of overhead trapeze to assist with bed mobility. Observation on 6/4/2024 at 10:11am of the exit door at the end of the Hall A near resident rooms 101-106 revealed the exit door was physically barricaded with plywood that was secured with a bolt to the exterior door frame. The residents in rooms 101-106 had only 1 exit path. The door had an EXIT sign above it. Record review of resident daily census dated 6/4/2024, listed 8 residents in rooms 101-106. Rooms 102B, 103B and 105A were empty. An interview with the Administrator on 6/4/2024 at 10:49 a.m., revealed the air conditioning systems in the facility had not been working well. He said there were 5 to 7 total units throughout the facility. He said the unit in the back of the building where Nursing station 2 was located was leaking freon, another unit in the back unit needed a compressor and Hall A unit needed a blower motor replaced. He stated the plywood that replaced the exit door was put in place because the portable air conditioning ducts had to go through that door to cool Hall A. He stated the portable air conditioning inserted through the plywood in the exit door was done on 6/2/2024 by a local contractor. He stated the plywood had been there for only two days. He said the Maintenance Director oversaw this project. He was asked why the residents on Hall A were not moved to another hall where the exit door was not barricaded, and he stated the interviewable residents were asked about moving to other rooms and they said they were fine remaining in their rooms. He did not recall which residents were asked specifically. He stated if there was an emergency, they would have evacuated the residents on Hall A through the front entrance door . He stated the evacuation routes were posted at the nursing stations and near each exit door. An interview with Resident # 8 on 6/4/2024 at 11:18 a.m., she stated that it had been warm in her room. She was unaware of the temperature. She stated she did not recall maintenance or the ADM coming in to check the temperature prior to today. She said the temperature was bearable because she had her fans. She said she had both fans on to ensure she was cool. She used a small personal fan that sat on her nightstand and a floor fan. She said she did not notice plywood covering the exit door on Hall A. She said she did not know what would have happened in an emergency because the door near her was closed off. She said she guessed staff would have to bring her through another door. An interview with the FM of Resident #6 on 6/4/2024 at 11:25 a.m., revealed he was not aware of the plywood on the exit door on hall A. He stated he visited Resident #6 once a week and said the plywood was not there when he visited on last Wednesday (5/29/24). He said the facility was usually cool and there were no issues. The FM stated Resident #6 was not verbal. He said she was cold-natured and not sure if she was affected by the air conditioning not working well. He stated he noticed the plywood over the door today (6/4/2024). He stated he asked himself, Are they allowed to have that there? He said Resident #6 would need help in an evacuation as she required total care by staff. He said he guessed they would have to evacuate her through another door in an emergency. An interview with RN B on 6/4/2024 at11:56 a.m. revealed she had been employed with the facility for a few months. She stated she normally worked the morning shift. She stated the air conditioning had been out for about two weeks. She stated a family member had inquired about the air conditioning not working and about the exit door in Hall B. She said the thermostat on Hall A read 83 degrees Fahrenheit a few days before the yellow portable was placed. She said it really got warm in the front of the building. She said she saw the plywood covering the door but was more concerned the residents had cool air and figured the Administrator or maintenance must have given the okay for the contractor to install it. She did not ask any questions about it. She said in an emergency they would have evacuated the residents on Hall A out the front door which was the closest exit. An interview with CNA B on 6/4/24 at 12:21pm, she stated she had been employed since 2023. She stated she normally worked the 6a-6p shift. She stated she normally worked Hall A. She stated that the air conditioning had been an issue since the end of May 2024. She said she mentioned to the Maintenance Director that it was warm down that hall. He said the air conditioning was flipping the breaker at first then the unit went out. She stated she saw the plywood but was happy the residents had cooler air. She said they would have had to move the residents through another exit or the front door in the event of an emergency. She said she knew boarding that exit door on with wood was a bad idea. An interview with the DON on 6/4/2024 at 2:01p.m., she stated she did not work between 5/25/24-6/3/2024. She said she was on vacation and returned to work on today (6/4/24) and although she did see the plywood, she was going to ask questions about it in the morning meeting, but the Investigator entered the facility, so they did not have a morning meeting. She said her backup while she was off was the MDS Nurse. She stated she was not made aware of the plywood barricading the exit door prior to observing it on 6/4/24. She said she did not know that was considered a dead-end corridor. She said in an emergency they could have gotten the residents out of the windows. She said the nurse on duty could have made the decision to move the residents to another hall. She said she was not sure why the residents down Hall A were not moved to another hall with two exit doors. An interview with the Medical Records Coordinator on 6/4/2024 at 2:35 p.m., revealed she had been employed at the facility for nine years. She stated the plywood had been setup by a local contractor to run the portable air conditioning ducts through to help cool Hall A. She stated she did notice the plywood replaced the exit door. She stated she only thought about the residents getting cool air and did not think it was a hazard. She said the air conditioner on Hall A went out on or about 5/25/2024 and the portable was setup on 6/2/2024. In a subsequent interview with the Administrator on 6/4/2024 at 3:27 p.m. revealed him to state the air conditioning blower motor on Hall A unit was being repaired right now and the Maintenance Director would remove the plywood from the exit door. He was asked why residents on Hall A were not moved to another hall since that door had been replaced with plywood and he stated he was not aware that created a dead-end corridor. He said in an emergency like a fire, the residents might have been harmed or burned from not having an exit closest to them to get out. He said having that door barricaded could have caused a delay in exiting the building, smoke inhalation, and bodily harm could have happened to residents and staff. An interview with the Maintenance Director on 6/5/24 at 1:08 p.m. He has been employed at the facility for about 6 months. He stated this was his first maintenance job. He said he had no experience working with air conditioning. He stated the only complaints about the facility being warm came from staff, not residents. He stated he had kept a temperature log and took temperatures in areas with portables. No rooms or hallways were over 78 degrees Fahrenheit. He stated he did not know the plywood bolted down to the door frame created a dead-end corridor. He said he was not aware of that. He said in an emergency staff could have evacuated the residents out the front door, which was the nearest exit. He said he received an in-service on door egress and blocking the exit doors. He said the Regional Maintenance Director had trained him and he was in-serviced by the Administrator as well. An interview with the MDS Nurse on 6/7/24 at 10:01am, revealed she had been employed at the facility for [AGE] years. She worked the Friday before (5/24/24) the holiday and returned on 6/3/24. She stated she did not work weekends. She said she saw the portable air conditioning units down Hall A but she did not notice the plywood. She stated she did not go down Hall A. She said generally she did not go down that hall unless she had an assessment. She said staff did not inform her about the plywood being installed on Hall A. She said the residents could have perished in an emergency. She said as far as she knew the evacuation route was not changed due to the barricaded door. She said she was in-serviced by the maintenance director and DON on door egress. She said she was informed about door egresses and doors should not be blocked. She said also if she noticed a change in the temperature in the building to notify both the Administrator and Maintenance right away. An interview on 6/7/24 at 11:58 a.m., LVN B stated she had been employed at the facility about 1 year and usually worked the day shift, 6a-6p. She said she did not work on Hall A. She said she was at work when Hall A air conditioning portables were installed and lots of staff had asked her what was going on. She said she wondered if they could do that (board up the exit door). It was being installed in the later part of her shift like 4pm or so. She said she did not give it much thought. She said residents on Hall A would have needed to be rerouted through another exit door in an emergency. She said residents on Hall A could have been injured by fire, or harmed from not being evacuated in a timely manner. She stated she had been in-serviced on reinforcing access to all exit doors, evacuation routes, and nursing stations evacuation routes were pointed out. Record review of safety and supervision of resident policy revised on July 2017, reflected the facility strives to make environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. An immediate jeopardy (IJ) was identified on 6/4/2024 at 5:37 p.m. The Administrator and traveling DON were notified. The Administrator was provided with the IJ template on 6/4/2024 at 5:37 p.m. A Plan of Removal was requested at that time. The following Plan of Removal was submitted by the facility was accepted on 6/5/2024 at 12:01pm and included: 6/4/2024 - F689 PLAN OF REMOVAL Date: 6/04/24 Summary of details which leads to outcomes. On 6/4/24 an investigation on a priority 1 was initiated at 5:37 pm, a surveyor provided an IJ Template notification that the Survey Agency has determined that has determined that the condition at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: F689 Free of accidents and hazards/ Supervision/ Devices. The facility failed to ensure that 8 residents could evacuate due to a barricade at the end of a corridor. The barricade consisted of plywood which was bolted down. Immediate Corrective Actions For Removal Of Immediate Jeopardy The plywood physically barricading the exit door at the end of the 101-106 hall near resident rooms 101-106 was immediately removed by the Maintenance Assistant. The exit door is no longer barricaded. 6/4/2024 at 3:45 pm. The facility reviewed the system for ensuring that all exits are not blocked. Ad Hoc QAPI meeting was completed with the IDT, Administrator, DON, and Medical Director on 6/4/24 at 9:00 pm. Facility Plan to ensure compliance quickly: 1. The Administrator checked all exits to ensure these areas were not blocked. 2. Education provided to the administrator by the Regional Maintenance Director regarding Exit and Means of Egress. 6/4/2024 at 6:30 p.m. 3. Education provided to Maintenance Director by the Administrator on ensuring exits are not blocked and Exit and Means of Egress. 6/4/2024 at 6:40 p.m. 4. Education initiated on 6/4/24 at 7:52pm, to all department staff by the Administrator and Maintenance Director; related to means of egress must remove free from any blockage and evacuation routes. Staff will not be able to work their scheduled shifts without prior in-service on egress. Whoever discovers a blocked exit shall clear the exit, if possible, and the report the finding to his or her immediate supervisor or to a supervisor or manger in the building, if the immediate supervisor is not present. If no supervisor is on the building is present staff has been educated to call the Administrator or Maintenance Director. The Administrator and/or Maintenance Director will make sure it is immediately corrected. 5. Facility will be in compliance by 6/5/24 by noon. Monitoring of the plan of removal from 6/4/2024 to 6/7/2024 included: Observation on 6/4/2024 at 5:50pm revealed the plywood and portable air conditioning ducts had been removed from Hall A's exit door. Interviews on 6/5/24 at 12:38pm, with the DON, Administrator and Social Services Coordinator revealed the Administrator stated the Regional Maintenance Director in-serviced him, the DON, Maintenance Director and Social Services on door egress. He stated the egress was not to be blocked. He said he also in-serviced the Maintenance Director about not putting anything to block the exit doors. If someone saw anyone put boxes or anything in front of the doors everyone was responsible for moving it immediately or report to the Administrator or Maintenance Director for help moving. There was a consensus with that group that they understood the plywood barricaded the door on Hall A and made it a dead-end corridor. It created a hazardous situation for residents down that hall. Record Review of the ad hoc QAPI meeting reflected that on 6/4/24 at 9:00 p.m., the IDT, DON/MDS /ADM- once compliance is established the Administrator and maintenance will monitor to make sure no exit door is blocked to ensure continuation of resident's care is safe. Record review of exit or means of egress huddle sign-in sheet dated 6/4/2024 revealed the Maintenance Director and the Administrator were trained by Regional Maintenance Director on exit and means of egress. Record Review of exit and egress log dated 6/5/2024 revealed the maintenance director had checked all exit doors to ensure nothing blocked the doors. Interviews were completed between 6/5/2024-6/7/2024 with 3 CNAs on 6am-6pm and 2 CNAs on 6pm-6am shifts, 2 RNs, 3 charge nurses, the Social Services Coordinator, Dietary Manager, Activity Director and 2 LVNs on night shift revealed they were aware of the exits not being blocked, reporting any blocked exits and evacuation route locations . The Administrator was informed the Immediate Jeopardy was removed on 6/7/24 at 2:30 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included a fall mat at Resident #1's bedside. The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included her bed should have been placed in the lowest position This failures placed the resident at risk for injury. Finding included: Record review of the admission sheet for Resident #1 revealed an [AGE] year-old female admitted on [DATE] and readmitted [DATE]. Her diagnoses included: diagnosis of muscle weakness, abnormal gait/mobility, cerebrovascular accident (loss of blood flow to a part of the brain) and dementia (group of symptoms that affects memory, thinking and interferes with daily life). Record review of Resident #1's Significant Change MDS assessment, dated 2/28/2024, revealed a BIMS score of 13 out of 15 which indicated her cognition was intact. Resident #1 used a wheelchair for mobility. Resident #1 required total dependence from two-person physical assist from staff for bed mobility and transfer. Record review of Resident #1's care plan, initiated 3/8/2024 revealed the following: Focus: (Resident #1) is at risk for falls/injuries related to CVA weakness. Goal: (Resident #1) will have no falls/injuries daily through next 90 day review. Interventions: .Fall mat in place (date initiated 5/6/2024) Keep bed in low position (date initiated 11/21/22 and revised 8/29/23). Record review of Resident #1's Fall assessment dated [DATE] revealed Resident #1 had a score of 17 which indicated a High Risk for falls. Observation on 5/8/2024 at 10:07 a.m., revealed Resident #1 awake in bed with her bed not in the low position, and there was no fall mat at bedside or in the room. Observation on 5/8/2024 at 10:39 a.m., revealed Resident #1 awake in bed with her bed not in the low position, and there was no fall mat at bedside or in the room. Observation on 5/8/2024 at 10:59 a.m., revealed Resident #1 awake in bed with her bed not in the low position and there was no fall mat at bedside or in the room. Interview on 5/8/2024 at 11:00 a.m. with CNA A, who was assigned to Resident #1, revealed the nurses would tell her if there were any interventions that the resident needed. She was aware that the resident had falls in the past but was not aware of the fall mat intervention for Resident #1. She was not able to say why the bed was not in the lowest position. She said care planned interventions should be in the Kardex (system that organizes resident information). CNA A said she had been trained on reviewing the documentation system at the beginning of the shift, but she relied on the nurses to update her on intervention changes. Observation on 5/8/2024 at 11:15 a.m. of Resident #1 in her bed without a mat on the side of her bed and not in the low position was observed by CNA B and the ADMIN. Interview on 5/8/2024 at 11:16 a.m. with CNA B revealed Resident #1's bed was not in the lowest position and there was not a mat at the bedside. She said the bed was in a mid-position. She said it put the resident at risk for injury since she was a fall risk. She said it was the CNA's and Nurses responsibility to ensure interventions were in place. Observation on 5/8/2024 at 1:46 p.m., revealed Resident #1 awake in bed with her bed not in the low position and there was no fall mat at bedside or in the room. Interview on 5/8/2024 at 2:10 pm with LVN A revealed she had been off for two days and this was her first day back, and she did not realize that the fall mat intervention was started. She said she should have looked at the Kardex. She said it was all staff's responsibility to ensure fall interventions are in place. Interview on 5/8/2024 at 1:41pm with the DON, revealed Resident #1's had multiple previous falls they discussed interventions during the morning meetings after the falls and decided to implement the fall mat on 5/6/2024. She said she was not sure what happened and why the fall interventions were not in place for Resident #1. The DON said CNA's had been trained to refer to the Kardex for interventions needed and should read them daily. She said the nurses should have ensured the fall mat and the low bed intervention was in place for Resident #1. She said Central Supply should have initially placed the mat in the room on 5/6/2024. She said Central Supply should have been updated when the intervention was updated. Interview on 5/8/24 at 1:57 pm with Central Supply, revealed she was responsible for supplies needed for interventions like fall mats. She said she was not told Resident #1's needed a fall mat. She said she was told approximately 20 minutes prior to that interview (1:37pm). Interview on 5/8/24 4:40 p.m. with, the Admin. revealed Resident #1 was supposed to have a fall mat and her bed should have been in a low position. He said the staff should have followed the care plans. He said the Nurses and CNA's were responsible for ensuring fall interventions are in place. He said it is the DON's responsibility and should have ensured the intervention was in place for Resident #1. He said the new interventions should have be communicated to the charge nurses. The charge nurses should have informed CNA's about Resident #1's interventions were in place. Record review of facility's policy, Care Plans Comprehensive Person-Centered (revised December 2016) revealed the following in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 10. Identifying problems areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Record review of facility's policy, Fall Prevention Program not dated, revealed the following in part: .The Interdisciplinary Team will review fall risk assessments completed by the nursing department, as well as completing the Fall Resident Assessment Protocol and if appropriate, a fall prevention protocol will be initiated . Purpose: To ensure consistency in the implementation of preventive measures to assist with the reduction of falls . Procedure: 4. All resident receiving a score of ten (10) or more will be considered at risk for falls .6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced recent falls have all recommended interventions in place .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety and failed to ensure that one of one dish washing machine in the kitchen had a readable hot water gage in 1 of 1 kitchen observed for kitchen sanitation. -The facility failed to ensure that cooking utensils were kept clean and in proper working order. -The facility failed to ensure foods items in the walk-in cooler were properly stored, labeled (missing label identifying items in the bag), and dated (date prepared or date expired). -The facility failed to ensure that expired food products were removed from the walk-in cooler and dry good storage area. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the facility's kitchen on [DATE] between 6:15AM and 6:50AM with Cook A revealed the following: One of one can opener had dark built-up substances around the cutting blade and the blade holder. The vent hood above the stove had grease build up. One of one deep fryer had dark cooking oil and brown floating substances on top of the grease. Observation of the walk-in cooler revealed the following items, and all unlabeled and undated food products were identified by Cook A: Half a bag of shredded carrots and purple cabbage were placed together in a plastic bag unlabeled and undated. Leftover uncooked rolls in a plastic bag that was unlabeled and undated. Two cartons, 28 oz of thickened lemon-flavored water had a manufactural stamp date of used by [DATE]. Observation of the walk-in freezer revealed a 16-inch pan of angel food cake stored underneath the condenser that had ice built up. Observation of the dry goods storage revealed: 3 bottles of 32 oz of foam concentrated lemon juice dated use by [DATE]. 3 cartons of 28 oz of creamy rice dated use by [DATE]. 10 cartons of 28 oz of thickened apple juice dated use by [DATE]. During an interview with the DM on [DATE] at 11:00AM, she said all food in the walk-in refrigerator and the cooler should be dated and labeled. She looked at the expired food products and said she would trash them. She started removing them from the shelves. She said serving expired food products could lead to food poison and sickness. She said the deep fryer grease was supposed to be changed every Sunday, but she did not have enough grease to change the grease in the deep fryer. She did not answer to when the last time the grease was changed. The DM said the oven hood was cleaned last in August of 2023 and was due for cleaning in October of 2023. Record review of the stamped date on the vent 11ood indicated the oven hood should be cleaned every three months. She said the ice built up on the cake was from the condenser because there are always ice buildup in the morning and the staff had to scrape the ice off the door of the walk in-freezer every morning. In an interview with the facility Administrator on [DATE] at 1:00PM, he said the contractor that was schedule to clean the oven hood had another job at a local hospital and they were engaged with that job. Observation on [DATE] at 2:00PM revealed one of one dishwashing machines in the kitchen was washing at an unknown temperature with a PPM reading of 200. The temperature gage on the dishwashing machine was not readable. Record review of the temperature log dated 11 /,d+[DATE] through [DATE], indicated the dish washing machine wash and rinse daily at a temperature of 120-degrees Fahrenheit and sanitized at a PPM reading of 200. In an interview with Cook B on [DATE] at 2:15PM, he said he used the strips to test the water and compared the result with the range. He did not answer the question of how he determined the water temperature. In an interview with Cook C on [DATE] at 2:20PM, she said the temperature gage did not work and she had told the company representative several times that the temperature gage was bad and needed to be changed. She said the dishwasher was a low temperature machine and was supposed to wash and rinse at ,d+[DATE]-degrees Fahrenheit. No answer was given about the recorded reading of 120-degrees Fahrenheit. In an interview with the cooperate Manager on [DATE] at 2:22PM, he said not knowing the correct temperature could result in the dishes not washing and sanitating correctly. Record review of the facility's food service policy revised ,d+[DATE] reflected in part, .All foodservice equipment will be clean, sanitary, and in proper working order. Procedures: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-foods contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Dining Services Director will notify the Administrator when repairs are completed. 7. Copies of service repairs and preventative maintenance reports will be submitted monthly. Food label: Guidelines for Labeling and Dating o All foods should be dated upon receipt before being stored. o Food labels must include: o The food item name o The date of preparation/receipt/removal from freezer o The use by date as outlined in the attached guidelines o Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date as outlined in the Retention Guide attached. (Example: A tube of ground beef). o Leftovers must be labeled and dated with the date they are prepared and the use by date. Record review of the U.S. Public Health Service, Food Code, dated 2022, reflected the following, XXX,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include .(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section.

Based on observation, interview, and record review, the facility failed to conduct initially and periodically comprehensive, accurate, standardized reproducible assessments of each resident's functional capacity for 3 of 16 residents (Resident #5, Resident #41, and Resident #47) reviewed for comprehensive assessment. -The facility failed to ensure that assessments accurately reflected Residents #5 and 41's falls. -The facility failed to ensure that Resident # 5 was accurately assessed for her oral cavity. -The facility failed to ensure that Resident #47 was accurately assessed for her falls and oral dental health. These failures could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings included: Resident #5 Record review of Resident #5's face sheet, dated 11/28/23, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hypertensive heart disease, hypothyroidism, vascular disease, arthritis, muscle weakness (generalized), lack of coordination, unspecified abnormalities of gait and mobility, age-related osteoporosis, vitamin d deficiency, altered mental status, unspecified, major depressive disorder, and anxiety. Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed Resident # 5 had a BIMS score of 99 which indicated severe cognitive impairment. Ssection J reflected, Resident #5's fall history was not coded; it was left blank. Section L of the MDS for Oral/Dental status revealed Resident #5 was assessed and coded for broken or loosely fitting, full or partial denture (chipped, cracked, uncleanable, or loose). Record review of Resident #5's care plan dated 04/05/21 and revised 07/26/23 indicated she was care planned for alteration in nutrition R/t Dx of anorexia, hypothyroidism and no teeth. Record review of the facility's 6 months accident and incident history (July 1st through November 20th), indicated Resident #5 had an unwitnessed fall without injury on 06/29/23. Observation on 11/28/23 at 8:10AM revealed Resident # 5 was in the dining room having breakfast. Breakfast consisteds of a regular puree diet. Observation indicated no teeth in her oral cavity. An Aattempt was made to have an interview, but she did not answer. During an interview on 11/29/23 at 1: 00PM, Resident #5 said she wanted to go to bed. She spoke very few words. She said she does not have any teeth and no dentures. Resident #41 Record review of Resident #41's face sheet, dated 11/28/23, revealed [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, unspecified protein-calorie malnutrition, retention of urine, viral pneumonia, covid-19, altered mental status (confusion) , essential hypertension, major depressive disorder, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and muscle weakness lack of coordination. Record review of Resident # 41's Quarterly MDS assessment dated [DATE] revealed a BIMs score of 3 which indicated severely impaired cognition. Section J for, fall history reflected the section was not coded. This section was left blank. Record review of the facility's 6 months accident and incident history (July 1st through November 20th), indicated Resident #5 had an unwitnessed fall without injury on 06/29/23. Record review of the nurses note dated 9/9/2023 10:48PM, reflected in part-: unwitnessed fall -Vitals: 165/87 P76 R18 T97.6 , head to toe skin check-no new issue pain level 6 .all responsible parties notified . No new orders. Resident # 47 Record review of Resident #47's electronic face sheet, dated 11/28/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included, Hip fracture, type 2 diabetes mellitus, essential hypertension, osteoarthritis (bone disease), displaced intertrochanteric fracture of right femur , bipolar disorder, depression, major depressive disorder, recurrent, severe with psychotic symptoms, insomnia (lack of sleep), pain, muscle weakness, cellulitis , abscess of mouth, difficulty in walking and abnormal weight loss. Record review of Resident # 47's significant change MDS dated [DATE] revealed Resident # 47 had a BIMs score of 12 which indicated moderately impaired cognition. Record review of section J for, fall history reflected it was not coded. This section was left blank. = Section L for oral/dental reflected no issue. Record review of Quarterly MDS assessment dated [DATE] revealed a BIMs score of 13 indicated intact cognition. Record review of section J, fall history was not coded. This section was left blank. Record review of Resident #47's care plan dated 10/13/23 reflected in part, potential for impaired chewing r/t poor dental condition abscessed tooth. Goals: Resident will be able to always chew food adequately through next 90day review Date Initiated: 10/13/2023 Revision on: 11/17/2023 Target Date: 02/27/2024. Interventions: Antibiotic as ordered. Date Initiated: Monitor for s/s of oral pain/discomfort such as verbal c/o pain, poor oral intake, inability to chew Obtain order for dental consult. Record review of facility's accident and incident history from From June 1st through November 25th indicated Resident #47 had falls as followedon 07/21/23 and 11/01/23 had a fall on 09/09/23. Observation on 11/28/23 revealed Resident # 47 was in the dining room for breakfast and her breakfast was a mechanically altered diet. Observation indicated she had some missing teeth. She did not answer too many questions but said she did not have any dentures. She said she had tooth pain on and off but her rResponsible party usually tooktake care of it. During an interview with the MDS Coordinator on 11/30/23 at 3:00PM, she said Resident #5 did not have any teeth in her mouth and did not have any dentures looked at the MDS and said it should have been coded as no natural teeth or edentulous . She said she overlooked the fall assessment and would make an addendum to the indicated MDS. She said inaccurate assessments could prevents from getting the necessary care needed. She said the facility diddoes not have policy on MDS assessments but followeds the resident assessment manual recommended by CMS.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan describing services (Resident #45 was care planned for thickened liquids while receiving thin liquids) that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 15 residents, (Resident #45) reviewed for care plan revision and completion. Resident #45's care plan was not revised to accurately reflect his current nutritional needs for fluid intake. Resident #45 was care planned for thickened liquids while receiving thin liquids. This failure placed residents at risk of not receiving appropriate or accurate nutritional needs. Findings include: Record review of Resident #45's Admission Record revealed a [AGE] year-old male who admitted on [DATE] and was diagnosed with peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce the flow of blood to the limbs of the body), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity and slow imprecise movement), hyperlipidemia (abnormally high concentration of fats or lipids in the blood), and cerebral infarction (condition caused by disrupted blood flow to the brain). Record review of Resident #45's Quarterly MDS assessment, dated 10/02/2023, revealed the resident's BIMS score was a 13 out of 15 indicating he was cognitively intact for daily decision making. Further review of Section K -Swallowing/Nutritional Status K0300. Weight Loss . Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, was coded as 2. Yes, not on physician-prescribed weight loss regimen. Record review of Resident #45's undated care plan, revealed the following: Focus .Potential for altered nutritional needs .Goal .Resident will have no significant weight change of > 5% in 1 month, >7.5% in 3 months, or >10% in 6 months .Date Initiated: 07/06/2023 .Target Date: 01/15/2024. Interventions .Diet and food texture provided as tolerated CCD mechanical soft diet, health shakes .nectar thick liquids .Date Initiated 07/06/2023 .Revision on: 08/16/2023. Record review of Resident #45's Medication Review Report dated 11/30/23 revealed the following physician's order: Consistent Carbohydrate (CCD) diet Dysphagia Level 3 Advanced texture. THIN (Regular) 1 consistency, large portion .Order Status .active .Start Date .08/21/2023. Observations of Resident #45 on 11/29/23 at 12:38 pm revealed he was in the main dining room for the lunchtime meal service, drinking thin liquids. His meal ticket attached to his meal tray served reflected: Dysphagia (difficulty or discomfort in swallowing), Level 3 Advanced Texture diet, thin (regular) 1 consistency, large portion. Interview with the DON on 11/29/23 at 1:12 pm, who said that the MDS Coordinator was responsible for both acute, quarterly, and annual care plans. The DON said that nursing staff would complete care plans if the MDS Coordinator was off. Interview on 11/29/23 at 1:17 pm with MDS Coordinator, who said that all the nurses helped complete resident care plans. The MDS Coordinator said that she sometimes completed the acute resident care plans but mostly completed the care plans when she completed the residents scheduled assessments such as quarterly and annual assessments. The MDS Coordinator said that she used the RAI manual as the policy, procedure, and guidance for the completion of all care plans. She said that the undated care plan for Resident #45, she provided on 11/30/23 was the most up to date care plan for Resident #45 and was the revised care plan for Resident #45 because it had the revision date on it. The MDS Coordinator did not know why Resident #45 was still care planned for Nectar thick liquids. The MDS Coordinator said she did not know exactly who was supposed to update the information regarding Resident #45's nectar thick liquids and said that the risk to the resident could be that he would not receive the correct liquids to drink. Record review of undated facility policy and procedure titled Comprehensive Assessments and the Care Delivery Process revealed in part: a. Assess the individual. (1). Gather relevant information from multiple sources, including a). Observation .(d). Resident and family interview; (f). Consultant reports; and (h). Evaluations from other disciplines (for example, dietary .

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 9 residents (CR#1) reviewed for incontinent care in that: -The facility failed to document treatment orders for the catheter for CR#1 including the purpose, care, and monitoring. This failure could place residents with urinary catheters at risk for discomfort, trauma, and possibly urinary tract infections. The findings included: Record review of CR #1's face sheet revealed he was 63year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His discharge date was 10/08/2022. Record review of CR #1's discharge summary from a local veterans medical center dated 09/29/2022 revealed that he was admitted on [DATE] for shortness of breath and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He was to be discharged to a skilled nursing facility with additional provider instructions to call urology for follow up since he had a foley catheter placed. Record review of CR #1's physician order summary report dated 09/30/2022 revealed that there were no orders entered addressing residents' treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's baseline care plan dated 09/30/2022 revealed that he was admitted with an indwelling catheter. Record review of CR #1's comprehensive skilled assessment dated [DATE] indicated that resident was admitted with an indwelling catheter. Record review of CR #1's admission progress note entered by LVN A on 09/30/2022 indicated. Record review of CR #'s comprehensive care plan with initial date 09/30/2022 and revisions on 10/03/2022 did not reveal a focus, goal, or intervention addressing residents treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's discharge summary from a local hospital dated 10/04/2022 revealed that he was diagnosed with a CAUTI (Catheter-Linked Urinary Tract Infection) associated with indwelling urethral catheter, initial encounter. A CAUTI was defined as infection of the urinary tract. A CAUTI is caused by bacteria that get into the urinary tract when a urinary catheter is used. Record review of CR #1's Admission MDS assessment dated [DATE] revealed CR #1 was cognitively intake with a BIMS (Brief Interview for Mental Status) score of 14. He was not triggered for an indwelling catheter in section H for Bladder and Bowel. In an interview on 10/26/2022 at 12:10pm with the ADON, she stated that it would be the responsibility of the admitting nurse to ensure that physician orders were entered for newly admitted residents. She stated that the admitting nurse for CR#1 was LVN A. She stated that CR#1 admitted to the facility on [DATE] with a catheter from the a local verterans hospital. She stated that resident was discharged to a local hospital in [NAME] on 10/04/2022 he was diagnosed with a [CONDITION(S)], prescribed antibiotics, and readmitted to the facility on [DATE]. She stated that nursing staff would document that treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that if a resident's catheter did not receive proper treatment the risk could be infection, and resident could be diagnosed with an [CONDITION(S)]. In an interview on 10/26/2022 at 2:00 pm with the DON, she stated that after a review of CR#1's records she could see that he admitted to the facility with catheter. She stated that upon admitting a new resident the admitting nurse is responsible for completing the comprehensive skilled assessment, baseline care plan, admission progress note, admission check list, enter physician orders, and the nurse would review hospital records. She stated that the admitting nurse did not enter physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the staff at the facility document treatment orders on the MAR. She stated that the IDT Team consists of the DON, ADON, and MDS Coordinator, and they share oversite to ensure that a resident's admissions are complete with accuracy. She stated that the risk of not having orders entered for CR#1's catheter treatment could lead to infection. She stated that CR#1 was diagnosed with a [CONDITION(S)] while admitted to the facility. In an interview on 10/26/2022 at 2:05pm with the MDS Coordinator, she stated that it is the responsibility of the admitting nurse to enter physician orders for newly admitted residents. She stated that the IDT Team consists of the DON, ADON, and MDS Coordinator, and they share oversite to ensure that a resident's admissions are complete with accuracy. She stated that the risk of not having orders entered for CR#1's catheter treatment could lead to bleeding and infection. She stated that she was not aware that CR#1 was diagnosed with a [CONDITION(S)] while admitted to the facility. In an interview on 10/26/2022 at 2:30pm with the Administrator, he stated that the oversite for ensuring that newly admitted residents had the appropriate treatment orders is the DON. Record review and interview, completed on 10/27/2022 at 11:00 am, of the nurse shift report/24-hour report that there was an entry for CR#1, dated 09/29/2022, even though his PCC/EMR admission documentation was dated on 09/30/2022 for admission. The ADON, who provided the report, stated that there were no entries in the facility's nurse to nurse shift report/24- hour report for 09/30/2022 or 10/01/2022. She stated that the pages were missing. The ADON, stated that she did not know why the pages were missing or why CR#1 was entered on 09/29/2022. In an interview on 10/27/2022 at 12:00 pm, with the ADON she stated that She stated that the admitting nursing would use the admission check list to once a new resident arrives, and the check list tells the nurse what all needs to be completed after the resident arrives to the facility which would include the physician orders. She stated that within 24 hours of the resident being admitted the ADON is to check the work of the admitting nurse for accuracy. She stated that within 48 hours the IDT completes a secondary review to ensure accuracy of the admitting nurse, which consists of the DON, ADON, and MDS coordinator. She stated that CR#1 was admitted to the facility after hours on Friday,09/30/2022. She stated that she failed to review the work of the LVN A when she returned to the facility on [DATE], and the IDT Team never meet to review the admission of CR#1. She stated that had the IDT Team reviewed the admission of CR#1 it could have been caught LVN A failed to entire treatment orders for the CR#1's catheter. She stated that any nurse that provided treatment to CR#1 should have alert the DON or ADON that there was no place to capture treatment on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 10/27/2022 at 12:34pm with MDS Coordinator, she stated that the IDT Team tries to come together within 24-48 hours after the admission of a new resident to review accuracy. She stated that she does not remember if the IDT Team every meet after the admission of CR#1. In an interview on 10/27/2022 at 12:40pm with the ADON, she stated the admission check list completed by LVN A at the admission of CR#1 could not be located. She stated that the facility does have a standing order for catheter care, LVN A should have entered the standing orders at the time of CR#1's admission and captured it on the Admission Check List under Batched Orders. Interview with the DON on 10/27/2022 12:45pm with the DON, she stated that She stated that the facility does have a standing order for catheter care, and LVN A should have entered the standing orders at the time of CR#1's admission. Record Review of the facility Admission/Discharge Checklist that read in part, .Enter Batched/Fixed Order Sets as indicated: Foley Batch Record review of the facility policy and procedure entitled Urinary Continence and Incontinence-Assessment and Management dated 2021 read in part, .Policy Statement - 1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. Policy Interpretation and Implementation - As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence. Examples of sources of such information may include the resident, family, or a hospital discharge summary describing placement of an indwelling urinary catheter during a recent hospitalization Record review of the facility policy and procedure entitled Catheter Care, Urinary dated 2018 read in part, .The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the residents care plan to assess for any special needs of the resident. Input/Output: 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Documentation: The following information may be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) given the catheter care .

Based on interview and record review, the facility failed to have physician's orders for the resident's immediate care for 1of 9 residents (CR#1) reviewed for admission physician orders. -The facility failed to have physician's orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -This failure could place residents at risk for not receiving appropriate care and urinary infection. Findings included: Record review of CR #1's face sheet revealed he was 63year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His discharge date was 10/08/2022. Record review of CR #1's discharge summary from a local veterans medical center dated 09/29/2022 revealed that he was admitted on [DATE] for shortness of breath and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He was to be discharged to a skilled nursing facility with additional provider instructions to call urology for follow up since he had a foley catheter placed. Record review of CR #1's physician order summary report dated 09/30/2022 revealed that there were no orders entered addressing residents' treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's baseline care plan dated 09/30/2022 revealed that he was admitted with an indwelling catheter. Record review of CR #1's admission progress note entered by LVN A on 09/30/2022 indicated that resided admitted to the facility with foley catheter. Record review of CR #1's comprehensive skilled assessment dated [DATE] that was completed by LVN A indicated that resident was admitted with an indwelling catheter. Record review of CR #'s comprehensive care plan with initial date 09/30/2022 and revisions on 10/03/2022 did not reveal a focus, goal, or intervention addressing residents' treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR#1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's discharge summary from a local hospital dated 10/04/2022 revealed that he was diagnosed with a CAUTI associated with indwelling urethral catheter, initial encounter. A CAUTI was defined as infection of the urinary tract. A CAUTI is caused by bacteria that get into the urinary tract when a urinary catheter is used. Record review of CR #1's Admission MDS assessment dated [DATE] revealed CR #1 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14. He was not triggered for an indwelling catheter in section H for Bladder and Bowel. In an interview on 10/26/2022 at 12:10 pm with the ADON, she stated that it would be the responsibility of the admitting nurse to ensure that physician orders were entered for newly admitted residents. She stated that the admitting nurse for CR#1 was LVN A. She stated that CR#1 admitted to the facility on [DATE] with a catheter from the veterans hospital. She stated the resident was discharged to the hospital on 10/04/2022 and he was diagnosed with a [CONDITION(S)], prescribed antibiotics, and readmitted to the facility on [DATE]. She stated that nursing staff would document that treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that if a resident's catheter did not receive proper treatment the risk could be infection, and the resident could be diagnosed with an [CONDITION(S)]. In an interview on 10/26/2022 at 2:00 pm with the DON, she stated that after a review of CR#1's records, she could see that he admitted to the facility with a catheter. She stated that upon admitting, a new resident the admitting nurse was responsible for completing the comprehensive skilled assessment, baseline care plan, admission progress note, admission check list, entering physician orders, and the nurse would review hospital records. She stated that the admitting nurse did not enter physician orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that staff at the facility documented treatment orders for residents on the MAR. She stated that the Interdisciplinary Team (IDT) consists of the DON, ADON, and MDS Coordinator, and they share oversite to ensure that a resident's admissions are complete with accuracy. She stated that the risk of not having orders entered for CR#1's catheter treatment could lead to infection. She stated that CR#1 was diagnosed with a [CONDITION(S)] while admitted to the facility. In an interview on 10/26/2022 at 2:05 pm with the MDS Coordinator, she stated that it was the responsibility of the admitting nurse to enter physician orders for newly admitted residents. She stated that the IDT consists of the DON, ADON, and MDS Coordinator, and they share oversite to ensure that a resident's admissions are complete with accuracy. She stated that the risk of not having orders entered for CR#1's catheter treatment, could lead to bleeding and infection. She stated that she was not aware that CR#1 was diagnosed with a [CONDITION(S)] while admitted to the facility. In an interview on 10/26/2022 at 2:30 pm with the Administrator, he stated that the oversight for ensuring that newly admitted residents had the appropriate treatment orders was the responsibility of the DON. In an interview on 10/27/2022 at 12:00 pm, with the ADON, she stated that the admitting nursing would use the admission check list once a new resident arrived. She stated the check list tells the nurse what all needs to be completed after the resident arrives to the facility which would include the physician orders. She stated that within 24 hours of the resident being admitted , the ADON is to check the work of the admitting nurse for accuracy. She stated that within 48 hours, the IDT completes a secondary review to ensure accuracy of the admitting nurse, which consists of the DON, ADON, and MDS Coordinator. She stated that CR#1 was admitted to the facility after hours on Friday, 09/30/2022. She stated that she failed to review the work of LVN A when she returned to the facility on [DATE], and the IDT never met to review the admission of CR#1. She stated that had the IDT reviewed the admission of CR#1, it could have been caught that LVN A failed to enter the treatment orders for CR#1's catheter. She stated that any nurse that provided treatment to CR#1 should have alerted the DON or ADON that there was no place to capture the treatment on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 10/27/2022 at 12:34 pm with MDS Coordinator, she stated that the IDT tried to come together within 24-48 hours after the admission of a new resident, to review accuracy. She stated that she does not remember if the IDT ever met after the admission of CR#1. In an interview on 10/27/2022 at 12:40 pm with the ADON, she stated the admission check list completed by LVN A, at the admission of CR#1, could not be located. She stated that the facility had a standing order for catheter care. She stated LVN A should have entered the standing orders at the time of CR#1's admission and captured it on the Admission Check List under Batched Orders. In an interview on 10/27/2022 at 12:45pm with the DON, she stated that the facility had a standing order for catheter care, and LVN A should have entered the standing orders at the time of CR#1's admission. Record review of the facility's Admission/Discharge Checklist read in part, .Enter Batched/Fixed Order Sets as indicated: Foley Batch Record review of the facility's standing order ,dated 09/03/2021, read in part, .Texas Foley Cath Orders, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record every shift, foley catheter, French and balloon size . Record review of facility's policy entitled Medication Orders, dated year 2021 with no year provided, read in part, .The purpose of this process is to establish uniform guidelines in the receiving and recording of medication orders. 2. A current list of orders must be maintained in the clinical record of each resident. 6. Treatment Orders-When recording treatment orders, specify the treatment, frequency and duration of the treatment .

Based on interview and record review, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 8 residents (CR#1) whose assessments were reviewed in that: -CR#1's MDS did not reflect his indwelling catheter -This failure could affect residents at the facility who had been assessed and could contribute to inadequate care. The findings included: Record review of CR #1's face sheet revealed he was 63year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His discharge date was 10/08/2022. Record review of CR #1's discharge summary from a local veterans medical center dated 09/29/2022 revealed that he was admitted on [DATE] for shortness of breath and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He was to be discharged to a skilled nursing facility with additional provider instructions to call urology for follow up since he had a foley catheter placed. Record review of CR #1's baseline care plan dated 09/30/2022 revealed that he was admitted with an indwelling catheter . Record review of CR #1's admission progress note entered by LVN A on 09/30/2022 indicated that resided admitted to the facility with foley catheter. Record review of CR #1's comprehensive skilled assessment dated [DATE] that was completed by LVN A indicated that resident was admitted with an indwelling catheter. Record review of CR #'s comprehensive care plan with initial date 09/30/2022 and revisions on 10/03/2022 did not reveal a focus, goal, or intervention addressing residents' treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's discharge summary from a local hospital dated 10/04/2022 revealed that he was diagnosed with a CAUTI associated with indwelling urethral catheter, initial encounter. A CAUTI was defined as infection of the urinary tract. A CAUTI is caused by bacteria that get into the urinary tract when a urinary catheter is used. Record review of CR #1's Admission MDS assessment dated [DATE] revealed CR #1 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14. He was not triggered for an indwelling catheter in section H for Bladder and Bowel. In an interview on 10/26/2022 at 2:00 pm with the DON she stated that after a review of CR#1's records she could see that he admitted to the facility with a catheter. She stated that CR #1's Admission MDS was not triggered for a catheter, and the care area should have been included on the Admission MDS to give an accurate picture of the residents' care needs. She stated that the MDS Coordinator completed all MDS assessments for residents at the facility. In an interview on 10/26/2022 at 2:05 pm with the MDS Coordinator, she stated that she was responsible for completing the Admission MDS for all residents at the facility. She stated that she was never made aware that CR#1 was admitted to the facility with a catheter, so it was not triggered on the residents Admission MDS. She stated that she is notified of new admissions in the morning meeting following the admission, and she should have been told of CR#1's catheter then. She stated that the risk of the resident not being triggered for a catheter on the Admission MDS could lead to the resident not receiving appropriate care that could cause bleeding an infection. In an interview on 10/27/2022 at 12:24pm with the MDS Coordinator, she stated that she used the RAI manual when completing the Admissions MDS. She stated that she was not able to physically go to the resident's room to complete a physical assessment of residents as stated in section H of the RAI. She stated that she used staff interviews and clinical records obtained at admission to complete section H for newly admitted residents. She stated that she used the baseline care plan/assessment, admission progress notes, hospital records, and the admission check sheet to assist in completing the MDS. She stated that she missed the information provided when reviewing the documents that stated that CR#1 had a catheter. She stated that she could not remember the interviews with staff she completed to complete section H of the MDS. She stated that if she had gone to the room of CR#1, she would have been able to see that he had a catheter upon admission. Record review of policy entitled Resident Assessment Instrument dated September 2010 read in part, .A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the residents to reach his/her highest practicable level of functioning . Record review of CMS RAI 3.0 User's Manual dated October 2019 read in part, .Section H: Bladder and Bowel Planning for Care - Care planning should include interventions that are consistent with the resident's goals and minimize complications associated with appliance use. Care planning should be based on an assessment and evaluation of the resident's history, physical examination, physician orders, progress notes, nurses' notes and flow sheets, pharmacy and lab reports, voiding history, resident's overall condition, risk factors and information about the resident's continence status, catheter status, environmental factors related to continence programs, and the resident's response to catheter/continence services. Steps for Assessment - 1. Examine the resident to note the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 8 residents (CR#1) reviewed for comprehensive person-centered care plans. -The facility failed to develop and implement a care plan for CR#1 for the care area of Bladder and Bowel. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings Include: Record review of CR #1's face sheet revealed he was 63year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His discharge date was 10/08/2022. Record review of CR #1's discharge summary from a local veterans medical center dated 09/29/2022 revealed that he was admitted on [DATE] for shortness of breath and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He was to be discharged to a skilled nursing facility with additional provider instructions to call urology for follow up since he had a foley catheter placed. Record review of CR #1's comprehensive care plan, with initial date 09/30/2022 and a revision date of 10/03/2022, did not reveal a focus, goal, or intervention addressing resident's treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's baseline care plan, dated 09/30/2022, revealed that he was admitted with an indwelling catheter. Record review of CR #1's admission progress note entered by LVN A on 09/30/2022 indicated CR#1 admitted to the facility with a foley catheter. Record review of CR #1's comprehensive skilled assessment, dated 09/30/2022 and completed by LVN#1, indicated that the resident was admitted with an indwelling catheter. Record review of CR #1's physician order summary report, dated 09/30/2022, revealed there were no orders entered, addressing residents' treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's discharge summary from a local hospital dated 10/04/2022 revealed that he was diagnosed with a CAUTI associated with indwelling urethral catheter, initial encounter. A CAUTI was defined as infection of the urinary tract. A CAUTI is caused by bacteria that get into the urinary tract when a urinary catheter is used. Record review of CR #1's admission MDS assessment, dated 10/06/2022, revealed CR#1 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14. He did not triggered for an indwelling catheter In an interview on 10/26/2022 at 2:00 pm with the DON, she stated that after a review of CR#1's records she could see that he admitted to the facility with a catheter. She stated that CR #1's admission MDS was not triggered for a catheter, and the focus should have been included on the care plan to give an accurate picture of the residents' care needs. She stated that the MDS Coordinator completed all comprehensive care plans for residents at the facility. In an interview on 10/26/2022 at 2:05pm with the MDS Coordinator, she stated that she was responsible for completing the comprehensive care plans for all residents at the facility. She stated that she was never made aware that CR#1 was admitted to the facility with a catheter. So it was not triggered on the residents admission MDS which resulted in the care plan not having a focus for catheters. She stated that she was notified of new admissions in the morning meeting following the admission, and she should have been told of CR#1's catheter then. She stated that the risk of the resident not having an accurate comprehensive care plan related to his catheter could lead to the resident not receiving appropriate care that could cause bleeding and infection. In an interview on 10/27/2022 at 12:24pm with the MDS Coordinator, she stated that she was not able to physically go to residents' room to assess them, and she relied on interviews with staff when completing care plans. She stated that she could not remember what staff she interviewed after CR#1 was admitted . She stated that she used the baseline care plan/assessment, admission progress notes, hospital records, and the admission check sheet to assist in completing the MDS. She stated that she missed the information provided when reviewing the documents that stated that CR#1 had a catheter. Record review of the facility policy and procedure entitled Care Plans, Comprehensive Person-Centered dated December 2016 read in part, .A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will a. include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the r resident's highest practicable physical, mental, and psychosocial well-being;

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen storage and sanitation in that: Cook D used the facility phone 3 times during meal service without washing her hands afterwards. This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness. The findings were: Observation on 09/22/2022 at 11:52 a.m. revealed Cook D was plating food for the residents for lunch. Observation revealed after she placed the food on a plate, she would place the plates on trays which were on a cart used to deliver the food to each hall. When the cart was completed, the kitchen staff would notify staff per facility phone in the kitchen that their carts were ready to be retrieved. Observation on 09/22/2022 at 11:56 a.m. revealed Cook D realized the staff had not retrieved the cart so she used the facility phone in the kitchen to notify the staff over the intercom the cart was ready, and then returned to the steam table to plate food without washing her hands. Observation on 09/22/2022 at 12:04 p.m. revealed Cook D had completed plating food for the 2nd cart. The cook then used the facility phone and called over the intercom to notify staff the next cart was ready. The cook then returned to the steam table to plate food without washing her hands. Observation on 09/22/2022 at 12:21 revealed Cook D had completed plating food for the 3rd cart. The cook then used the facility phone and called over the intercom to notify staff the next cart was ready. The cook then returned to the steam table to begin cleaning the steam table. Interview on 09/22/2022 at 03:31 p.m. with the Food Service Supervisor, after the surveyor notified the Supervisor the cook had not washed her hands between meals, revealed she spoke to Cook D who reported she was nervous and that cook knows she should wash her hands between tasks. Interview on 09/23/2022 at 10:40 a.m. with Cook D she revealed she had made a mistake by not washing her hands between tasks and that she knows she was supposed to. Review of an in-service dated 09/22/2022, no time noted, presented by the Food Service Supervisor revealed, Practicing hand hygiene is an effective way to prevent infections and Always wash your hands when: changing gloves, after bathroom use, after leaving the service line, touching face/body, touching trash, etc. Review of the facility policy, Food Preparation and Service, under the heading, Food Preparation Area, revised October 2017 revealed, 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.

Based on observations, interviews and record reviews the facility failed to have an accurate MDS assessment for 3 residents (#26, #50 and #54) out of 24 residents reviewed for accurate MDS assessments in that: 1. The facility did not have Resident #26's pacemaker coded on the MDS. 2. The facility did not have Resident #50's pacemaker coded on the MDS. 3. The facility active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice could affect residents who required assessments at the facility and result in resident needs not being met. The findings were: 1. Review of Resident #26's face sheet dated 9/26/2022 revealed he was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease with heart failure, [CONDITION(S)] (paralysis on one side of the body) and [CONDITION(S)] (mild weakness or loss of strength to one side of the body) following cerebral infarction (a disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, [CONDITION(S)] (a condition in which there are high levels of fat particles/lipids in the blood) and presence of automatic (implantable) cardiac defibrillator (a device that sends an electric pulse or shock to the heart to restore a normal heart beat). Review of the Quarterly MDS dated [DATE] revealed there was no diagnoses for pacemaker on the MDS. Review of Resident #26's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an undated list of residents that had pacemakers, provided by the facility, revealed Resident #26 had a pacemaker. Interview on 9/23/2022 at 12:22 p.m. with Resident #26 he confirmed he had a pacemaker, reported he has had it for a while and that he was seeing his physician for follow up in coming weeks. Interview on 9/23/2022 at 12:06 p.m. with the MDS Coordinator she reported she should have documented the pacemaker on the MDS. She reported, I have no answer why it did not get documented on the MDS. 2. Review of Resident #50's face sheet dated 9/21/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included chronic [CONDITION(S)] (an irregular, often rapid heart rate that commonly causes poor blood flow), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and chronic respiratory failure with [CONDITION(S)] (a condition where there is not enough oxygen in the blood but carbon [MEDICATION(S)] levels are close to normal). Review of resident #50's MDS dated [DATE] revealed there was no pacemaker listed in the resident's diagnoses. Review of an undated list of residents that had pacemakers, provided by the facility, revealed Resident #50 had a pacemaker. Interview on 9/23/2022 at 12:48 p.m. with Resident #50 revealed he had a pacemaker. The resident reported he had the pacemaker for 4 or 5 years. Review of Resident #50's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 9/23/2022 at 11:56 a.m. with the MDS Coordinator she reported she usually uploaded the resident's diagnoses in the resident's electronic record. The MDS Coordinator reported because she missed putting the pacemaker as a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator reported she was usually told in the department head morning meeting if a resident had a pacemaker. In an interview on 9/23/2022 at 1:23 p.m. with the DON she reported pacemakers should be coded on the MDS. The DON reported they discuss which resident's had pacemakers in their morning meetings. 3. Review of Resident #54's electronic face sheet dated 09/23/2022 revealed he was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (high blood pressure and dysfunction of the heart), depression (mood disorder), [CONDITION(S)] heart disease (plaque buildup in heart arteries), peripheral vascular disease (blood flow impairment of extremities) and arthritis (inflammation of joints causing pain). Review of Resident #54's Admission MDS assessment dated [DATE] revealed under Section I - Active Diagnoses that he did not have section . Heart Failure (e.g., congestive heart failure (CHF) ) checked off as a diagnosis. He scored a 14/15 on his BIMS which indicated he was cognitively intact and he could understand and be understood. Review of Resident #54's comprehensive care plan which was completed in place of the baseline dated 08/24/2022 revealed he did not have heart failure or cardiac issues addressed. His care plan reflected he wished to be treated as a full code for advanced directives. Review of Resident #54's Order Summary Report .Active Orders As Of: 09/23/2022 revealed he was ordered [MEDICATION(S)] (diuretic) Tablet 40 MG, give one tablet by mouth two times a day for CHF. Observation on 09/23/2022 at 1:30 p.m. of Resident #54 revealed he was sitting in the hallway in his wheelchair. Interview on 09/23/2022 at 1:30 p.m. with Resident #54 revealed he had a cardiac pacemaker a few months earlier related to heart failure. He stated that he had an appointment to get another one in October 2022. Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #54's heart failure was not coded on his Admission MDS assessment. She stated that with the medications he was on, and his diagnosis, heart failure needed to be coded. She stated it was important to have accurately coded MDS's because it was a reflection of the care required for the resident and triggered areas for the care plan. Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #54's heart failure needed to be coded on his Admission MDS, and that staff was not aware that he had a pacemaker until they caught him going out to an appointment. She stated his medications and history should have provided them with the information to ensure the MDS was coded accurately, but it was missed, and that impacted his care plan and focused area's for needs being met. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident ' s status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.

Based on observations, interviews and record reviews, the facility failed to develop and implement a baseline care plan for 3 (Resident's #54, #110 and #113) out of 3 residents reviewed for baseline care plans in that: 1. Resident #54's heart failure and cardiac issues were not addressed in his baseline care plan. 2. Resident #110's code status was not addressed in his baseline care plan. 3. Resident #113's code status was not addressed in her baseline care plan. This deficient practice could affect newly admitted residents and could result in inaccurate care provided. The findings were: 1. Review of Resident #54's electronic face sheet dated 09/23/2022 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's Admission MDS assessment dated [DATE] revealed under Section I - Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He scored a 14/15 on his BIMS which indicated he was cognitively intact and he could understand and be understood. Review of Resident #54's baseline care plan dated 08/24/2022 revealed he did not have cardiac issues addressed. His care plan reflected he wished to be treated as a full code for advanced directives. Review of Resident #54's Order Summary Report .Active Orders As Of: 09/23/2022 revealed he was ordered Aspirin Tablet Chewable 81 MG (blood thinner for cardiac issues) give one tablet daily order start dated 08/24/2022, [MEDICATION(S)] Tablet 75 MG (blood clot prevention) give one tablet by mouth one time a day .start date 08/24/2022 and [MEDICATION(S)] (diuretic) Tablet 40 MG, give one tablet by mouth two times a day for CHF. Observation on 09/23/2022 at 1:30 p.m. of Resident #54 revealed he was sitting in the hallway in his wheelchair. Interview on 09/23/2022 at 1:30 p.m. with Resident #54 revealed he had a cardiac pacemaker a few months earlier related to heart failure. He stated that he had an appointment to get another one in October 2022. Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #54's heart conditions were not on his baseline care plan and they needed to be to show the care he required. Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #54's heart conditions needed to be on his baseline care plan, and stated his medications and history should have provided them with the information to ensure the baseline care plan was accurate, but his cardiac issues were missed, and that could impact his medical needs from being met. 2. Review of Resident #110's electronic face sheet dated 09/22/2022 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #110's 48 HOUR INITIAL CARE PLAN dated 09/20/2022 only addressed his risk for falls, altered skin integrity and self care deficit and did not reflect his full code status. Review of Resident #110's Order Summary Report .Active Orders As Of 09/23/2022 revealed Resident #110 was ordered to have full code status with a start date of 09/19/2022. Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #110's full code status was not on his baseline care plan and they needed to be to show what he wished for advance directives. Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #110's full code status should have been on his baseline care plan, and stated his medications and history should have provided them with the information to ensure the baseline care plan was accurate. 3. Review of Resident #113's electronic face sheet dated 09/22/2022 revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #113's 48 HOUR INITIAL CARE PLAN dated 09/17/2022 only addressed her risk for falls and self care deficit and did not reflect her full code status. Review of Resident #113's Order Summary Report .Active Orders As Of 09/23/2022 with a start date of 09/15/2022 revealed Resident #113 was ordered to have full code status. Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #113's full code status was not on her baseline care plan and they needed to be to show what she wished for advance directives. Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #113's full code status should have been on her baseline care plan, and stated her medications and history should have provided them with the information to ensure the baseline care plan was accurate. Review of the facility policy and procedure titled Care Plans - Baseline revised December 2016 revealed 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate needs including but not limited to: a. initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights for 3 residents (Resident #21, Resident #35 and Resident #48) of 8 residents reviewed for comprehensive care plans in that: 1. Resident #35's 1/2 side rails were not reflected on her comprehensive plan of care. 2. Facility failed to ensure Resident #48's comprehensive care plan addressed her pace maker. 3. Resident #54's comprehensive care plan did not reflect his heart failure or cardiac status. This deficient practice could affect residents with person-centered comprehensive care plans and could result in missed care required. The findings were: 1. Review of Resident #35's electronic face sheet dated 09/22/2022 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's Admission MDS assessment dated [DATE] revealed she scored a 9/15 on her BIMS which indicated she was moderately cognitively impaired and was understood and was able to usually understand and required extensive assistance with her ADL's. Review of Resident #35's comprehensive care plan dated 08/17/2022 revealed she had impaired physical mobility r/t end stage disease, but the interventions did not reflect she had a 1/2 side bed rail on both sides of her bed. Observation on 09/19/22 at 10:45 a.m. revealed Resident #35 was lying in bed with 1/2 length siderails up X 2. Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #35's 1/2 length bed rails was not on her person-centered comprehensive care plan and it should have been because that was a part of her care. Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #35's 1/2 length side rails should have been noted on her person-centered comprehensive plan of care because it was an enabler for her if she used them for mobility. 2. Record review of Resident #48's face sheet, dated 09/21/2022, revealed she was readmitted to the facility on [DATE] (original admission on 04/13/2019) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #48's care plan revised on 07/26/2022 revealed it did not have cardiac issues nor the use of a pacemaker addressed. Record review of Resident #48's Annual MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment, and additional active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident#48's physician order summary dated 09/23/2022 revealed the following order [MEDICATION(S)] tablet 75mg give 1 tablet by mouth one time a day for prevent heart attack. During an interview on 09/23/2022 at 11:32 a.m. MDS coordinator stated Resident #48 had what they call a watch man, and it was like a defibrillator. MDS coordinator further stated it should be checked regularly and Resident #48 had a box in her room which notified the cardiologist of any unusual readings. MDS coordinator stated Resident #48 did not have a care plan for the pacemaker (watch man) and a pacemaker was an item she would typically care plan. MDS coordinator further stated she had thought the care plan had been done. During an interview on 09/23/2022 at 1:21 p.m. the DON stated the pacemaker should be listed on the care plan in order for staff to know what was going on with the resident. DON further stated the more the staff know about a resident the more accurate the care for the resident would be. 3. Review of Resident #54's electronic face sheet dated 09/23/2022 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's comprehensive care plan dated 08/24/2022 revealed he did not have heart failure or cardiac issues addressed. His care plan reflected he wished to be treated as a full code for advanced directives. His care plan further addressed nutritional needs, psychosocial well-being, falls, impaired mobility, altered skin integrity and urinary catheter, Review of Resident #54's Admission MDS assessment dated [DATE] revealed under Section I - Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Heart Failure (e.g., congestive heart failure (CHF) ) coded as a diagnosis. He did have coronary artery disease, hypertension and peripheral vascular disease coded. He scored a 14/15 on his BIMS which indicated he was cognitively intact and he could understand and be understood. Review of Resident #54's Order Summary Report .Active Orders As Of: 09/23/2022 revealed he was ordered Aspirin Tablet Chewable 81 MG (blood thinner for cardiac issues) give one tablet daily order start dated 08/24/2022, [MEDICATION(S)] Tablet 75 MG (blood clot prevention) give one tablet by mouth one time a day .start date 08/24/2022 and [MEDICATION(S)] (diuretic) Tablet 40 MG, give one tablet by mouth two times a day for CHF. Observation on 09/23/2022 at 1:30 p.m. of Resident #54 revealed he was sitting in the hallway in his wheelchair. Interview on 09/23/2022 at 1:30 p.m. with Resident #54 revealed he had a cardiac pacemaker a few months earlier related to heart failure. He stated that he had an appointment to get another one in October 2022. Interview on 09/23/2022 at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #54's heart failure was not coded on his Admission MDS assessment. She stated that with the medications he was on, and his diagnosis, heart failure needed to be coded. She stated it was important to have accurately coded MDS's because it was a reflection of the care required for the resident and triggered areas for the care plan. She stated that Resident #54's Admission MDS assessment should have been revised to address his cardiac issues. Interview on 09/23/2022 at 2:10 p.m. with the DON revealed that Resident #54's heart failure needed to be coded on his Admission MDS, and that staff was not aware that he had a pacemaker until they caught him going out to an appointment. She stated his medications and history should have provided them with the information to ensure the MDS was coded accurately and his care plan to be revised to show his cardiac issues, but it was missed. Review of the facility policy and procedure titled Proper Use of Side Rails (undated) revealed An assessment will be made to determine the residents symptom's, risk of entrapment and reason for using side rails. When used for mobility, and assessment will include a review of the resident's: bed mobility, ability to change positions .risk of entrapment, bed's dimensions are appropriate for the resident's size and weight. The use of side rails as an assistive device will be addressed in the resident care plan. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered revised date December 2016 revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .the comprehensive, person-centered care plan is developed within 7 days of the completion of the required comprehensive assessment (MDS).

Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 4 residents (#21, #31, #44, #48) out of 20 residents reviewed for comprehensive care plan revision in that: 1. Facility failed to ensure Resident #21's comprehensive care plan was revised after her Significant Change MDS assessment to reflect here DNR status. 2. Facility failed to ensure Resident #31's comprehensive care plan was revised to address the change in code status from DNR (Do Not Resuscitate) to Full code. 3. Facility failed to ensure Resident #44's comprehensive care plan was revised to address the change in code status from Full code to DNR (Do Not Resuscitate). 4. Facility failed to ensure Resident #48's comprehensive care plan was revised to address the change in code status from Full code to DNR (Do Not Resuscitate). The findings were: 1. Review of Resident #21's electronic face sheet revealed she was admitted to the facility on [DATE] after being in the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's Significant Change MDS assessment dated [DATE] revealed she scored a ,d+[DATE] on her BIMS which indicated she was cognitively intact. She required extensive assistance with her ADL's. Review of Resident #21's person-centered comprehensive care plan dated [DATE] revealed is a full code. Review of Resident #21's Order Summary Report .Active Orders As Of: [DATE] revealed she had no code status ordered. Review of Resident #21's Nurse Practitioner progress note dated [DATE] revealed the resident was DNR status. Review of Resident #21's OOH DNR order revealed it was signed on [DATE]. Observation on [DATE] at 1:10 p.m. Resident #21 revealed she was lying in bed. Interview on [DATE] at 1:11 p.m. with Resident #21 revealed Right now I would say I'm a DNR. The facility already knows I'm a DNR, I don't want CPR because they break your chest and put you on a ventilator. I know because I was a Respiratory Therapist. Interview on [DATE] at 2:00 p.m. with the MDS nurse revealed that she was out sick with COVID-19 for awhile and that she did not know why Resident #21's DNR status was not on her person-centered comprehensive care plan and it should have been revised after her Significant Change MDS assesmeent because that was a part of her wishes. Interview on [DATE] at 2:10 p.m. with the DON revealed that Resident #21's DNR status should have been in her physician orders and her comprehensive person-centered care plan revised when she returned from the hospital. She stated it slipped through the cracks and was missed. 2. Record review of Resident #31's face sheet, dated [DATE], revealed she was readmitted to the facility on [DATE] (original admission on [DATE]) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #31's Significant Change MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated intact cognition. Record review of Resident#31's physician order summary dated [DATE] revealed the following order Code Status: Full Code with an order date of [DATE]. Record review of Resident #31's care plan printed [DATE] revealed had not been revised to reflect Resident #31's Full Code status. Care plan further revealed Focus: Code Status: Do Not Resuscitate . Interventions/Task: Code status will be reviewed with change of condition and at least quarterly. Record review of Resident #31's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 2:07 p.m. Resident #31 stated she did want CPR (cardiopulmonary resuscitation) and no longer wanted her DNR in place. Resident #31 further stated she had wanted her DNR retracted. During an interview on [DATE] at 11:02 a.m. SW coordinator stated Resident #31 had voiced the desire to revoke her Texas OOHDNR and change code status to full code. SW coordinator further stated the care plan had not been revised with her request for resuscitation. SW coordinator stated it should have been revised and the MDS coordinator was responsible for the revision of care plans. SW coordinator further stated the MDS coordinator is informed during care plans and when the SW coordinator receives the request from a resident. During an interview on [DATE] at 11:22 a.m. MDS coordinator stated she was responsible for the revision of the code status care plans. MDS coordinator further stated they would try to do this when they spoke with the resident or the family/RP. MDS coordinator stated she would write down what was discussed in the care plan then go back to her computer to change the care plan. MDS coordinator further stated the SW coordinator would inform her sometimes and it would also be discussed in the facility morning meetings. MDS coordinator stated Resident #31's care plan had not been revised to reflect Full Code status for resuscitation. 3. Review of Resident #44's face sheet dated [DATE] revealed he was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's [DATE] Consolidated Physician Orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's Care Conference Summary dated [DATE] revealed a Social Services note revealed an Out of Hospital DNR had been signed and awaiting physician signature. Review of Resident #44's care plan date initiated [DATE] revealed the resident was a full code. In an interview on [DATE] at 11:10 a.m. with the Social Work Coordinator revealed she discussed code status with the resident and/or families during the care plan conference. The Social Work Coordinator reported the MDS Coordinator revised the care plans when there was a change in code status. In an interview on [DATE] at 11:24 a.m. with the MDS Coordinator revealed generally the Social Work Coordinator informs her at the morning meeting if a resident's code status had changed. The MDS Coordinator reported when care plan meetings were held quarterly they review the resident's code status. She reported she had no idea how she missed the resident changed the code status to DNR. In an interview on [DATE] at 1:02 p.m. with the DON reported it was necessary for the resident's code status to be accurate on the care plan because if the nurse was not able to locate a resident's code status the care plan was another option to review what the resident's code status was. 4. Record review of Resident #48's face sheet, dated [DATE], revealed she was readmitted to the facility on [DATE] (original admission on [DATE]) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #48's Annual MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment. Record review of Resident#48's physician order summary dated [DATE] revealed the following order Code Status: DNR/DNI with an order date of [DATE]. Record review of Resident #48's Texas Out of Hospital DNR (form instructs emergency medical personnel and other health care professionals to forgo resuscitation attempts) revealed signed and completed on [DATE]. Record review of Resident #48's care plan printed [DATE] revealed had not been revised to reflect Resident #48 DNR code status. Care plan further revealed Focus: code status: Full code .Interventions/Task: review code status with each care plan meeting and change of condition with a revision date of [DATE]. Record review of Resident #48's Care Plan Conference Summary dated [DATE] revealed, Discussed resident's code status resident and family requested to remain under DNR status. During an interview on [DATE] at 10:46 a.m. SW coordinator stated she would complete her section of the care plan summary, by discussing a resident's code status with the resident or the family/RP during a care plan meeting. SW coordinator further stated the MDS coordinator was responsible for the completion of the code status care plan and the revision. Revision usually would occur when the code status is discussed in the care plan meeting or once a Texas OOHDNR (out of hospital do not resuscitate) form was completed. SW coordinator stated she would inform the MDS coordinator of any changes. During an interview on [DATE] at 11:22 a.m. MDS coordinator stated she was responsible for the revision of the code status care plans. MDS coordinator further stated they would try to do this when they spoke with the resident or the family/RP. MDS coordinator stated she would write down what was discussed in the care plan then go back to her computer to change the care plan. MDS coordinator further stated the SW coordinator would inform her sometimes and it would also be discussed in the facility morning meetings. MDS coordinator stated Resident #48's care plan had not been revised to reflect the DNR code status. During an interview on [DATE] at 12:56 p.m. the DON stated MDS coordinator is responsible for the writing of the care plans and care plans were necessary to have a resident's code status (lets the patient's medical team know what they want and do not want in the event of a medical emergency such as their heart stopping). The DON further stated the care plan being revised was important so staff can identify the care the resident requires and for the continuity of care. Review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered revised [DATE] revealed 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change .14. The Interdisciplinary Team must review and update the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly in conjunction with the MDS assessment.

Based on observation, interview, and record review the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for 1 of 1 meal (dinner) observed, in that: Cook D pureed egg salad and macaroni salad with water for the lunch meal on 09/21/22, diluting the nutritive value. This failure could place residents who receive pureed meals from the kitchen at risk for malnutrition and/or weight loss due to decreased nutritive value of the food. The findings were: Observation on 09/21/2022 at 11:06 a.m. Cook D was preparing the pureed food for lunch. Cook D put 4 large scoops of egg salad into mixer and blended the mixture. While the food was blending the cook added 13 teaspoons of water to the egg salad in the mixer. When the food was blended to desired consistency the cook poured the puree egg salad into a small metal pan. Observation on 9/21/2020 at 11:15 a.m. Cook D put 4 large scoops of macaroni salad into the mixer. Cook D then slowly added 25 teaspoons of water to the macaroni salad while it blended. When the food was blended to desired consistency the cook poured the macaroni salad into a small metal pan. Interview on 9/21/22 at 11:25 am. with Cook D and the Food Service Supervisor the cook revealed sometimes the cook adds broth or milk to puree the food, depending on what the cook was preparing. The cook reported there was no specific reason why she chose to use water to add to the pureed food to reach the proper consistency. When discussed using water to puree the foods, Cook D and the Food Service Supervisor reported they did not realize the food was losing some of its nutritive value. Review of the Corporate Recipe, #4809, Egg Salad provided by the facility did not specify what type of fluid to add when purifying the egg salad, revealing, Add liquid if product needs thinning. The Food Service Supervisor provided a copy of the recipe for macaroni salad but reported there were no instructions on how to prepare the macaroni salad.

Based on interview and record review, the facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents.for 1 of 8 residents (CR #1) reviewed for free of accident, hazards, supervision and devices. -The facility failed to ensure CNA B used 2 staff during the transfer of CR #1 which resulted in a acute left [CONDITION(S)] and acute left femur fracture. This failure could affect residents who need assistance with transfers and place them at risk for injury and diminished quality of life. Findings: Record review of the face sheet for CR #1 revealed he was a [AGE] year old male. He was admitted to the facility on [DATE]. His diagnoses included flaccid [CONDITION(S)] affecting left dominant side, abnormal posture, muscle weakness, chronic pain, muscle spasm, lack of coordination, contracture of left hand, [CONDITION(S)], coronary angioplasty status, type 2 diabetes mellitus, severe protein-calorie malnutrition, lesion of sciatic nerve, facial nerve disorder, [CONDITION(S)] obstruction, post-traumatic stress disorder, [CONDITION(S)], sensorineural hearing loss, [CONDITION(S)], benign neoplasm of adrenal gland, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], [CONDITION(S)], anxiety disorder, [CONDITION(S)], and major depressive disorder. Record Review of the Quarterly Minimum Data Set (MDS) for CR #1, dated 05/12/2020, revealed a BIMS score 4 of 15 which indicated he had severe impairment of cognitive skills for daily decision making. He required supervision with setup for eating, total dependence for bathing, extensive assistance for all other ADLs, and a two-person assist for transfers. CR #1 had functional impairment in range of motion on one side of both upper and lower extremities and required a wheelchair for mobility. CR #1 was incontinent of bladder and frequently incontinent of bowel. Record review of the Comprehensive Care Plan for CR #1 read, in part, .potential for self-care deficit r/t immobility; At risk for injuries r/t recent history of falls; Instruct to call for assist with transfers; Monitor for side effects from medications, abnormal lab results, appetite as cause for falls; Impaired physical mobility R/T [CONDITION(S)], contractures, as manifested by limited muscle strength and pain with mobility; Reduce further contraction. Assess Pain; assist with transfers with 2 care givers . Record Review of Facility 5-day intake report, read, in part, . resident has hx of verbal aggression. On 03/6/2020, CR #1 was being assisted in shower by CNA B. CR #1 reported to nursing staff that he was being transferred from the shower chair to his wheelchair and slipped and fell to the floor at which time he experienced pain in his left hip. Swelling and tightness was noted to resident's left hip. After notifying resident's attending physician, receiving [MEDICATION(S)] for pain, physician ordered x-ray which showed fractured left hip. Physician ordered resident to be transferred to (outside hospital) for care. CNA B denied that resident hit the floor and therefore did not report the incident to charge nurse. CR #1 reported he had never been abused by CNA B or any other person. CNA B was suspended during investigation. All staff underwent in-services on abuse and neglect; CNA B underwent training with PT on safe transferring of residents . On 6/2/21 at 4:00pm, attempted to complete a telephone interview with CNA B. The number was not in working order. During an interview on 06/2/2021 at 4:12 pm with the Administrator, he stated he was not the Administrator during the period of occurrence. He said he had no information he could provide regarding what occurred. He reported that if a resident's MDS assessment and care plan assessment revealed that he or she required the assistance of two people for any ADL that two people should be present for that ADL, regardless of what the staff member felt their qualifications were. He said each staff member should review the resident's orders and care plan prior to providing care and follow the guidelines of the care plan always. Record review of Nurse's Notes for CR #1 dated 03/06/20 - 03/07/20 written by RN W read in part, .03/06/20 5:07 pm CNA C reports resident is having pain and needs nurse to evaluate resident in bed with L leg exposed. Skin L knee tight and shiny, L thigh muscle firm to touch. Resident c/o L hip and knee pain 10/10 states I fell in the shower resident asked if they fell before or after transfer from wheelchair to shower chair or shower chair to w/c, states after shower resident asked who gave you a shower? states I don't know asked resident what did she look like? responds with black, states it hurts, it hurts. Informed resident that physician will be called. In bed, CNA present performing brief change. Call light in reach. 03/06/20 5:10 pm FNP notified of reported fall by resident. N/O [MEDICATION(S)] x1 dose now for pain and xray of left hip, femur, knee, tibfib-foot 2 (view) STAT. Mobile x-ray called and confirmed stat order. RP notified of fall and new orders. 03/06/20 10pm On call physician given report on x-ray results acute left [CONDITION(S)], acute left femur fracture, N/O received to send resident to ER and set u transportation that will be there within the hour r/t residents stable vs. Note at 10:30 pm revealed that report was called the outside hospital ER, 10:50 note revealed transportation arrived and resident was transferred from bed to stretcher and left via the emergency transport . Record review of CNA B's written statement, dated 3/8/20, regarding CR #1's fall and subsequent injury read in part, .It is very normal to hear CR #1 say he is in pain. She further reported that she put baby oil on the resident's legs for moisturizer and pushed CR #1 up to the bar to stand. With him not being a 2 person transfer, I stood him up using the bar. In the mist of me pulling his shorts up his knees buckled hitting the wall. I was able to catch him on the way down and stand him back up right for positioning. On the pivot I lost traction and CR #1's feet slid right from under us with the wall breaking the fall. I was at an awkard [sic] position and unable to sit CR #1 properly in char with his hand still on the bar. I lowered him to the floor readjusted and put him in chair. It was out of reaction to get him in the chair. Overlooking his body seeing no visable [NAME] [sic] nor tears I asked CR #1 was he ok. On the way back to his room with no outburst I proceded [sic] to lay him down and l et the med aid know he would like some pain meds. And proceded [sic] with showers. Threw out the day I checked on CR #1 him being sound asleep and not wanted to attend lunch is very normal. He only asked to cover his feet. The nurses have informed me before unless someone out right falls and there are no known tears there is know judgement I love my job and residents and would never do anything to knowing to hurt them . Record review of facility's policy titled Falls and Fall Risk, Managing, dated Qtr. 3, 2018, reads in part, .According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g. a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . Record review of facility's policy titled Accidents/Incidents/Events - Investigating and Reporting, dated Qtr. 3 2018 read in part, .All accidents and incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator . Record review of facility's policy titled, Care Plans, Comprehensive Person-Centered, dated Qtr. 3, 2018, reads, in part, .8. The 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; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; l. Identify the professional services that are responsible for each element of care; m. aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and o. Reflect currently recognized standards of practice for problem areas and conditions .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of six residents (CR #1) reviewed for accidents and hazards, in that: CR #1 was at risk for falls based on fall risk assessments and behavior of hanging her legs of the side of bed while sleeping. CR #1's fall risk behavior was not communicated to appropriate staff to develop interventions to prevent falls and injury. CR #1 rolled out of her bed in her sleep and fell to the floor which resulted to a laceration to her head and transfer to the hospital where she was diagnosed with [REDACTED]. This failure placed residents at risk of pain, hospitalization and serious injury. Findings included: CR #1 Record review of CR #1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's significant change MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Further review of the MDS revealed she required extensive assistance with transferring, bed mobility, dressing, toilet use and personal hygiene. The resident was listed to be incontinent of bowel and bladder and used a wheel chair. Further review of the MDS revealed the resident had no fall history and was listed to have not taken anticoagulant medications with the last 7 days. Record review of CR #1's undated care plan (later identified to be dated 11/23/20) revealed she was at risk for injury related to falls as evidenced by fall with laceration, resident throws legs of edge of bed. The interventions included: rule out medical complications [REDACTED]. Periodic medication review. Ensure safe environment, free of clutter, adequate light, clean spills promptly. Ensure appropriate specialty/air mattress settings. Neuro checks per facility protocol for any/suspected head injury. Attempt to identify root cause for falls. When in bed keep resident away from edge of bed. Fall assessment on admission, quarterly and with changes or falls. Ensure appropriate footwear when out of bed. Call bell within reach. Provide adequate lighting. Clean and apply glasses daily as appropriate, PT eval/treatment as indicated. Further review of the care plan revealed no mention of use of anticoagulant medication [MEDICATION NAME] and risks associated. Interview on 11/23/20 at 2:00PM, MDS Nurse said she just developed the care plan area for fall risk for CR #1 today (11/23/20) and she did not have anything previously on her care plan about falls because she had not fallen before. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's fall risk assessments dated 11/19/18, 2/6/19, and 6/2/20 revealed she was a high risk for falls. Record review of CR #1's incident report dated 1/28/20 revealed residents leg gave out during transfer and she had to be lowered to the floor. Report said the facility would in the future transfer the resident with 2 people when she was fatigue. Record review of CR #1's incident report dated 11/21/20 at 12:51AM revealed she had a fall with injury. A CNA (CNA #1) was noted to be walking down the hall and noticed CR #1 was on the floor. She went into the room and found CR #1 laying on the floor wrapped in her blanket with a pool of blood under her head. CNA called for the nurse who immediately then called 911 and did not move resident until the EMTs arrived. There was a laceration noted on the right side of her head that appeared to be 7cm to 8cm before pressure dressing was applied. Resident was transferred to the hospital in ambulance. Record review of CR #1 investigation report conducted by the DON dated 11/23/20 revealed on 11/21/20 at approximately 12:15AM, CR #1 was observed on the floor next to her bed as a CNA was making routine rounds. The nurse (RN #1) was summoned to the room by the CNA (CNA #1) where she was immediately assessed, and a laceration was noted to the right side of her head, the wound was then cleaned and dressed. She was transferred to the hospital with a [DIAGNOSES REDACTED]. She initially was admitted to the ICU and then transferred to a lower level of care. Interview on 11/23/20 at 5:10PM, RN #1 said CNA #1 yelled out for her to come. She entered the room and observed CR #1 on the floor beside her bed rolled up in her blankets with blood all around her. She said she did not observe the fall, but it looked like the resident may have rolled out of bed. She said the resident has a behavior where she would always throw her leg out the side of the bed when she's sleeping. She said she has a pressure ulcer on her heel and she does that to relieve pressure from the heal. She said they always have to check in on her at night and tuck her leg back into the bed, so she does not roll out of bed. She said she had last saw the resident around 12AM and her leg was not hanging off the bed and then around 12:50AM was when the CNA #1 yelled out for her to come. RN #1 said she did not know that CR #1 was on [MEDICATION NAME] medication but figured she was when she saw how much she was bleeding. RN #1 said CR #1 did not have a fall mat in place. Interview on 11/23/20 a 5:15PM, CNA #1 said she was walking down the hallway and saw some blankets on the floor in the CR #1's room and thought her blankets had fallen on the floor. She said she went into the room and cut the light on and saw she was rolled in the blankets full of blood. She said the resident was not responsive when she found her but said she would flutter her eyes when they'd try and talk to her. She said the resident would not try and get out of bed by herself but said she would often dangle her leg off the side of the bed when she slept to relieve pressure off her pressure ulcer. She said she would check in during the night and tuck her leg back into the bed if she found it hanging off the bed. She said the resident was rolled up in her blankets as if she rolled out of bed onto the floor. She said CR #1 was not required to have a fall mat. Interview on 11/23/20 at 3:30PM, MDS Nurse said she did not consider [MEDICATION NAME] to be a blood thinner medication which is why it was not care planned. MDS Nurse also said she would usually care plan residents for fall risk if they have falls/history of falls and stated CR #1 had not had any falls at the facility, so she had not care planned her for being at risk. MDS Nurse said CR #1 did not have a fall mat or interventions to prevent falls because she had not previously fallen. MDS Nurse said all the residents at the facility could be at risk for falls if it's not based on if they've had previous falls. The MDS Nurse said she did not care plan residents for being at risk for falls if they had no fall history. The MDS Nurse said she wasn't made aware of CR #1's behavior of throwing her leg out of bed at night until after she fell . Interview on 11/23/20 at 5:00PM, the DON said there are risks associated with the use of [MEDICATION NAME] and Xarelto such as bleeding and bruising. She also agreed that it places a greater risk of head injury/brain bleeds for residents who use those medications who may hit their head. She said if a resident is at risk for falls per fall assessments then it should be care planned. The DON would not confirm whether the use of [MEDICATION NAME] or Xarelto should be care planned. She stated she was not sure what the residents were using the medication for as she had recently started as the DON of the facility. The DON said she was not aware CR #1 had behavior of throwing her legs off bed at night and reiterated she was a new DON to the facility.

Based on interview and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 3 residents (CR #1) reviewed for pressure ulcers. --The facility failed to document wound condition and measurements for CR #1. --The facility failed to have a plan of care for CR #1's sacral pressure ulcer. --The facility failed to document and treat two stage II pressure ulcers on CR #1's sacrum. --The facility failed to ensure staff performed skin assessments in an effective manner to identify pressure sores for CR #1. CR #1 was sent to the emergency room where 8 pressure ulcers were identified, an additional 5 pressure areas since admission to the facility. --Treatment Nurse B failed to document and report a change in condition for CR #1 when she noted increased swelling of the right foot. These failures affected 1 prior resident and placed her at risk for delayed treatment and worsening pressure ulcers which could result in pain, infection, and hospitalization . Intake # 8 and 8 Findings include: Record review of CR #1's admission record revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on [DATE]. Her [DIAGNOSES REDACTED]. reflux disease without esophagitis, anorexia, stage II pressure ulcer of the sacral region, unstageable pressure ulcer of left heel, unstageable pressure ulcer of right heel, other recurrent [MEDICAL CONDITIONS] unspecified, other amnesia, constipation, cough, other symptoms and signs concerning food and fluid intake and local skin infection of the skin and subcutaneous tissue, unspecified. Record review of CR #1's admission MDS assessment dated [DATE] revealed CR #1 was assessed as scoring a 9 out of 15 on her BIMS indicating she had moderate cognitive impairment. She was dependent on staff for her ADLs. She was coded as having unhealed pressure ulcers/injuries and as having one stage 2 that was present upon admission/entry or reentry. CR #1 was also coded as having one unstageable-slough and/or eschar that was present upon admission/entry or reentry and as having an unstageable-deep tissue injury that was present upon admission/entry or reentry. Under the heading for skin and ulcer/injury treatments, CR #1 was coded as having a pressure reducing device for chair, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet and applications of dressings to feet (with or without topical medications). Record review of CR #1's Nutritional Data Set and Progress Note dated 1/25/19 revealed under Skin Condition comments, DTI (Deep Tissue Injury) to left heel, unstageable pressure wound to right heel, and Stage 2 pressure wound to sacrum. Record review of CR #1's quarterly MDS assessment dated [DATE] revealed she was assessed as scoring a 10 on her BIMS indicating moderate cognitive impairment. She was dependent on staff for her ADLs. She was assessed as being at risk for developing pressure ulcers/injuries but no current pressure ulcer/unhealed pressure ulcers/injuries were coded. She was assessed as having Other open lesion (s) on the foot. Under the heading, skin and ulcer/injury treatments, she was assessed as, Pressure reducing device for chair, . Nutrition or hydration intervention to manage skin problems, and Application of dressings to feet (with or without topical medications). During an interview with MDS Coordinator A on 5/28/19 at 6:00 PM she said she did not know why she did not code CR #1's right heel as a pressure ulcer even though she knew Wound Care MD A was seeing CR #1 weekly in (MONTH) (2019). January 2019 Record review of CR #1's admission physician orders [REDACTED]. -Stage II to coccyx. Cleanse pressure ulcer to sacrum c NS, Pat dry, apply [MEDICATION NAME] topical + cover c border foam drsg q day and prn (as needed). - Deep Tissue Injury L heel: .apply skin prep to left heel topically BID. -Cleanse pressure ulcer to right heel with normal saline, pat dry, apply [MEDICATION NAME], wet to dry dressing, and wrap with kerlix Monday, Wednesday, and Friday, and prn. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's care plan signed 1/30/19 by MDS Coordinator A revealed CR #1 had impaired skin integrity AEB: deep tissue injury to bilateral heels. The care plan read that CR #1 would be free from additional skin breakdown/irritation x 90 days and would have weekly skin checks, treatment as ordered, and weekly wound monitoring. There was no care plan for CR #1's sacral pressure ulcer. There was no documentation in the care plan to indicate any behaviors of refusing treatments or care. Record review of CR#1's nursing progress note by LVN A, dated 1/16/19 at 4:11 p.m. revealed a late entry note for 2:30 p.m. and read in part, .noted 3cm x (by) 1cm stage 2 to coccyx, right buttock with X2 stage 2 , 1cm x 1cm and 1cm x ½cm . and .left heel 1cm x 1cm DTI, both heels with dryness,bil. Feet with foot drop, upper (exts) with contractures. There was no documentation of the physician being notified of two sacral pressure ulcer areas, as opposed to one. Record review of CR#1's nursing progress note by LVN B, dated 1/17/19 at 10:39 AM read in part, . She has a stage 2 ulcer to her sacral and right buttock area. She also has unstageable ulcer to right heel and left heel . Record review of CR #1's nursing progress note by Treatment Nurse A, dated 1/21/19 at 9:26 AM, read in part, .Resi has stage 2 ulcer to sacral area and RT buttock. She has unstageable ulcers to both heels. Record review of CR #1's nursing progress note by Treatment Nurse A dated 1/24/19 at 3:38 PM, read in part, .Cleanse pressure ulcer to sacrum w/NS, P (sic) scheduled for 1/24/19 at 12:00:00 PM. dc' d resolved cont. with preventative drsg x1 week. February 2019 Record review of CR #1's (MONTH) 2019 physician orders [REDACTED]. There was also an order [REDACTED]. Record review of CR#1's TAR (treatment administration record) dated (MONTH) 2019 and completed by Treatment Nurse A revealed: --Cleanse Pressure Ulcer to R heel w/NS, pat dry, apply [MEDICATION NAME] w/d drsg and wrap w/kerlix MWF for 2/01/19, 2/04/19, 2/15/19, and 2/18/19 were documented as N, meaning Not Administered, per the document legend. --Cleanse S/P Pressure ulcer site to sacrum with normal saline, pat dry, apply skin prep topically and cover with bordered foam dressing Monday, Wednesday, and Friday as a preventative was documented by Treatment Nurse A as N Not Administered on 2/1/19, 2/4/19, 2/15/19, 2/18/19, 2/22/19, 2/25/19, and 2/27/19. Record review of corresponding Administration Record Notes for CR # for (MONTH) 2019 revealed: - 2/6/19: Notes documenting that the right heel pressure ulcer treatment was to be done by the charge nurse. There was no documentation in the notes as to which charge nurse or whether the charge nurse had been informed that the treatment would not be done by Treatment Nurse A or why Treatment Nurse A was not performing the treatment. The notes were referencing the treatments that had been due days prior on Friday, 2/1/19 and Monday 2/4/19. The note did not include a rationale for the late entry. -2/6/19: Notes documenting that for ordered treatments for CR #1 for her sacrum scheduled for Friday, 2/1/19 and Monday 2/4/19 were to be done by the charge nurse. There was no documentation in the notes as to which charge nurse or whether the charge nurse had been informed that the treatment would not be done by Treatment Nurse A or why Treatment Nurse A was not performing the treatment. -Notes dated 2/15/19 and 2/18/19 documenting CR #1 refused treatments to her sacrum and right heel but did not say whether the physician or responsible party were notified of the refusal or reason for refusal. Record review of CR #1's (MONTH) 2019 Departmental Notes revealed no documentation to correspond with the above late entries on the TAR dated 2/2019. March 2019 Record review of CR #1's (MONTH) 2019 TARs revealed CR #1's treatment for [REDACTED]. The sacrum preventative treatment order had been documented as discontinued on 3/1/19. Record review of CR #1's Physician order [REDACTED].#1's treatment order for her sacrum was no longer on the document. The treatment for [REDACTED]. Record review of CR #1's Clinical Encounter Summaries dated 3/6/19 revealed that under the examination section for Skin, Physician A documented Sacral ulcer, right heel. Record review of CR #1's (MONTH) 2019 Physician order [REDACTED]. Of the 3 pages provided, there were no orders for wound care. April 2019 Record review of CR #1's Physician Telephone orders for (MONTH) 2019 revealed an order dated 4/4/19 for wound consult. There was a second Physician Telephone order dated 4/7/19 again for a wound consult. Record review of CR #1's SBAR dated 4/7/19 revealed it read in part, .Purulent drainage with odor unstageable right heel, with an onset date of 4/7/19. The document also noted [MEDICAL CONDITION] noted to the right foot, unstageable pressure area draining odorous purulent drainage. The only new order was for wound consult. Record review of CR #1's Departmental Nursing Note dated 4/7/19 read in part, .RESIDENT HAS UNSTAGEABLE AREA RIGHT HEEL. ESCAHAR (SIC) NOTED. SMALL OPENING NOTED JUST ABOVE RIGHT HEEL. AREA IS APPROXIMATELY 0.5 X 0.3 X 0.1. THICK PURULENT (containing pus) DRAINAGE NOTED, WITH FOUL ODOR. There was no documentation of any additional notes regarding CR #1's pressure area until 5/17/19 when she was sent to the emergency room at family's request. Record review of CR #1's Clinical Encounter Summaries dated 4/17/19 revealed under HPI (History of Present Illness), .Patient is a resident of (Nursing Home Name) and sitting in bed with eyes closed. Easily aroused. Staff reports that patient is not eating well and concerns about her ability to take in adequate amounts of food. Patient was started on Promod to improve her protein level and help with healing of wounds. Wound Care MD A, wound care, has been consulted for evaluation and treatment of [REDACTED]. left heel improving but right heel continues to have issues with healing. [MEDICATION NAME] seems to be helping with pain issues per staff as well as patient continues on [MEDICATION NAME]. Under Skin, it was documented that CR #1 had sacral ulcer and right heel ulcer. The ulcer was not staged. Record review of CR #1's (MONTH) 2019 TARs provided by the facility revealed the facility documented treatments to the right heel. It was noted the treatment order was changed on 4/17/19 but the previous treatment order was not discontinued. Staff continued to document doing both treatments simultaneously from 4/17/19 through 4/29/19. It was noted the scheduled daily treatment for 4/30/19 was not done due to noting a discontinue date of 4/30/19. There was no documentation of a new treatment order or a treatment for [REDACTED]. Record review of CR #1's Departmental Notes for 4/30/19 revealed there was no documentation of any notes for 4/30/19. Record review of CR #1's first Surgical and Wound Care consultant note dated 4/11/19 revealed the wound care specialist documented the right heel pressure ulcer and noted a treatment order of: --Cleanse/Irrigate wound with normal saline/water, apply Santyl Ointment, apply calcium alginate, apply [MEDICATION NAME] ointment, change dressing every day and as needed. May 2019 Record review of CR #1's Physician order [REDACTED]. Pressure ulcer treatment orders were as follows: --Right Heel: Cleanse pressure ulcer to right heel with normal saline, pat dry, apply [MEDICATION NAME] wet to dry dressing and wrap with kerlix Monday, Wednesday, and Friday. -- Right Heel: Cleanse pressure ulcer to right heel with normal saline, pat dry, apply [MEDICATION NAME] wet to dry dressing and wrap with kerlix as needed for soilage. --Left Heel: Apply skin prep topically to deep tissue to left heel twice daily. --The [DIAGNOSES REDACTED]. --There was no documentation of the order change for the right heel pressure ulcer that had been ordered by Wound Care MD A on 4/11/19. --The order set was not signed by Physician A until 5/21/19. Further record review of CR #1's Physician order [REDACTED]. Record review of CR #1's (MONTH) 2019 Treatment Record revealed the document continued to reflect two different treatment orders for CR #1's right heel. Staff continued to document that they were doing both orders simultaneously with the first order being: --Cleanse right heel wound with normal saline, pat dry, apply layer of bactriban (sic) ointment, coentamicen ointment (sic and not in doctor's order), Santly (sic) to wound bed, cover with calcium alginate and wrap with kerlix, secure with tape daily. Record review of Wound Care MD A's note for CR #1 dated 5/2/19 revealed there was no documentation of an order for [REDACTED]. Record review of CR #1's clinical record of all available documentation revealed a report dated for 1/15/19 through 5/23/19 for CR #1 Wound Healing Progress Report revealed a total of 5 entries for the left heel pressure ulcer and 5 entries for the right heel pressure ulcer. It was noted there were no entries for CR #1's sacral pressure ulcers. There were no entries for any of CR #1's pressure areas for (MONTH) 2019. The entries available read: -Pressure Ulcer Left Heel: 1/16/19: 1.00 x 1.00 Unstageable 1/23/19: 1.00 x 1.00 Unstageable 1/30/19: 1.00 x 1.00 Unstageable 2/6/19: 1.00 x 1.00 Unstageable 4/11/19: 4.50 x 4.00 Unstageable -Pressure Ulcer Right Heel: 1/16/19: 1.00 x 1.50 x 0.00 Unstageable due to slough/eschar 1/23/19: 1.00 x 1.50 x 0.00 Unstageable due to slough/eschar 1/30/19: 1.00 x 1.50 x 0.00 Unstageable due to slough/eschar 2/6/19: 1.00 x 1.50 x 0.00 Unstageable due to slough/eschar 5/9/19 4.50 x 5.50 x 0.90 Record review of Wound Care Physician A's notes revealed measurements of the right heel pressure ulcer as follows: 4/11/19:4 x 3.5 x 0.8 and then 4.5 x 4.0 x 1.0 post debridement 4/18/19: 4 x 4.5 x 0.3 and then 4 x 4.5 x 0.7 post debridement 4/25/19: 6.5 x 6.5 x 0.8 then 6.5 x 6.5 x 1.1 post debridement 5/2/19: 4 cm length x 5 cm width x 0.8 cm depth 5/9/19: 4.5 x 5.4x 0.4 then 4.5 x 5.5 x 0.9 post debridement 5/16/19: 5.0 x 5.4 x 0.4 then 5.0 x 5.4 x 0.5 there was no attached documentation of further assessment or whether debridement was done. During an interview on 5/23/19 at 2:29 p.m. the Corporate Nurse was asked for all documentation, MARs and TARs, for CR #1 from admission on 1/16/19 through discharge on 5/17/19. She said she had already looked and could not find any further documentation for CR #1. No additional documents were provided prior to exit on 6/12/19. During an interview on 5/23/19 at 2:50 p.m. with Treatment Nurse B she said she started as the wound care nurse officially on 5/7/19. She said the wound care doctor came in on Thursday mornings. She said she remembered CR #1 and said she admitted with bilateral heel wounds. She did not say anything about the sacrum. She said she worked on some weekends and she noted CR #1's right heel had some purulent drainage and an odor. She said she got the order from the on-call doctor for the wound consult. She denied any knowledge of sacral wounds on the resident but said the left heel pressure ulcer was closed. She said they only did wound consults when they believed that something needed further attention. She said the wound care doctor did not blanketly see all of their residents with wounds. When asked whether CR #1 was symptomatic with the odor and purulent drainage, she said she did an SBAR and there were no other signs and symptoms of infection other than the odor, drainage, and that the resident had stopped eating. She said they were addressing her not eating with [MEDICATION NAME] (an appetite stimulant). She then said she thought the resident had a stage 2 or 3 to the buttock but that the other treatment nurse healed that out. When asked how she knew it was healed and whether she looked at it, she said no. She said the weekly skin assessments were supposed to be done by Treatment Nurse A during the week. She said the charge nurses were supposed to do the weekly skin assessments if they were due on the weekend days. She said the task would pop up in eMAR (electronic medication administration record) to remind staff to perform the assessment. She demonstrated in the computer system, under assessments, the weekly skin assessment asked staff to document whether skin was intact or not intact and those were the only two options. There were no prompts for additional assessment information. She denied whether anyone else providing care had reported any skin issues or changes for CR #1 to her. She then said she believed something else was starting to develop in CR #1's right foot other than the heel but she said she did not think she documented it. She said she only worked weekends and had just come back from vacation so could not say how long ago it had been when she noticed the change. She said CR #1 had foot drop and her toes did not look right, and were, really swollen. When asked if she checked pedal pulses, she looked at the surveyor but did not respond. During a telephone interview with Treatment Nurse A on 5/28/19 at 6:18 p.m. she said that she did not remember everything about CR #1 and confirmed that she no longer worked at the facility and had stopped working at the facility some time in (MONTH) (2019). She said she had not trained anyone else to replace her. She said she thought CR #1 had an old stage 2 or stage 3 sacral or coccyx area that had healed. She said there was only a preventative treatment in place. She said if it was a preventative treatment, the charge nurses would do it. She said the charge nurses did wound treatments if she was not at work and or on the weekends, and as needed, if the dressings or treatments became soiled. She said if she documented an N that must have meant that she did not give or provide that treatment. She said that from what she remembered, all of CR #1's wounds were closed and had no drainage. She said that she had been told by management/administration, that the consultant wound care MD would only see residents with a Stage 3 pressure ulcer or greater. She said that the charge nurses should have been doing the weekly skin assessments. She said she did not know who was responsible for entering all of the different orders and assessments into the computerized documentation system. She said she did not remember completing an SBAR assessment for CR #1. She said that CR #1 had a right heel DTI and that the left heel was soft and boggy, but no areas were open or appeared infected. During an interview with Wound Care MD A on 5/24/19 at 11:09 am he said that he initially saw CR #1 for the first time on 4/11/19. He said that he only treated CR #1's right heel pressure ulcer. He said he was unaware of any sacral or coccyx wounds. He denied that CR #1's right heel had any signs or symptoms of infection. During an interview with MDS Coordinator A on 5/24/19 at 12:55 pm she said that Treatment Nurse A had been placed on an action plan because she would do the treatments and not the documentation. She said that Treatment Nurse A was supposed to complete the wound care plans and orders. She said that they would review wound care in the morning meetings daily. During an interview with the Corporate Nurse and Administrator on 5/24/19 at 6:30 p.m. they both said there was no additional documentation for CR #1 and that they had provided everything they could find. They said there were no other weekly skin assessment documents that could be found for CR #1. No further documents were provided prior to exit on 6/12/19. Record review of CR #1's weekly skin assessments revealed: -1/16/19 - Skin not intact-Existing -1/23/19 - Skin not intact-Existing -1/30/19-Skin not intact-Existing -2/06/19-Skin not intact-Existing -2/13/19- Skin not intact-Existing -2/20/19-Skin not intact-Existing -2/27/19-Skin not intact-Existing -3/06/19-Skin not intact-Existing -3/13/19-Skin not intact-Existing -3/20/19-Skin not intact-Existing; there was no documentation of where CR #1's skin was not intact, measurements of the exiting areas, or any other assessment information for any of the weekly skin assessments. Record review of all Wound and Skin Status Report documents provided by the Administrator and Corporate Nurse revealed the only documents with CR #1's name on them were dated 2/21/19 and documented right heel DTI measuring 1.00 x 1.50 x 0.00 unstageable Slough/eschar, 100% eschar and left heel DTI measuring 1.00 x 1.00 x 0.00 unstageable, pink, slight [MEDICAL CONDITION]. The second document dated 5/24/19 showed documentation of a sacral pressure ulcer resolved on 1/25/19. Record review of CR #1's local hospital records revealed: --Emergency Department Triage Note dated 5/17/19 revealed, .Family called 911 for patient from (Nursing Home Name) for pressure ulcers that are not receiving adequate care per family. In triage patient has ulcers on right knee, bilateral heels, and sacral region.family came to see the patient noticed that she had multiple open necrotic wounds on her lower extremities and her backside.Physical Exam .Multiple decubitus ulcers localized to the ankle of the left foot. A large gangrenous ulcer on the right heel that is foul-smelling. She has a decubitus ulcer with an open tract in the sacrum. Additionally a small ulcer on the left knee.CBC WITH DIFFERENTIAL .Result WBC (white blood cell count) 15.36 (H) (high) Ref (Reference) Range 4.30-11.10 .Imaging .Diffuse osteopenia is present. Radiographs of both feet demonstrate soft tissue defect of the right heel with minimal erosion and periosteal new bone formation along the adjacent calcaneal cortex. A linear lucency noted on the oblique image through the right calcaneus may represent a nondisplaced fracture. Mild diffuse soft tissue swelling is noted about both feet.Impression .Ulceration of the right heel with suspected osteo[DIAGNOSES REDACTED] of the calcaneus. suspected nondisplaced right calcaneal fracture.[DIAGNOSES REDACTED]. Pressure injury of right heel, stage 3 3. Pressure injury of left ankle, stage 2 .4. Acute hematogenous osteo[DIAGNOSES REDACTED] of right foot 5. Acute [MEDICATION NAME] without hematuria . --History and Physical dated 5/18/19 revealed, .Spoke to the nursing staff at (Nursing Home Name).They also note that she is physically paralyzed and likes to lay on the left side. They note that when they try to move her she screams and hollers. They note that she had her right foot debrided by the wound care specialist yesterday. They stated that the family got concerned after seeing the debrided foot . --General Surgery Consultation note dated 5/18/19 and timed 3:21 p.m. read in part, .On admission, her initial WBC was elevated to 15.36K, her BUN (blood urea nitrogen) and creatinine were mildly elevated to 25 and 1.37 respectively, her lactic acid level was elevated to 3.11, and her U/A (Urinalysis) was positive for blood, leukocyte esterase, TNTC WBC/HPF, and bacteria. X-rays of her feet were obtained; the x-ray of her right heel demonstrated ulceration of the right heel, possible osteo[DIAGNOSES REDACTED] of the right heel, and diffuse severe osteopenia of both the right and left feet. A CT scan of the abdomen and pelvis with contrast was obtained which demonstrated skin thickening along the gluteal cleft with adjacent [MEDICAL CONDITION] changes and a small abscess measuring up to 1.4 cm.Diagnosis .Acute osteo[DIAGNOSES REDACTED] (inflammation .usually caused by infection: Taber's Cyclopedic Medical Dictionary Edition 19 Copyright 2001) Physical Exam .Sacral area: Stage 2 decubitus ulcers, the one closest to the rectum measures 0.6 cm by 0.6 cm, the other more cephalad ulcer measures 0.3 cm by 0.3 cm, I do not appreciate an abscess or drainable fluid collection Right anteromedial leg: Stage 2 decubitus ulcer measuring 1.75 cm wide by 2.0 cm long Right distal lateral left: Stage 1 decubitus ulcers measuring 2.5 cm wide by 2.25 cm long Right lateral malleolus: Stage 1 decubitus ulcer measuring 2.0 cm wide by 3.5 cm long Right medial malleolus: Stage 1 decubitus ulcer measuring 3.0 cm wide by 2.5 cm long Right heel: Stage 3 to 4 decubitus ulcer measuring 4.5 cm wide by 5.0 cm long by 0.3 to 0.5 cm deep, no drainage, no odor, no active infection Left knee: Stage 2 decubitus ulcer measuring 1.25 cm wide by 2.0 cm long . Record review of facility Skin Committee Meeting revealed the facility held meetings twice, once on 4/11/19 and again on 5/16/19. Record review of the facility's undated policy and procedure for wound care management read in part, . 6. Upon identification of skin/wound impairment the nurse will: complete the SBAR and obtain orders from the physician for care in accordance with the formulary guidelines for the identified wound. Note the change of condition in the 24-hour report .7. The skin committee will meet at least weekly to review the care of the residents with pressure injury, complex wounds, surgical wounds, or any other skin compromise.

Based on observation, interview, and record review the facility failed to ensure that residents remained free from accidents and injuries for 1 of 4 residents (Resident #1) reviewed for accidents and hazards in that: --Resident #1 was transferred manually by one staff instead of via mechanical lift with 2 staff resulting in a left distal tibia and fibula fracture. This failure affected 1 resident and placed an additional 11 residents that require 2 person hoyer lifts for transfers, at risk for injury, hospitalization , and/or death. Findings Include: Record review of Resident #1's admission sheet revealed she was admitted to the facility on [DATE] and was [AGE] years old. Resident #1's [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] revealed she had severely impaired cognitive skills for daily decision making and was totally dependent for transfers and required 2 person physical assist with transfers, bed mobility, dressing, eating, toileting, and personal hygiene. Record review of Resident #1's care plan signed by interdisciplinary team on 7/25/2018 revealed Resident #1 had a self care deficit AEB: Need for Total-assist of 2 staff members with all ADL's, provide MAX of assist with all ADL's, use of hoyer lift and two staff for all transfers, and uses geri chair for mobility. Record review of Resident #1's hospital X-ray result dated 8/11/18 revealed, .Impression: Mildly displaced [MEDICAL CONDITION] tibia. Comminuted [MEDICAL CONDITION] fibula. Observation on 8/15/18 at 9:45 am of Resident #1 revealed her to be non-interviewable. She was in her room in bed, awake and alert but aphasic (without speech). She was casually and seasonably dressed. She had an indwelling urinary catheter to bedside drainage noted with privacy bag. She had clear yellow urine noted in tubing. She had an immoblizer to the left, lower extremity. Record review of the facility investigation report dated 8/13/18 revealed NA A provided a statement that she signed and said that she transferred Resident #1 by herself. During an interview with the Administrator on 8/15/18 at 1:30 pm regarding accident and injury of Resident #1, she said that Resident #1's injury was discovered on 8/11/18 by the nursing staff. She said that administration became aware of the incident and reported the injury on 8/13/18. She said NA A admitted , during investigation and questioning, that she had transferred Resident #1 without assistance or a hoyer lift on 8/09/18. She said NA A said that she did not notice any injury or complaints from Resident #1 at that time. She said NA A had only worked at the facility for a short time and was in-serviced and had a written counseling. During an interview with NA A on 8/15/18 at 3:32 pm she said that she was a nurse aide in training who had completed her classroom course and was scheduled to take her test for CNA on 9/2/18. NA A said that she had worked at the facility since 6/6/18 and said that she transferred Resident #1 by herself because she did not know she was not supposed to. She stated, We always pick em up when they're light. She said that she was told to do this by CNA B. She said that 8/9/18 was the first and last time she worked with Resident #1. She said she was only trained for 1 day. She said that she did know about a care plan guidelines sheet that are used in the facility. She said she could have asked the nurse about a resident's transfer status. She said she was unsure why she did not ask the nurse or check any transfer guidelines sheets. She denied that Resident #1 sustained any injury during her transfer and said that Resident #1's legs never touched the floor or bed. During an interview with Human Resources on 8/15/18 at 4:15 pm she said that everyone got orientation and that CNAs normally got 3-4 weeks, depending on their progress. She said that staff got competencies updated yearly and that staff had to complete computer based training, Relias. She denied that anyone would be working who had only received 1 day of training. During an interview with CNA B on 8/15/18 at 5:12 pm CNA B denied telling NA A to not use a hoyer lift or 2 people to transfer any residents. CNA B said that he was just returning to work after vacation and last worked at facility on 8/6/18. CNA B denied being paired with NA A for training and said that NA A mostly trained with NA C, who quit about 2 weeks ago. CNA B said he had worked at the facility for 6 years. Record review of NA A's training revealed NA A completed training titled: Safe Transfers on 7/3/18. Record review of the facility Nursing Assistant Guideline Manual, Transferring a Resident dated as effective 1/2005 revealed, .F. Transferring the dependent resident .Two to three people must assist with a dependent resident to ensure the safety of the resident and the staff. The Facility matrix and transfer guidelines revealed 12 residents dependent on 2 person hoyer lift transfers.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free from accident/hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 12 residents (Resident #1, Resident #3 and Resident #9) reviewed for quality of care in that: Staff failed to protect Resident #1 from from multiple falls and to care plan effectively. He had 9 falls from 8/5/17 to 9/4/17 with no changes in interventions. He sustained a fractured ankle and a fractured hip after falls. Staff failed to protect Resident #3 by not following the Care plan to prevent falls. He had no low bed, fall mat, or bed roll for positioning as per his care plan. He had a fall on 9/17/17 and care plan interventions were not put in place. Staff failed to protect Resident #9 by not updating his Care Plan with individualized approaches when he sustained a fall on 3/7/17. The facility failed to protect 43 residents on Station I, halls Aspen Drive, Birch Lane, Cedar Street, and Dogwood Blvd, from potential abuse/neglect due to LVN A sleeping at the nurse's station while on duty. These failures affected 3 residents and placed an additional 49 residents at risk for falls, injury, hospitalization , pain, and neglect. Intake# 7, 2, 0, 8 Findings included: Resident #1 Record review of Resident #1's face sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed he had a BIMS score of 15 which meant he had no cognitive impairment. He was assessed as having a fall in the last 2-6 months. He was incorrectly coded as having no falls since admission. Record review of the facility incident log for August and September 2017 revealed Resident #1 had falls on 8/3/17, 8/14/17, 8/15/17, 8/22/17, twice on 8/23/17, 8/28/17, and twice on 9/4/17. All were documented to have no apparent injuries. Record review of Resident #1's nurse notes stated that Resident #1 had a fall on 8/3/17, 8/15/17, 8/22/17, 8/23/17, 8/28/17. Record review of Resident #1's Care Plan dated as initiated on 7/26/17 revealed Resident #1 had falls with injury on 8/3/17, 8/14/17, 8/15/17, 8/22/17, 8/23/17, 8/24/17, and 8/28/17. Original interventions in place on 7/26/17 included keeping the call bell in reach. On 8/3/17 it was documented to remind the resident to use his call bell to request assistance and to remind staff to offer assistance. No additional interventions were put in place beyond reminders. Record review of Resident #1's X-ray results from the hospital dated 8/28/17, 4 days after his most recent fall, revealed a nondisplaced subcapital right femoral neck fracture. Record review of the facility Provider Investigation Report with an incident date of occurance as 8/23/17 revealed, .Investigation Summary: .After being sent to the hospital, (Resident #1) was found to have a fracture of his right ankle. His ankle fracture was treated according to the doctor's order. Record review of Resident #1'sorthopaedic surgery physician's progress note dated 9/1/17 revealed, Assessment/Plan .Diagnosis: [REDACTED]. In an interview on 9/26/17 at 9:30 a.m. the DON stated that Resident #1 had two unwitnessed falls. Resident #1 had a fractured ankle during the storm. The DON stated the resident was found with discolored ankle and bruising was found. Resident #1 had another fall the next day and he complained of pain in his leg and they found the resident had a fractured hip. The first x rays found a fracture the facility tried to get Resident #1 to a surgeon and there were no surgeons available at two local hospitals. The Medical Director ordered the resident's foot to be wrapped and to get a boot on it. The hip was the same story and the surgeon at the local hospital did not have equipment for the surgery. Resident #1 was seen as outpatient and the doctor determined that his hip was non surgical. Observation on 09/26/17 at 10:15 AM in his room revealed Resident #1 was laying in bed and there was no fall mat, bed was medium height and there were no other safety devices for the resident observed. In the interview on 09/26/17 at 10:15 AM Resident #1 stated that he was not feeling too great and that he had some falls. Resident #1 stated that he got off balance and did not remember going to the hospital. In a further interview on 9/29/17 at 10:20 AM the DON stated that Resident #1 was care planed for falls by having the resident to press his call light and the staff were to monitor him closely. The DON stated that the facility did not do bed or chair alarms because the residents felt it was impairing their movements. The DON stated that she thought the facility put falls mats, but she was not sure. Resident #1 was said to have a low bed. The DON did review Resident #1's Care Plan she she did not find low bed on the care plan and no other devices to prevent falls. The DON stated that she was going to get maintenance to get Resident #1 a scoop mattress and a fall mat. Resident #3 Record review of Resident #3's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's MDS dated [DATE] revealed he had a BIMS of 03 which meant he had significant cognitive impairment. He was assessed as having no history of falls. Record review of Resident #3's Care Plan dated 5/14/17 stated that the resident had a history of [REDACTED]. Observation on 09/26/17 at 10:50 AM revealed Resident #3 was sleeping in his geri chair. Observation on 9/28/17 at 1:00 PM revealed Resident #3 was in bed with the bed in the lowest position. There was no fall mat in place. He had a geri chair and boots on both feet. There was no bed roll in the room. In an interview on 09/26/17 at 10:50 AM Resident #3 stated that he contacted staff by call light and that 3 weeks ago he got out of balance. Resident was observed to be confused and there were concerns with speech. He would not speak very much. In an interview on 09/26/17 at 9:57 AM DON stated that on 9/17/17 at 4:00 p.m. the staff put Resident #3 in the bed and 15 minutes later the resident fell out if his bed and the staff found him with laceration to his forehead and a skin tear on his arm. The facility did investigate the fall and sent him to the emergency room and Resident #3 got staples in his forehead. The staff were inserviced for treating areas, fall mats, high/low bed and the resident should be close to the floor. In an interview on 9/28/17 at 1:00 PM with Nurse Aide in Training #2 she stated that Resident #3 did not have a bed alarm and had an incident where he had fallen. She said Resident #3 has an air mattress for pressure sores and the bed has bed rails. NAT #2 did look for the bed rails and could not find them. In an interview on 9/29/17 at 10:27 A.M. DON stated that Resident #3 had a fall with injury and that he was Care Planned to have a bed roll on the bed and a fall mat. Observation on 9/29/17 at 10:40 a.m. revealed Resident #3 did not have a bed roll, no fall mat, and he had an air mattress. Resident #9 Record review of Resident #9's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's Care Plan dated 12/20/2016 revealed that the resident was identified with risk for injury r/t falls and the approach was stated to rule out medical complication with increased falls, call bell in reach, fall assessment on admission, adequate lighting and assistive device within reach. On 3/7/17 the plan was revised due to a fall and the intervention added was to re orient the resident to the call light. His plan was not updated to include the placement of a fall mat. He had a care plan dated 12/20/16 with no documentation of quarterly updates, for Impaired Cognition as evidenced by [DIAGNOSES REDACTED]. Interventions included in part to provide cueing, prompting, and assist for personal care as needed and to ask simple yes/no questions. He had a care plan dated 12/20/16 for self care deficit as evidenced by need for moderate assist of one to two with activities of daily living related to weakness and confusion with additional risk for decline secondary to Parkinson's disease. Observation on 9/26/17 at 11:22 A.M. revealed resident #9 in his room and he was identified for all entering the room to stop and see Nurse. Observation revealed that Resident #9 had a fall mat at bedside. During an interview on 9/29/17 at approximately noon with Resident #9 when asked how he contacted the staff if he needed anything, he said, I don't know. When asked if he had any falls, he said no. In an interview on 9/29/17 at 10:34 A.M. DON stated that Resident #9 had a fall mat in place, but the fall mat was not listed on his care plan. Observation on 9/27/17 at 4:11 A.M. revealed the facility front door unlocked. LVN A was observed sleeping, leaning forward in front of the computer with her eyes closed at the nurse's station. She did not respond when surveyor said hello and waited for a response. In an interview on 9/27/17 at 4:30 A.M. with LVN A she stated that there were only two staff for the front of the facility today and they had 24 rooms. LVN A did not have a response for her sleeping. LVN A stated that the facility was supposed to have another staff from 2 P.M. to 10 P.M. to pull a double shift, but she had an emergency and could not stay. In an interview on 9/27/17 at 12:20 P.M. DON stated that she was texting LVN A during the day before the nurse's shift while she was supposed to be sleeping in preparation for her shift because she asked her about some in-services that she was missing. The DON stated that she would counsel with LVN A. In an interview on 9/28/17 at 11:00 A.M. DON stated that LVN A was suspended for 3 days for sleeping while on duty and leaving the front door unlocked to the facility. Record review of LVN A's employee file revealed a date of hire of 3/21/16. A disciplinary report dated 9/27/17 revealed that LVN A was sleeping at desk while on the clock and she was given a 3 day suspension. There was another note which read that LVN A was being disciplined for leaving the front door of the facility unlocked. In an interview on 9/29/17 at 10:32 A.M. DON stated that LVN A was suspended until Monday and the Administrator stated that she wanted to be at the facility when LVN A was terminated. The DON said LVN A had told her that she took pain medication that made her drowsy. In a telephone interview on 9/29/17 at 12:24 P.M. with LVN A she stated that she was responsible for 43 residents and that covers all of the rooms in the 100's. LVN A stated that she had just finished doing all her work and she leaned back to close her eyes. LVN A stated she was busy until 2:30 A.M. doing medications, charting, and helping the CNA. LVN A stated that she guessed she closed her eyes too long and she had not had a break. LVN A stated being short staffed was not a problem. LVN A stated that she had just checked a resident's blood sugar at 4:05 to 4:10 A.M. LVN A stated that her eyes were hurting. The facility room roster listed 43 residents on Station I. The CMS 802 revealed 22 residents with falls, 9 on Station II and 13 on Station I.

Based on observation, interview and record review, the facility failed to ensure 3 of 12 residents (Resident #1, Resident #3 and Resident #9) reviewed for neglect were free from neglect in that: Staff failed to protect Resident #1 from multiple falls and to care plan effectively. He had 9 falls from 8/5/17 to 9/4/17 with no changes in interventions. He sustained a fractured ankle and a [MEDICAL CONDITION] after falls. Staff failed to protect Resident #3 by not following the Care plan to prevent falls. He had no low bed, fall mat, or bed roll for positioning as per his care plan. He had a fall on 9/17/17 and care plan interventions were not put in place. Staff failed to protect Resident #9 by not updating his Care Plan with individualized approaches when he sustained a fall on 3/7/17. The facility failed to provide adequate supervision for 43 residents due to LVN A sleeping while on duty at the nurse's station. These failures affected 3 residents and placed an additional 49 residents at risk for falls, injury, hospitalization , pain, and neglect. Intake# 7, 2, 0, 8 Findings included: Resident #1 Record review of Resident #1's face sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed he had a BIMS score of 15 which meant he had no cognitive impairment. He was assessed as having a fall in the last 2-6 months. He was incorrectly coded as having no falls since admission. Record review of the facility incident log for August and September 2017 revealed Resident #1 had falls on 8/3/17, 8/14/17, 8/15/17, 8/22/17, twice on 8/23/17, 8/28/17, and twice on 9/4/17. All were documented to have no apparent injuries. Record review of Resident #1's nurse notes stated that Resident #1 had a fall on 8/3/17, 8/15/17, 8/22/17, 8/23/17, 8/28/17. Record review of Resident #1's Care Plan dated as initiated on 7/26/17 revealed Resident #1 had falls with injury on 8/3/17, 8/14/17, 8/15/17, 8/22/17, 8/23/17, 8/24/17, and 8/28/17. Original interventions in place on 7/26/17 included keeping the call bell in reach. On 8/3/17 it was documented to remind the resident to use his call bell to request assistance and to remind staff to offer assistance. No additional interventions were put in place beyond reminders. Record review of Resident #1's X-ray results from the hospital dated 8/28/17, 4 days after his most recent fall, revealed a nondisplaced subcapital right femoral neck fracture. Record review of the facility Provider Investigation Report with an incident date of occurance as 8/23/17 revealed, .Investigation Summary: .After being sent to the hospital, (Resident #1) was found tohave a fracture of his right ankle. His ankle fracture was treated according to the doctor's order. Record review of Resident #1's orthopaedic surgery physician's progress note dated 9/1/17 revealed, Assessment/Plan .Diagnosis: [REDACTED]. In an interview on 9/26/17 at 9:30 a.m. the DON stated that Resident #1 had two unwitnessed falls. Resident #1 had a fractured ankle during the storm. The DON stated the resident was found with discolored ankle and bruising was found. Resident #1 had another fall the next day and he complained of pain in his leg and they found the resident had a [MEDICAL CONDITION]. The first x rays found a fracture the facility tried to get Resident #1 to a surgeon and there were no surgeons available at two local hospitals. The Medical Director ordered the resident's foot to be wrapped and to get a boot on it. The hip was the same story and the surgeon at the local hospital did not have equipment for the surgery. Resident #1 was seen as outpatient and the doctor determined that his hip was non surgical. Observation on 09/26/17 at 10:15 AM in his room revealed Resident #1 was laying in bed and there was no fall mat, bed was medium height and there were no other safety devices for the resident observed. In the interview on 09/26/17 at 10:15 AM Resident #1 stated that he was not feeling too great and that he had some falls. Resident #1 stated that he got off balance and did not remember going to the hospital. In a further interview on 9/29/17 at 10:20 AM the DON stated that Resident #1 was care planed for falls by having the resident to press his call light and the staff were to monitor him closely. The DON stated that the facility did not do bed or chair alarms because the residents felt it was impairing their movements. The DON stated that she thought the facility put falls mats, but she was not sure. Resident #1 was said to have a low bed. The DON did review Resident #1's Care Plan she she did not find low bed on the care plan and no other devices to prevent falls. The DON stated that she was going to get maintenance to get Resident #1 a scoop mattress and a fall mat. Resident #3 Record review of Resident #3's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's MDS dated [DATE] revealed he had a BIMS of 03 which meant he had significant cognitive impairment. He was assessed as having no history of falls. Record review of Resident #3's Care Plan dated 5/14/17 stated that the resident had a history of [REDACTED]. Observation on 09/26/17 at 10:50 AM revealed Resident #3 was sleeping in his geri chair. Observation on 9/28/17 at 1:00 PM revealed Resident #3 was in bed with the bed in the lowest position. There was no fall mat in place. He had a geri chair and boots on both feet. There was no bed roll in the room. In an interview on 09/26/17 at 10:50 AM Resident #3 stated that he contacted staff by call light and that 3 weeks ago he got out of balance. Resident was observed to be confused and there were concerns with speech. He would not speak very much. In an interview on 09/26/17 at 9:57 AM DON stated that on 9/17/17 at 4:00 p.m. the staff put Resident #3 in the bed and 15 minutes later the resident fell out if his bed and the staff found him with laceration to his forehead and a skin tear on his arm. The facility did investigate the fall and sent him to the emergency room and Resident #3 got staples in his forehead. The staff were inserviced for treating areas, fall mats, high/low bed and the resident should be close to the floor. In an interview on 9/28/17 at 1:00 PM with Nurse Aide in Training #2 she stated that Resident #3 did not have a bed alarm and had an incident where he had fallen. She said Resident #3 has an air mattress for pressure sores and the bed has bed rails. NAT #2 did look for the bed rails and could not find them. In an interview on 9/29/17 at 10:27 A.M. DON stated that Resident #3 had a fall with injury and that he was Care Planned to have a bed roll on the bed and a fall mat. Observation on 9/29/17 at 10:40 a.m. revealed Resident #3 did not have a bed roll, no fall mat, and he had an air mattress. Resident #9 Record review of Resident #9's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's Care Plan dated 12/20/2016 revealed that the resident was identified with risk for injury r/t falls and the approach was stated to rule out medical complication with increased falls, call bell in reach, fall assessment on admission, adequate lighting and assistive device within reach. On 3/7/17 the plan was revised due to a fall and the intervention added was to re orient the resident to the call light. His plan was not updated to include the placement of a fall mat. He had a care plan dated 12/20/16 with no documentation of quarterly updates, for Impaired Cognition as evidenced by [DIAGNOSES REDACTED]. Interventions included in part to provide cueing, prompting, and assist for personal care as needed and to ask simple yes/no questions. He had a care plan dated 12/20/16 for self care deficit as evidenced by need for moderate assist of one to two with activities of daily living related to weakness and confusion with additional risk for decline secondary to [MEDICAL CONDITION]. Observation on 9/26/17 at 11:22 A.M. revealed resident #9 in his room and he was identified for all entering the room to stop and see Nurse. Observation revealed that Resident #9 had a fall mat at bedside. During an interview on 9/29/17 at approximately noon with Resident #9 when asked how he contacted the staff if he needed anything, he said, I don't know. When asked if he had any falls, he said no. In an interview on 9/29/17 at 10:34 A.M. DON stated that Resident #9 had a fall mat in place, but the fall mat was not listed on his care plan. Observation on 9/27/17 at 4:11 A.M. revealed the facility front door unlocked. LVN A was observed sleeping, leaning forward in front of the computer with her eyes closed at the nurse's station. She did not respond when surveyor said hello and waited for a response. In an interview on 9/27/17 at 4:30 A.M. with LVN A she stated that there were only two staff for the front of the facility today and they had 24 rooms. LVN A did not have a response for her sleeping. LVN A stated that the facility was supposed to have another staff from 2 P.M. to 10 P.M. to pull a double shift, but she had an emergency and could not stay. In an interview on 9/27/17 at 12:20 P.M. DON stated that she was texting LVN A during the day before the nurse's shift while she was supposed to be sleeping in preparation for her shift because she asked her about some in-services that she was missing. The DON stated that she would counsel with LVN A. In an interview on 9/28/17 at 11:00 A.M. DON stated that LVN A was suspended for 3 days for sleeping while on duty and leaving the front door unlocked to the facility. Record review of LVN A's employee file revealed a date of hire of 3/21/16. A disciplinary report dated 9/27/17 revealed that LVN A was sleeping at desk while on the clock and she was given a 3 day suspension. There was another note which read that LVN A was being disciplined for leaving the front door of the facility unlocked. In an interview on 9/29/17 at 10:32 A.M. DON stated that LVN A was suspended until Monday and the Administrator stated that she wanted to be at the facility when LVN A was terminated. The DON said LVN A had told her that she took pain medication that made her drowsy. In a telephone interview on 9/29/17 at 12:24 P.M. with LVN A she stated that she was responsible for 43 residents and that covers all of the rooms in the 100's. LVN A stated that she had just finished doing all her work and she leaned back to close her eyes. LVN A stated she was busy until 2:30 A.M. doing medications, charting, and helping the CNA. LVN A stated that she guessed she closed her eyes too long and she had not had a break. LVN A stated being short staffed was not a problem. LVN A stated that she had just checked a resident's blood sugar at 4:05 to 4:10 A.M. LVN A stated that her eyes were hurting. The facility room roster listed 43 residents on Station I. The CMS 802 revealed 22 residents with falls, 9 on Station II and 13 on Station I.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for 1 of 5 residents (Resident #1) reviewed for neglect in that: --Resident #1 was left unattended on the toilet by staff. She fell and sustained a head injury. She was sent to the hospital and received sutures. This failure affected 1 resident and placed an additional 16 residents on Fir Road Hall at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization . Intake # 7 Findings include: Record review of Resident #1 ' s admission sheet revealed she was [AGE] years old and was admitted to the facility 9/21/16. Her [DIAGNOSES REDACTED]. Record review of Resident #1 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview of Mental Status (BIMS) of 5 out of 15 indicating she had severe cognitive impairment. Her Functional Status revealed: She needed extensive assistance in transfer by one person and extensive assistance in toilet use with two- person assistance. She was assessed as having no falls, was frequently incontinent of bladder and occassionally incontinent of bowel. Record review of Resident #1's Screening for Fall Risk (undated) revealed she had a fall on 9/19/16 (prior to admission). She was assessed as scoring a 14 indicating a higher risk for falls. Record review of Resident #1 ' s Plan of Care dated 9/25/16 and updated 11/24/16 revealed: Problem Onset - Risk for injury related to falls as evidence by history of falls. Goal &Target Date: Will transfer safely to and from all surfaces with (level of assist) x 90 days. Approaches - Ensure safe environment, free of clutter, adequate lighting, and clean spills promptly. Record review of Resident #1's Resident Incident Report dated 11/28/16 revealed: Incident date of 11/24/16 and timed 9:35 a.m. completed by LVN A; incident type was fall with head injury and type of injury hematoma, laceration. Narrative of incident and description of injuries: .At 9:35 AM CMA (MA B) called this nurse to resident ' s room, stating she was on the floor. On assessment, resident noted in prone position on bathroom floor, moderate bleeding from the head. Resident alert and oriented x ' s 2 which is normal for her. She stated her head was ' hurting very badly, ' but she denied being in pain anywhere else on her body. Open gash to L (left) eye noted. Pressure applied to open area to slow/stop bleeding. Record review of the medical record from the emergency department of the hospital dated 11/24/16 revealed: CT head without contrast and CT Maxilla-facial without contrast revealed: MD Impression: No acute intracranial abnormality. Comminuted, minimally displaced fractures of the lateral wall left orbit and left maxillary sinus. A fracture is also noted through the left zygoma. Hyperdense fluid is noted within the left maxillary sinus suggestive of acute blood products.Consider MRI brain for further evaluation. Observation on 1/18/17 at 9:00 a.m. of Resident #1 revealed she was watching television in her room. During an interview on 1/18/17 at 9:15 a.m. with Resident #1 she said she was taken to the bathroom and when she tried to get up she fell into the door that connected the other room to the shared bathroom. She said there was blood coming from her left upper eye. She said she was sent to the hospital. When she was asked if it was the practice of staff to give the call light to her while she used the restroom in order to call staff after toilet use, she said that the day staff gave her the call light after they had placed her on the toilet. During an interview on 1/18/16 at 10:38 a.m. with LVN A she said MA B and NAT C came to her and reported Resident #1 had fallen in the bathroom. LVN A said she observed the resident on the floor and blood coming from her upper left face. She said they helped the resident and Resident #1 was transported to hospital. She said a CT scan was done. She said the upper left side of Resident #1's eye was stitched. She said under no circumstances should MA B and NAT C have left Resident #1 alone in the bathroom because she was very impulsive. During an interview on 1/18/17 at 10:56 a.m. with MA B he said he went in the room to assist putting Resident #1 on the toilet. He said NAT C was with him. He said they gave the resident the call light to use when she finished using the toilet and left. He said he saw the call light went off and when he reached the bathroom the resident was on the floor bleeding from the left side of her eye. He said Resident #1 complained of pain. He said they should not have left her alone. During an interview on 1/18/17 at 11:30 a.m. with NAT C she said she called MA B to help her put Resident #1 on the commode. She said MA B gave the resident the call light to use when she finished using the toilet and left. NAT C said she left to see another resident and when she said the call light went on in Resident 1 ' s bathroom she went over. She said she saw Resident #1 on the floor bleeding around the left eye. She two staff were there and the nurse was called into the bathroom. During an interview on 1/18/17 at 11:52 a.m. with the Director of nursing she said when Resident #1 fell in the bathroom she asked the resident about how she sustained her injury resident was able to tell her what happened. Record review of MA B's employee file revealed he also held a current CNA certificaton. Record review of facility Prevention and Investigation of Abuse, Neglect and/or Exploitation dated 4/29/2009 revealed: 4. Neglect allegations (as referenced in Chapter 19, 40 TAC 19. 101). The facility must determine if the injury, harm or death of the resident was due to facility failure to provide services, treatment or care to a resident. The resident room roster revealed a census of 17 residents on Fir Road Hall.