Every finding on record at Dallas Retirement Village Health Center

Based on observation, interview, and record review it was determined the facility failed to disinfect reusable resident equipment between residents for 2 of 6 halls reviewed for infection control and failed to ensure staff implemented proper hand hygiene while assisting residents with meals 1 of 2 dining rooms reviewed for dining observation. This placed residents at risk for exposure to infections and illness from cross contamination. Findings include: 1. The facility's Disinfection of Resident Care Items and Equipment policy revised 11/2025 stated: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). On 4/6/26 at 9:39 AM Staff 7 (CNA) exited room [ROOM NUMBER] with a mechanical lift then took the mechanical lift to room [ROOM NUMBER] without cleaning and disinfecting it. At 9:47 AM Staff 7 left room [ROOM NUMBER] and parked the mechanical lift in the hallway without cleaning and disinfecting it. Staff 7 stated the mechanical lift was not cleaned then but another staff member came through during the day and wiped off the lifts. On 4/8/26 at 3:19 PM Staff 2 (DNS) stated mechanical lifts were reusable equipment and were to be disinfected between each resident. 2. On 4/9/26 at 12:36 PM Staff 11 (CNA) utilized a ceiling-mounted lift device to transfer a resident in room [ROOM NUMBER]. At 12:45 PM Staff 11 put the lift onto a cart, moved it into the hallway, and left without cleaning the lift. At 12:48 PM Staff 12 (CNA) moved the same ceiling lift cart into room [ROOM NUMBER] to use with a different resident. Staff 12 was stopped by the surveyor and notified the ceiling lift was not cleaned after it was last used. On 4/9/26 at 12:50 PM Staff 12 stated the ceiling lifts were to be cleaned after each use and he assumed the lift was clean because it was in the hallway. On 4/9/26 at 12:51 PM Staff 11 (CNA) confirmed she did not clean the lift before placing it in the hallway. Staff 11 stated ceiling lifts were to be cleaned after each use. On 4/10/26 at 10:24 AM Staff 2 (DNS) stated ceiling lift devices were to be cleaned after every use prior to placing them in the facility hallway. 3. During a breakfast dining observation on 4/6/26 at 8:12 AM Staff 23 (CNA) was observed to assist Resident 35 with drinking from a straw. Staff 23 used his hand to adjust the straw up and down and held the straw to Resident 35's mouth. Staff 23 then, without sanitizing his hands, assisted Resident 43 with eating yogurt from a spoon and wiped her/his mouth with a napkin. Staff 23 returned to Resident 35 and assisted her/him with eating eggs from a spoon, without sanitizing his hands. On 4/6/26 at 8:48 AM, Staff 23 stated he was not expected to sanitize his hands between residents while assisting with eating unless he got up from the table. Staff 23 acknowledged he did not sanitize his hands while he assisted Resident 35 and 43. On 4/6/26 at 8:53 AM, Staff 2 (DNS) stated staff were expected to perform hand hygiene between assisting residents with eating when food, straws, or the resident's face were touched.

Based on observation, interview, and record review it was determined the facility failed to ensure staff assisted a resident with toileting for 1 of 1 sampled resident (#67) reviewed for incontinence. This placed residents at risk for increased incontinence and lack of dignity. Findings include:Resident 67 was readmitted to the facility in 4/2023 with a diagnosis of chronic kidney disease. Resident 67's Care Plan revised on 4/2/26 revealed she/he had an ADL self-care deficit. Resident 67 was identified to be mostly incontinent of bowel and bladder, occasionally used a bedside commode for toileting, and required the use of a mechanical lift for transfers. On 4/7/26 at 12:45 PM Staff 15 (CNA) was observed to enter Resident 67's room. Resident 67 stated she/he had to go to the bathroom. Staff 15 informed Resident 67 that she/he had an incontinent brief on and he would assist with incontinent care after lunch. Staff 15 was then observed to exit Resident 67's room and was observed to distribute other residents' meal trays. Resident 67 was observed to attempt to stand and this surveyor notified Staff 15 of Resident 67's attempt to self-transfer. When Staff 15 re-entered Resident 67's room she/he was located in her/his bathroom. On 4/8/26 at 8:15 AM Staff 15 stated Resident 67 did not always like to use the bedpan, was usually incontinent, and did not walk for at least three weeks. Staff 15 also stated on 4/7/26 he had to finish distributing other residents' meal trays and informed Resident 67 he would assist her/him with incontinent care after lunch. On 4/9/26 at 12:08 PM Staff 2 (DNS) stated if there were two staff in the hall, one staff should assist residents with toileting upon their request. On 4/10/26 at 11:20 AM Staff 1 (Administrator) stated a resident should be assisted with toileting when requested.

Based on interview and record review it was determined the facility failed to develop a baseline care plan within 48 hours of admission for 1 of 3 sampled residents (#59) reviewed for falls. This placed residents at risk for injury from falls. Findings include: The facility's Baseline Care Plan policy dated 1/2026 stated, a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission.Resident 59 admitted to the facility on [DATE] with a diagnosis of nondisplaced fracture of right femur. Review of Resident 59's Baseline Care Plan revealed it was completed and reviewed with the resident on 3/30/26.On 4/10/26 at 10:02 AM Staff 20 (RNCM) stated baseline care plans for newly admitted residents were finalized within 72 hours of admission. On 4/10/26 at 11:38 AM Staff 2 (DNS) acknowledged Resident 59's Baseline Care Plan was not completed timely and needed to be finalized within 48 hours of her/his 3/27/26 admission.

Based on interview and record review it was determined the facility failed to ensure a resident or resident representative was provided a bed hold policy for 1 of 2 sampled residents (#8) reviewed for hospitalization. This placed residents at risk for lack of information regarding their right to return to the facility. Findings include: Resident 8 was admitted to the facility in 4/2025 with a diagnosis of a stroke. Resident 8's 10/24/25 Quarterly MDS revealed she/he was moderately cognitively impaired. Resident 8's Progress Notes revealed on 11/28/25 she/he was admitted to the hospital. Resident 8's clinical record did not reveal she/he or her/his representative was provided bed hold information. On 4/6/26 at 11:21 AM Witness 3 (Family) stated in 11/2025 when Resident 8 was admitted to the hospital, she was not provided information related to a bed hold. On 4/8/26 at 10:10 AM Staff 14 (LPN) stated when residents were transferred to the hospital, bed hold information was placed in a packet, and provided to the transportation team to deliver to the hospital staff. Staff 14 stated she did not follow up with a resident or resident's representative to ensure they received the bed hold information. On 4/9/26 at 11:45 AM Staff 2 (DNS) stated when a resident was transferred to the hospital, a transfer packet, including the bed hold policy, was sent with the resident. Staff 2 stated Staff 13 (Admissions Director) reviewed the bed hold policy with the resident or resident's representative if a resident was admitted to the hospital. On 4/9/26 at 11:50 PM Staff 13 stated she followed up with residents or residents' representatives when they were admitted to the hospital, and then she made a note in a resident's clinical record. Staff 13 stated she did not recall if she/he followed up with Resident 8 or her/his family. On 4/10/26 at 10:41 AM Staff 1 (Administrator) stated when a resident who resided on the long-term care unit was admitted to the hospital they were always allowed back to the facility. Staff 1 also stated the bed hold information was more directed toward the skilled residents.

Based on interview and record review it was determined the facility failed to obtain physician orders for treatment of a change in skin impairment for 1 of 5 sampled residents (#80) reviewed for ADLs. This placed residents at risk for a delay in treatment. Findings include:Resident 80 was admitted to the facility in 4/2025 with diagnoses including depression and anxiety.The 10/2/25 Quarterly MDS indicated Resident 80 had a BIMS score of 13 which indicated the resident was cognitively intact.A 10/22/25 Physician Order revealed Resident 80 had erythema (abnormal redness under the skin) under her/his neck fold. Staff were to monitor the skin impairment every shift and notify the provider if the area deteriorated.A 12/3/25 Progress Note by Staff 8 (LPN) revealed Resident 80's erythema under the neck fold showed signs of deterioration including increased size and was tender to the touch. Staff 8 notified the provider and waited for a response.A review of Resident 80's Provider Progress Notes on 12/3/25, 12/5/25, and 12/7/25 revealed no response from Staff 8's notification related to the deterioration of erythema under Resident 80's neck fold.A review of Resident 80's progress notes revealed no follow-up notes related to a response from the provider or any further follow up calls placed to the provider to obtain further directions.A review of Resident 80's 12/2025 TAR revealed no new treatments for the deterioration of erythema under Resident 80's neck fold. On 4/10/26 at 11:15 AM Staff 8 stated he did not recall the 12/3/25 progress note or if the provider ever responded.On 4/10/26 at 11:45 AM Staff 2 (DNS) stated she expected staff to follow up with the provider the next day if a response was not received. Staff 2 confirmed there was no follow up to the provider completed for Resident 80's deterioration of erythema under her/his neck fold.

Based on interview and record review it was determined the facility failed to implement appropriate transfer interventions to prevent falls for 1 of 3 sampled residents (#59) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 59 admitted to the facility on [DATE] with a diagnosis of nondisplaced fracture of right femur. Review of Resident 59's Care Plan initiated 3/30/26 revealed nursing staff were to use a ceiling lift for transfers. Resident 59's Care Plan initiated 4/1/26 also revealed the resident was only to ambulate with therapy staff. A 3/31/26 Functional Abilities Evaluation revealed Resident 59 was dependent on facility staff for transfers. A 3/31/26 Incident Report indicated Resident 59 had a witnessed fall without injury in her/his room when Staff 19 (CNA) attempted to ambulate the resident with a front wheel walker and gait belt. A statement from Staff 19 revealed Resident 59 lost her/his balance during a transfer and was guided to the ground with low impact. A 3/31/26 Nursing Progress Note indicated Resident 59's care plan directed nursing staff to use a ceiling lift for transfers and the resident was only to ambulate with therapy staff. On 4/6/26 at 10:05 AM, Resident 59 stated she/he fell during a standing transfer with nursing staff in her/his room. On 4/9/26 at 12:02 PM and 4/10/26 at 10:39 AM attempts to reach Staff 19 were unsuccessful. On 4/9/26 at 1:39 PM Staff 18 (RN) stated Staff 19 told her he did not check Resident's 59 care plan before he attempted to transfer the resident. On 4/10/26 at 10:09 AM Staff 20 (RNCM) confirmed Resident 59's care plan directed nursing staff to use a ceiling lift to assist Resident 59 with transfers on 3/31/26, and the resident fell on 3/31/26 when her/his care plan was not followed by nursing staff.

Based on observation, interview, and record review it was determined the facility failed to ensure community use CBG glucometers were properly cleaned and sanitized between resident use, failed to follow transmission based precautions, and failed to process laundry to produce hygienically clean laundry to prevent the spread of infection for 4 of 6 sampled residents (#s 33, 80, 83, and 84) and 1 of 1 laundry room reviewed for infection control. This placed residents at risk for bloodborne illness, exposure to infections, and contaminated laundry. Findings include: 1. The facility's 3/2024 Blood Glucose Monitoring policy indicated to follow the manufacturer instructions for cleaning and disinfection of the meter. The Even Care G3 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes. Resident 80 admitted to the facility in 2023 with diagnoses including diabetes. On 12/2/24 at 11:34 AM, Staff 14 (LPN) was observed to obtain a CBG from Resident 80. Staff 14 exited the room and cleaned the glucometer with alcohol wipes. Staff 14 stated she used alcohol wipes on a regular basis to clean the glucometer. Staff 14 stated she was assigned rooms 130-144 and the community use glucometer was used for five different residents on the hall. On 12/2/24 at 12:28 PM and at 1:00 PM, Staff 11 (LPN) stated she already completed resident CBG checks for the day and was assigned rooms 201-216. Staff 11 stated she primarily used alcohol wipes to clean the glucometer and the community use glucometer was used for three different residents on the hall. On 12/2/24 at 12:03 PM and on 12/3/24 at 9:27 AM, Staff 2 (DNS) stated the expectation was for staff to use EPA wipes between every glucometer use and ensure proper dwell times were reached. 42270 2. Resident 33 admitted to the facility in 6/2020, with diagnoses including lung cancer. On 12/02/24 at 2:18 PM, Resident 33's room was observed to have a sign which indicated staff were to follow enhanced barrier precautions when providing high contact activities, there was a cart outside the door which contained gloves, masks, and gowns. On 12/3/24 at 1:16 PM, Staff 17 (CNA) entered Resident 33's room and assisted her/him in using a bedpan. Staff 17 wore gloves and a mask but did not wear an isolation gown. On 12/3/24 at 1:21 PM, Staff 17 exited Resident 33's room, confirmed she assisted her/him with toileting. Staff 17 stated she knew Resident 33 required additional precautions previously, but she was told Resident 33 no longer needed the additional precautions. On 12/4/24 at 9:50 AM, Staff 18 (CNA) entered Resident 33's room and assisted her/him in using the toilet. Staff 18 wore a mask and gloves but did not wear an isolation gown. On 12/4/24 at 10:01 AM, Staff 18 was asked about Resident 33's enhanced barrier precautions, she stated the staff were to wash their hands instead of sanitizing, but was not aware of the need to wear a gown during any care activities. On 12/4/24 at 2:20 PM, Staff 3 (Assistant Director of Nurses) stated the staff were to wear a gown, gloves and mask when they provided high contact care such as toileting for all residents on enhanced barrier precautions. Staff 3 confirmed Resident 33 was on enhanced barrier precautions and the staff should have worn gloves, gown, and a mask when they assisted her/him with toileting. 47005 3. Resident 83 admitted to the facility on ,d+[DATE], with diagnoses including bilateral post-surgical femoral artery resection and repair. On 12/1/24 Resident 83 tested positive for COVID and was placed on Contact and Droplet Precautions, signage at the door and personal protective equipment (PPE) cart was placed outside of the resident's door. On 12/3/24 at 1:16 PM, observed Staff 19 (CNA) exit a resident room while wearing a face mask without completing hand hygiene and retrieved a lunch tray for Resident 83. Staff 19 donned gown and gloves and entered Resident 83's room. Staff 19 exited the room, doffed gown and gloves, kept the same face mask and went back to retrieve another lunch tray to deliver. On 12/3/24 at 1:30 PM, Staff 19 acknowledged he should have sanitized his hands before and after handling the foods trays, worn full PPE and changed his face mask. On 12/6/24 at 9:53 AM, Staff 2 (DNS) stated she expected all staff to complete hand hygiene before and after entering a resident room and wear full PPE when entering an isolation room to decrease the spread of COVID in the facility. 4. Resident 84 admitted to the facility on ,d+[DATE], with diagnosis including clostridioides difficile (C. diff). On 11/25/24 Resident 84 tested positive for COVID and was placed on Contact and Droplet Precautions, signage was placed on the resident's door, and personal protective equipment (PPE) cart was placed outside of the resident's door. On 12/4/24 at 10:04 AM, Staff 20 (RN) was observed to place her face mask on the PPE cart without a barrier and entered the isolation room on the COVID hall. Staff 20 exited Resident 84's room and donned the same face mask she had put on the PPE cart. On 12/4/24 at 10:10 AM, Staff 20 stated she should have put on a new face mask after exiting Resident 84's room. On 12/6/24 at 9:53 AM, Staff 2 (DNS) stated she expected all staff to use and wear proper PPE at all times to decrease the spread of COVID in the facility. 48830 5. According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left in machines overnight. On 12/4/24 at 1:34 PM, Staff 8 (Laundry) stated his shift ended at 10:30 PM and he had the last shift of the day. Staff 8 stated when wet laundry was not completed in the washing machine at the end of his shift, he left the wet laundry in the washing machine overnight. On 12/4/24 at 1:38 PM, Staff 9 (Laundry) stated her shift started at 5:30 AM and she transferred the wet laundry to the dryer and did not rewash the laundry. On 12/5/24 at 1:24 PM, Staff 10 (Environmental Services Department Manager) stated wet laundry was left in the washing machine overnight and was placed in the dryer the next morning. The wet laundry was never rewashed as it would take too long to do so. On 12/5/24 at 1:37 PM, Staff 1 (Administrator) stated she was unaware of a laundry policy regarding damp laundry left in the washing machine overnight.

Based on observation, interview, and record review it was determined the facility failed to ensure medication storage temperatures were logged and failed to ensure proper labeling of biologicals for 3 of 3 medication storage refrigerators reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: 1. On 12/4/24 at 9:15 AM, one open, undated vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) was observed in the nurses' station three medication room refrigerator. The manufacturer's instructions indicated to discard the medication 30 days after opening. On 12/4/24 at 9:15 AM, Staff 11 (LPN) acknowledged the vial of tuberculin was open and not labeled with an open date. On 12/4/24 at 12:12 PM, Staff 2 (DNS) stated the expectation was for staff to label tuberculin with an open date. 2. On 12/4/24 at 8:56 AM, the nurses' station one hall medication room refrigerator temperature logs was observed to be blank from 11/1/24 through 11/25/24. On 12/4/24 at 8:56 AM, Staff 12 (LPN) acknowledged the temperature logs were blank on the identified dates. On 12/4/24 at 12:12 PM, Staff 2 (DNS) stated the expectation was for the medication room refrigerator temperature to be checked and logged twice daily. Staff 2 acknowledged there were no temperatures documented from 11/1/24 through 11/25/24. 3. On 12/4/24 at 9:08 AM, the nurses' station two hall medication room refrigerator temperature logs was observed to be blank on 11/17/24 and 11/29/24. On 12/4/24 at 9:08 AM, Staff 13 (RNCM) acknowledged the temperature logs were blank on the identified dates. On 12/4/24 at 12:12 PM, Staff 2 (DNS) stated the expectation was for the medication room refrigerator temperature to be checked and logged twice daily. Staff 2 acknowledged there were no temperatures documented on 11/17/24 and 11/29/24.

Based on observation and interview it was determined the facility failed to serve, store, and label food in a sanitary manner for 1 of 2 dining rooms and 1 of 2 facility refrigerators observed for dining. This placed residents at risk for contamination and at risk for food borne illness. Findings include: 1. On 12/4/24 at 1:00 PM, Staff 15 (Dietary Aid) was observed serving lunch in the second floor kitchen. While Staff 15 served a meal ticket fell off the serving station into the dining room. Staff 15 walked out of the kitchen, picked up the meal ticket with her gloved hand, returned to the kitchen with the meal ticket, placed it back on the service station, and touched multiple service items while wearing the same gloves. Staff 15 confirmed the meal ticket should not have been placed back on the service station once it fell on the floor and her gloves should have been changed after she touched the floor. On 12/4/24 at 1:43 PM, Staff 16 (Dietary Manager) confirmed once the meal ticket fell it should not be placed back on the service station. 50928 2. On 12/2/24 at 10:25 AM, a communal refrigerator in the facility's pantry area was observed with the following: -One clear container filled with meat covered in gravy with no date. -One clear container with a red top containing left over white cake with white and chocolate frosting with no date. On 12/2/24 at 10:32 AM, Staff 1 (Administrator) stated it was her expectation food items were to be dated and labeled with the residents room number in which the item belonged to.

Based on observation, interview, and record review it was determined the facility failed to protect a resident's right to be free from physical abuse by staff for 1 of 4 sampled resident (#1) reviewed for abuse. This placed residents at risk for physical abuse. Findings include. On 11/4/24, the State Survey Agency received a public complaint which alleged Resident 1 was treated roughly and slapped by a CNA. Resident 1 was admitted to the facility in 9/2024, with diagnoses including post-traumatic hydrocephalus (traumatic brain injury, TBI). A 9/18/24 Admission care plan indicated Resident 1 had left sided weakness, required substantial-total assist with bed mobility and spoke Spanish. A 9/19/24 Admission MDS indicated the resident had severe cognitive impairment. On 11/7/24 at 9:41 AM, Resident 1 was observed to be resting comfortably in bed with bolsters on each side of the bed, the bed was lowered, fall mats were in place, the bed was up against the wall, and the call light was within reach. The residents spouse was in the room. Resident 1 was sleeping off and on with no signs of distress. On 11/7/24 at 1:56 PM, Staff 5 (CNA) stated if he was aware a resident was being abused he would make sure the resident was safe and report it to the nurse. On 11/7/24 at 2:08 PM, Staff 7 (RN) stated if she was aware a resident was being abused she would make sure the resident was safe, alert the Administrator and file a report with the state. On 11/7/24 at 2:44 PM, Staff 8 (CNA) stated she always worked on the skilled side of the facility and enjoyed working double shifts from evenings to night shift. Staff 8 stated if residents were bed bound, she was able to turn residents by herself. Staff 8 stated she had never been rough with Resident 1, never caused physical abuse to Resident 1 and had never slapped Resident 1. On 11/8/24 at 1:17 PM, Staff 9 (CNA) assisted with Spanish translation. Staff 9 asked Resident 1 (in Spanish) if she/he felt safe at the facility. Resident 1 answered 'No' and when asked why, Resident 1 was unable to answer. Resident 1's demeanor was calm. On 11/12/24, the State Survey Agency received a public complaint. The anonymous complainant included video footage of Resident 1 and Staff 8 on 10/27/24. On 11/13/24 at 12:58 PM, Witness 3 (Client Care Surveyor, Interpreter) interviewed Resident 1 via phone with the surveyor in the room. Resident 1 stated she/he was aware there was a camera in the room. When Resident 1 was asked if any of the staff had been rough with her/him, Resident 1 started to cry and was upset. Resident 1 stated she/he did not feel safe in the facility. On 11/13/24 at 2:39 PM, Staff 8 (CNA) stated Resident 1 was a 'heavy turn' and stated most of the time she was able to turn Resident 1 in the bed by herself. Staff 8 stated she was not rough with the resident when she provided care and did not slap the resident. God no I wouldn't slap a resident. Staff 8 was made aware Resident 1 had a camera in her/his room on the same day of her interview. On 11/13/24 at 2:39 PM, the video footage of Resident 1 taken on 10/27/24 at 2:13 AM was reviewed with Staff 8 (CNA). Staff 8 denied the CNA in the room was her. I don't have a scrub top like that. I have never treated a patient like that. Look, that is not my hair! The 10/27/24 staff schedule revealed Staff 8 (CNA) worked a double shift from evening shift to night shift. Staff 8 was assigned to Resident 1 in room [ROOM NUMBER]. On 11/13/24 at 2:45 PM, the video was reviewed by the surveyor, Staff 1 (Administrator) and Staff 2 (DNS). Staff 1 and Staff 2 identified Resident 1 and Staff 8 (CNA) in the video. The video revealed Resident 1 in bed on 10/27/24 at 2:13 AM. Staff 8 was observed to forcefully and roughly push Resident 1's legs to the side in the bed while Staff 8 performed a linen change. Resident 1 can be heard saying, No, no, no and Ai yai yai (Spanish for oh no or oh my god) while Staff 8 pushed Resident 1's legs side to side. At one point, Staff 8 used a slapping motion in the direction of Resident 1's face. The slap was heard on the audio. Staff 8 was then seen grabbing Resident 1's right hand and arm and pushing it away. On 11/13/24 at 2:49 PM, Staff 1 (Administrator), Staff 2 (DNS) and the state surveyor, reviewed facility video footage taken from the hallway on 10/27/24 between 2:00 AM and 2:30AM. Staff 8 (CNA) was observed to walk out of room [ROOM NUMBER] where Resident 1 resided. On 11/13/24 at 3:20 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Staff 8 (CNA) was rough, aggressive and made a 'slapping motion' at Resident 1. Staff 1 stated the care provided in the video by Staff 8 was not conducted according to the facility standards and expectations. Staff 8 was sent home.

Based on interview and record review, it was determined the facility failed to have policies and procedures in place in the event of a facility closure for 1 of 1 sampled facility. This placed residents at risk for displacement. Findings include: On 7/31/23 the facility was asked to provide a policy and procedure in the event of a pending or potential facility closure. On 7/31/23 at 11:31 AM Staff 1 (Administrator) stated the facility did not have a policy and procedure for pending or potential facility closure.

Based on interview and record review it was determined the facility failed to provide a qualified social service worker. This placed all residents at risk for unmet medically related emotional and social service needs of the residents. Findings include: The Facility assessment dated [DATE] revealed the following information regarding qualifications for the Social Service Director: -(A) Have bachelor's or master's degree in behavioral sciences with at least on years' experience in a health care setting; or -(B) An associate degree in behavioral sciences with two years' experience in a health care setting; or -(C) Receive regular on-site consultation, no less often than quarterly, from an individual who has a bachelor's or master's degree in social work or related behavioral science, and one year's experience in a long-term care setting working directly with individual resident, and have written procedures for referring resident in need of social services to appropriate resources; -The Social Service Director of a facility with more than 120 beds shall be full-time and shall meet requirements in either paragraph (A) or (B) of this rule. A review of Staff 16's (Social Service Director) work history/resume indicated she did not have one year of supervised work experience in a health care setting working directly with individuals. The facility's approved bed capacity was 121 beds and included Medicare and Medicaid contracts with a license expiration date of 8/31/23. On 7/31/23 at 8:46 AM and 7/28/23 at 10:50 AM Staff 16 (Social Service Director) stated her degree was in criminal justice with a minor in human services. Staff 16 stated she was hired in 11/2022 and the facility had her complete a 10-hour online course for social service work. Staff 16 stated she only received one day of training from the previous social service director before that individual left. Staff 16 stated she corresponded with a Social Service Director from another facility but only for the first two or three months. Staff 16 stated she did not correspond with anyone currently regarding social service concerns and she had no prior experience in a long-term care facility setting. Staff 16 further stated she was in charge of training the social service assistants including Staff 22 (Social Service Assistant). During the survey the following concerns were identified related to social services and determined to reflect a systemic failure to provide adequate social services to all residents within the facility: -Residents Rights/treated with dignity (Refer to F550). -Follow up related to Advance Directives (Refer to F578). -Medicaid/medicare Coverage/liability (Refer to F582). -Grievances (Refer to F585). -Discharge planning process (Refer to F660). -Maintaining vision services (Refer to F685). -Provisions of medically related services regarding medical appointments (Refer to F745). -Psychotropic medication assessments (Refer to F758). -Routine and dental services (Refer to F790). -Residents medical records accurate and complete (Refer to F842).

Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment for 1 of 1 sampled facility. This placed residents at risk for lack of quality of care and quality of life. Findings include: On 7/31/23 at 12:20 PM the 6/8/23 Facility Assessment was reviewed. The assessment was not comprehensive and did not include information on the following: -Facility staffing levels; -Staff competencies that were necessary to provide the level and types of care needed for the resident population; -Ethnic or cultural factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services; -The facility's resources, including but not limited to all personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; and contracts, memorandums of understanding. On 7/31/23 at 12:30 PM Staff 1 (Administrator) reviewed the Facility Assessment and acknowledged the assessment was not comprehensive and did not include the identified information.

Based on observation, interview and record review it was determined the facility failed to ensure records were complete and accurate for 5 of 8 sampled residents (#s 30, 32, 47, 58 and 89) reviewed for medications, dialysis and planned discharge. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 58 admitted to the facility in 3/2023 with diagnoses including Chronic Kidney Disease. Resident 58's Care Plan dated 4/6/23 revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week outside the facility. On 7/26/23 at 1:32 PM Staff 11 (Agency/CNA) stated he did not know where Resident 58's dialysis fistula (a surgical connection between an artery and a vein) was located and used the resident's legs for blood pressures. On 7/27/23 at 8:13 AM Staff 37 (Agency/RN) stated he thought Resident 58's dialysis fistula was in her/his left upper extremity. On 7/27/23 at 8:28 AM Resident 58 stated staff did not monitor her/his dialysis catheter in her/his neck. Observation of Resident 58's upper extremities revealed no dialysis fistulas. A review of Resident 58's TARs from 4/2023 through 7/2023 revealed staff were monitoring the following: -Resident 58 had a dialysis fistula and staff were to check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals. Every day and evening shift for dialysis care. -Dialysis fistula care. Staff were to check the color and temperature of the fingers and the radial pulse of the access arm when performing routine care and at regular intervals. Every day and evening shift for dialysis care. -Staff were to check the fistula patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access. This was done daily or as ordered by the physician every day shift for dialysis site patency check. On 7/27/23 at 4:00 PM Staff 2 (DNS) confirmed and acknowledged Resident 58 did not have a fistula and the 4/2023 through 7/2023 TARs were inaccurate. Staff 2 stated staff were expected to document accurately in the medical record and document the appropriate access site. 46841 2. Resident 47 was admitted to the facility in 2023 with diagnoses including pneumonia, PTSD (Post-Traumatic Stress Disorder), anxiety disorder and depression. Resident 47's 6/12/23 Care Plan indicated staff were to observe the resident for signs of anxiety and depression (including crying), and if present to document the symptom occurrences in the clinical record. On 7/24/23 at 2:30 PM Resident 47 stated a couple of weeks ago Staff 16 (Social Service Director) came to her/his room and said staff reported that she/he was sexually aroused during peri-care (genital cleaning) which made the staff uncomfortable. Resident 47 denied being sexually aroused during peri-care and stated the conversation upset her/him and she/he cried. On 7/28/23 at 11:47 AM Staff 16 stated in early July 2023 she had a conversation with Resident 47 about staff reports of feeling uncomfortable when the resident was provided peri-care due to the resident's sexual arousal response. Staff 16 stated the resident was shocked and upset as a result of the conversation. Staff 16 stated she did not document the conversation with the resident in the clinical record. No information was found in the the clinical record regarding the above incident. On 7/28/23 at 1:48 PM Staff 17 (RNCM) verified there was no documentation in Resident 47's progress notes regarding the incident. On 7/31/23 at 11:05 AM Staff 2 (DNS) confirmed she expected staff to document interactions regarding this incident. Refer to F550. 3. Resident 30 admitted to the facility in 2022 with diagnoses including end-stage renal disease. Resident 30's 7/18/23 Quarterly MDS BIMS score indicated the resident was cognitively intact. Resident 30's Care Plan dated 7/20/23 revealed the resident received dialysis (a process used to remove waste products from the blood when the kidneys stop working) three times a week outside of the facility. A Progress Note dated 7/20/23 at 2:55 AM indicated the resident returned to the facility via stretcher from Salem Hospital emergency room for a fistula clot. A Progress Note dated 7/21/23 at 4:20 AM indicated the resident had a wrap covering the previous AV shunt (tube used for dialysis) in the left upper extremity and a new dialysis shunt was placed in the resident's right lateral neck following a 7/19/23 emergency room visit. On 7/26/23 at 12:19 PM Resident 30 stated staff did not check the new dialysis site in her/his neck. A review of Resident 30's TARs from 7/1/23 through 7/31/23 revealed staff were monitoring the following: Dialysis-Fistula patency check: Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear a bruit of blood flow through the access. This should be done daily. Staff check marked it was completed. Dialysis-Fistula Care CMS (circulation, movement, sensation) check: check the color and temp of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals every day and evening shift. Staff check marked it was completed. Facility would monitor hemodialysis central lines at a minimum of twice a day for bleeding and s/s of infection: Staff check marked it was completed. On 7/27/23 at 4:00 PM Staff 2 (DNS) confirmed and acknowledged Resident 30 did not have a fistula in her/his arm and the 7/2023 TARs were inaccurate. Staff 2 stated staff were expected to document accurately in the medical record and document the appropriate access site. 48830 4. Resident 32 was admitted to the facility in 9/2019 with diagnoses including diabetes, stage 3 chronic kidney disease, and severe obesity. Resident 32's 6/2023 and 7/2023 MARs indicated the following: -Insulin Aspart Solution 100 unit/ml- inject as per SS for diabetes start date 10/18/22: If CBG was 200 to 399 staff were to inject six units below the skin at bedtime If CBG was 400 to 800 staff were to inject 10 units below the skin with meals A review of the resident's clinical record revealed a signed physician order dated 6/8/23 which directed staff to administer the insulin only at bedtime and not with meals. The 6/8/23 order did not change the ordered amount of insulin but clarified that the insulin was only to be administered at bedtime, and not with meals. However, the 6/8/23 was not transcribed on Resident 32's MARs so the order was unchanged since 10/18/22. No evidence was found in the resident's medical record to indicate the order was administered with meals instead of at bedtime despite the error on the MARs. On 7/27/23 at 3:40 PM Staff 17 (RNCM) acknowledged the 6/8/23 order was not entered and verified Resident 32's 6/2023 and 7/2023 MARs' instructions were inaccurate. 5. Resident 89 was admitted to the facility in 6/2023 with diagnoses including a stroke. Resident 89's discharge summary was incomplete and in accurate. The Resident/Responsible Party signature line and Nurse signature line were blank and included a discharge date of [DATE]. Resident 89's correct discharge was 7/17/23. The medications listed on the 8/20/22 discharge summary were not the same medications Resident 89 was ordered prior to her/his 7/17/23 discharge. On 7/31/23 at 11:13 AM Staff 2 (DNS) acknowledged the 8/20/22 discharge summary was not correct for Resident 89. She/he was unable to provide other documentation.

Based on observation, interview and record review it was determined the facility failed to ensure food textures and food temperatures were maintained for food trays served from 1 of 1 facility kitchen and for 4 of 4 sampled residents (#s 17, 22, 47 and 50) reviewed for food service. This placed residents at risk for food that was not palatable or appetizing. Findings include: Interview with residents indicated the following: -On 7/24/23 at 11:50 AM Resident 50 stated the food was not always hot. Resident 50 stated the food was not great tasting and lacked quality. -On 7/24/23 at 12:09 PM Resident 17 stated the food was terrible and she/he often refused to eat it. Resident 17 stated the food was served cold most of the time. -On 7/24/23 at 2:49 PM Resident 47 stated the food was terrible and cold when it was delivered. -On 7/25/23 at 10:16 AM Resident 22 stated she/he ate in her/his room and experienced cold food by the time it arrived to her/his room. Resident 22 stated when they had the smaller dining room staff were able to warm up food in the microwave but now staff had to walk all the way to the big dining room to reheat food which took time. Resident 22 stated butter did not melt when placed on the vegetables due to the food not being warm enough. Resident 22 further stated the issue was brought up in Resident Council, but nothing was done. Review of Resident Council notes revealed the following: - 4/2023 residents indicated the meatloaf was flavorless, the pasta was overcooked, and weekend meals were served late. - 6/2023 residents indicated food was served cold even when on the hot plates. On 7/27/23 at 1:03 PM a test tray was sampled with the survey team; the meal consisted of chicken strips, french fries and cooked carrots. The french fries were lukewarm and soggy, and the carrots were overdone. On 7/27/23 at 1:09 PM Staff 1 (Administrator) acknowledged the fries were lukewarm and mushy and the carrots were overdone.

Based on observation, interview, and record review it was determined the facility failed to honor resident dining room choices and preferences for 3 of 3 sampled residents (#s 22, 37 and 50) reviewed for honoring choices. This placed residents at risk for increased isolation, lack of socialization and lack of self-determination. Findings include: Review of Resident Council Minutes revealed the following: 4/19/22: -Residents aired their concerns about D Hall Pantry/Dining Room closing and having to eat in the main dining room. -Too far for CNAs to travel, if something was forgotten on the meal tray. -Meals were delivered late. -Too much was expected from the CNAs so they were unable to do their job well. -Main dining room was loud, socializing was difficult, not a nice place to enjoy a meal and with so much going on and so many people crammed into a small space. -Resident 22 wrote concerns regarding the D Hall Pantry/Dining Room which revealed the following: -There is a sign in the front that states Residents Do Not Live in Our Facility. We Work in Their Home. -Lately residents felt we had been invaded in our home and lost control of our care. -We were never asked for our opinion regarding our wants or needs. -Meals were delivered and CNAs did not stay long enough to make sure the meals were correct or hot. If anything was wrong it took 10 or 15 minutes before the concern was corrected and the meals were cold because of the extra time it took to pass out meal trays. The response/resolution from Staff 1 (Administrator) requested the residents to give the new dining situation a chance. In regards to meals delivared to resident's, CNAs were instructed to delivar a meal tray to whatever meal tray came up in the kitchen regardless of what hall the residents were on. 5/17/23: Resident Council was canceled due to Norovirus (a contagious virus that causes vomiting and diarrhea) outbreak. 6/28/23 and 7/19/23: Dining hours were 8:00 AM to 9:00 AM breakfast, 12:00 PM to 1:00 PM lunch and 5:00 PM to 6:00 PM dinner. -Residents stated meals were not delivered to their rooms until after hours. -Food was still periodically served cold on hot plates. -Inconsistent portions being served. -CNAs put residents to bed prior to meals being delivered. There was no indication or documentation the concerns related to dining from 6/2023 through 7/2023 were addressed or any follow up conversations regarding how residents were feeling regarding the closure of the D Hall Pantry/Dining Room. On 7/27/23 at 12:50 PM Staff 27 (CNA), at 1:00 PM Staff 32 (CNA) and at 3:15 PM Staff 17 (RNCM) all stated the residents who lived on the D Hall enjoyed the togetherness by having meals in the D Hall Dining room. One resident was so upset she/he cried as the resident did not want to go to the main dining room. Family members were also upset the D Hall Dining room was closed as they spent time with their family members and socialized with other residents in the D Hall Dining room during meals. On 7/27/23 at 2:35 PM Staff 33 (Activity Director) stated several residents were upset at the 4/19/23 Resident Council meeting and voiced their concerns after being informed the D Hall Dining room was being closed. Residents stated CNAs went a long distance to pick up their meal trays, drinks, and anything else that was forgotten in the main dining room. This resulted in longer call lights during meals and took time away from the residents. Management's response to the residents' concerns was to give the new dining situation a chance. The Sun Rise Room (a smaller room near the main dining room) was opened, but the residents from D Hall did not go because it was too far from their rooms. a. Resident 50 admitted to the facility in 9/2022 with diagnoses including Guillain-Barre syndrome (body's immune system attacks the nerves) and osteoarthritis. A Dallas Retirement Village Concern and Grievance Form Dated 4/10/23 from Resident 50 revealed the following concerns: -The D Hall Dining room was closed and moved to the main dining room so more residents would come out of their rooms and socialize. Where are they? -Resident 50 preferred to eat breakfast in her/his room and most of the time the meal was lukewarm. -During lunch and dinner in the main dining area the TV, music and noise from the kitchen was overwhelming and communication was almost impossible. -One of the first days in the main dining another resident was crying and when asked why she/he was crying she/he stated, I don't eat here, change for some people was really hard without notification. -A few days in the main dining and multiple residents were not being attended too appropriately. -There was more care and easier communication with the small dining room than in the main dining. -Resident 50 ate her/his lunch as fast as possible because of the noise level and lack of socialization. The Summary of Findings/Action taken/Conclusion: Staff 16 (Social Service Director) spoke with Resident 50 about other dining options moving forward and explained the reason for the closure. The facility opened up a new dining room (the Sun Rise Room) and notified residents and invited the residents down for meals. On 7/24/23 at 11:50 AM Resident 50 stated since the facility closed the D Hall Dining the food was not always hot, but cold and the closure of the D Hall Dining area was very upsetting to her/him. Resident 50 stated staff had to go to the main dining/kitchen to warm-up food when her/his food was cold because staff no longer had access to a microwave. Resident 50 stated the main dining was too loud and hard to socialize with others and the new dining spot opened up was on the other side of the building. On 7/26/23 at 11:38 AM Staff 21 (CNA) and at 10:15 AM Staff 27 (CNA) both stated residents were very upset about the closure of the D Hall Dining and meals delivered to the D Hall were often cold even on a plate warmer because of the distance staff traveled to deliver meals. Staff 21 and Staff 27 stated if they needed to warm up a cold meal they returned to the main dining area to use the microwave because there was no longer one on the D Hall. Staff 27 stated a meeting was held regarding the closure of the D Hall Dining for family and residents but was just to inform them of the decision. On 7/27/23 at 10:31 AM Staff 20 (LPN) stated Resident 50 and other residents were upset regarding the closure of the D Hall Dining. Staff 20 stated meals were delivered to each residents' room one at a time from the kitchen for those residents who stayed in their rooms or did not care to go to the main dining for meals. Staff 20 further stated D Hall was the farthest from the kitchen and once meals were delivered to residents in their rooms they were often cold. Staff 20 further stated if residents requested staff to reheat the food it took a while because there was no microwave on the D Hall unit and this was an ongoing issue. 48830 b. Resident 22 admitted to the facility in 11/2018 with diagnoses including Parkinson's disease and depression. On 7/25/23 at 10:16 AM Resident 22 and Witness 4 (Family Member) expressed their frustrations since the D Hall Dining room closed. Resident 22 stated she/he and her/his neighbors were upset as several of them ate and socialized together in the D Hall Dining room. Resident 22 stated she/he was not given a straight answer as to why the D Hall Dining was closed. She/he was told the residents had to eat in the main dining room or their rooms. The facility eventually opened a new dining room (the Sun Rise Room) and invited residents. Resident 22 stated the Sun Rise Room was on the other side of the building and she/he did not want to go that far and remained in her/his room to eat all meals. Witness 4 stated several residents who went to the D Hall Dining room now ate all meals in their rooms. Resident 22 experienced cold food by the time the meal tray arrived. The D Hall Dining room had a microwave for staff to reheat cold food but it was no longer was available. Staff now walked to the main dining room to retrieve tea/coffee. Resident 22 worried the extra time it took staff to walk back and forth took time away from other residents who needed help. Resident 22 further stated she/he attended Resident Council meetings and brought concerns regarding the closure of the D Hall Dining. Resident 22 stated management did not address her/his concerns and she/he missed going to the D Hall Dining room. c. Resident 37 admitted to the facility in 1/2019 with diagnoses including diabetes. On 7/31/23 at 9:52 AM Resident 37 stated when the D Hall Dining room closed, staff had to bring down each meal tray from the main dining to residents room. Resident 37 stated the soup on her/his meal tray was cold daily. She/he asked staff to heat up the cold soup, but not anymore because, it's not fair to the CNAs to have to walk all the way down there to the main dining room when they are already so busy taking care of us residents. Resident 37 was not made aware when the D Hall Dining room was closed. She/he verbalized concerns to the CNAs and nurses and was frustrated management did not do anything. Observations of the 7/27/23 lunch meal for the D Hall revealed multiple residents eating in their rooms. Staff had to carry each residents' meal tray individually to the residents' rooms. The first tray was delivered at 12:21 PM and the last tray was delivered at 12:53 PM. This took staff a total of 32 minutes. There were a total of 10 trays delivered to residents' in their rooms. Staff had to walk approximately 280 feet back and forth from the main dining room to residents room, every time they had to deliver a meal tray. On 7/27/23 at 1:09 PM Staff 1 (Administrator) stated D Hall Dining was closed back in 5/2023 because only five residents utilized the services. Staff 1 stated they opened up the Sunrise Room which had plenty of space for residents and family. Staff 1 stated residents and family were not happy regarding the closure at first and had to work out the kinks which took a few months. When asked about accommodation of needs or honoring resident choices Staff 1 indicated she encouraged residents and family to give the new process time. Staff 1 stated she was unaware of ongoing complaints regarding D Hall Dining being closed and had not attended resident council but relied on staff to report concerns regarding D Hall Dining concerns.

Based on observation and interview it was determined the facility failed to maintain and provide a clean homelike environment for 4 of 6 halls reviewed for environment. This placed residents at risk for living in an unclean and an unhomelike environment. Findings include: On 7/24/23 and 7/28/23 the following observations were made: -room [ROOM NUMBER]: Had a dark black stain which measured approximately one foot by one and a half feet across and adjacent to the stain was another black stain which measured approximately six inches by one foot across. -room [ROOM NUMBER]: Had a dark black stain which measured approximately seven inches by 19.5 inches across, adjacent to that was two smaller black spots the size of approximately two silver dollars. -room [ROOM NUMBER]: Had a dark black stain which measured approximately one foot four inches by six inches wide. -room [ROOM NUMBER]: Had huge gouges in the wall behind the recliner with sheet rock exposed. The wall heater was partially disconnected from the wall and had a broken plastic vent. -room [ROOM NUMBER]: The pads on the wheelchair arm rests and wheelchair were covered with dried orange food substance. -The carpets near the D hall dining room had multiple scattered black stains in/down the hallway. -room [ROOM NUMBER]: Had a large dark black stain on the carpet. -The day room at the end of D hall had several scattered black stains on the carpet. On 7/28/23 at 2:00 PM Staff 23 (Maintenance Director) made observations of the identified rooms and acknowledged the multiple stained carpets, broken wall heater and the unclean wheelchair.

Based on interview and record review it was determined the facility failed to obtain copies of Advance Directive for 1 of 4 sampled residents (#5) reviewed for Advance Directives. This placed residents at risk for lack of end of life choices being honored. Findings include: Resident 5 was admitted to the facility in 2023 with diagnoses including UTI and muscle weakness. Resident 5's 5/23/23 Admission MDS indicated she/he was cognitively intact. Resident 5's 5/23/23 Health Center Admission Agreement indicated the resident had an Advance Directive. Resident 5's 6/6/23 Care Conference Note indicated the resident's Advance Directive was not reviewed. Resident 5's clinical record revealed there was no copy of her/his Advance Directive. On 7/26/23 at 11:00 AM Staff 16 (Social Service Director) stated upon admission residents were asked if they had an Advance Directive and if so to provide a copy. Staff 16 stated if a copy of the resident Advance Directive was not provided on admission, her process was to follow-up within a few days to obtain a copy. Staff 16 stated she did not follow-up with Resident 5 to obtain a copy of her/his Advance Directive.

Based on observation and interview the facility failed to ensure residents were treated with respect for their personal possissions for 1 of 1 sampled resident (#56) reviewed for choices. This placed residents at risk for lack of respecting private belongings. Findings include: Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke. On 7/24/23 at 12:16 PM Resident 56 stated on multiple occasions she/he requested for staff to ask permission before they retrieved something from her/his nightstand. Resident 56 stated staff continued to retrieve items from her/his nightstand without asking and this was very upsetting because it's my private stuff! Resident 56 was observed to be anxious and tearful when she/he expressed the concern. The night stand had the top drawer opened approximately four inches and the resident's personal items were visible inside the drawer. On 7/27/23 at 10:31 AM Staff 21 (LPN) stated Resident 56 had concerns regarding staff opening and grabbing things out of her/his nightstand without asking. Staff 21 stated the resident was upset because of her/his personal papers and own private items in the nightstand. Staff 21 stated this was an ongoing issue mostly with agency staff but all staff were expected to ask permission before getting into Resident 56's nightstand. On 7/27/23 at 11:37 AM Staff 19 (CNA) stated Resident 56 had ongoing concerns with staff not asking permission prior to getting into her/his nightstand and was very upset and tearful. Staff 19 stated all staff were expected to ask permission before just grabbing items out of Resident 56's nightstand. On 7/28/23 at 2:03 PM Staff 17 (RNCM) stated she was unaware Resident 56 had concerns regarding staff getting into her/his nightstand without permission. Staff 17 stated she expected staff to ask permission prior to accessing items in Resident 56's nightstand.

Based on interview and record review it was determined the facility failed to treat a resident with dignity for 1 of 1 sampled resident (#47) reviewed for dignity. This placed residents at risk for lack of dignity and quality of life. Findings include: Resident 47 was admitted to the facility in 2023 with diagnoses including PTSD (Post-Traumatic Stress Disorder), anxiety disorder and depression. Resident 47's 6/11/23 Quarterly MDS indicated a moderately severe score for depression. Resident 47's 6/12/23 Care Plan for psychosocial well-being indicated staff were to involve the resident in all aspects of care to encourage resident empowerment. A Progress Note dated 7/18/23 indicated the resident complained of itching in her/his private genital area. A physician's order was received for the resident to be administered Diflucan (anti-fungal medication) orally one time a day for three days for the yeast infection. Resident 47's provider progress note dated 7/27/23 indicated Resident 47 continued to experience genital discomfort and itchiness. A physical exam was performed and the resident was ordered a cream for her/his genital area for symptoms of burning and itching. On 7/24/23 at 2:30 PM Resident 47 stated a couple of weeks ago Staff 16 (Social Service Director) came to her/his room and said staff reported that she/he was sexually aroused during peri-care (genital cleaning) which made the staff uncomfortable. Resident 47 reported she/he was not sexually aroused and was humiliated by this information and cried. On 7/28/23 at 9:50 AM Staff 28 (CNA) stated Resident 47 moaned during peri-care from the itching and pain. Staff 28 stated she was told by Staff 20 (LPN) the resident was changed from a one-person staff assist to a two-person staff assist due to reports about the resident being sexually aroused with cares. On 7/28/23 at 10:50 AM Staff 27 (CNA) stated she had a conversation with Resident 47 which occurred after the resident was changed from a one-person staff assist to a two-person staff assist to provide cares. The resident told her Staff 16 reported there was a staff complaint that the resident enjoyed peri-care in a sexual manner. Staff 27 reported the resident was upset and cried. On 7/28/23 at 11:47 AM Staff 16 stated she had a conversation with Resident 47 in 7/2023 about staff reports of feeling uncomfortable when providing the resident peri-care. Staff 16 told the resident staff reported her/his response to peri-care appeared to be sexual arousal. Staff 16 reported the resident was shocked and upset as a result of the conversation. On 7/28/23 at 1:48 PM Staff 17 (RNCM) stated two agency CNAs on evening shift reported being uncomfortable when providing peri-care to the resident as the resident made sounds like it was pleasurable. Staff 17 stated no other CNAs had concerns with providing peri-care to Resident 47. Staff 17 stated the resident was changed to a two-person assist for all cares due to the situation. A review of Resident 47's clinical record revealed no documentation to indicate the facility thoroughly investigated or took into consideration the resident's diagnosed condition. On 7/31/23 at 11:05 AM Staff 1 (Administrator) and Staff 2 (DNS) stated two agency staff from evening shift reported concerns regarding Resident 47's sexual response during peri-care. The situation was discussed in a morning meeting. Staff 16 discussed the concern with the resident and how it made staff uncomfortable. Staff 1 and Staff 2 reported Resident 47 did not previously demonstrat sexual behavior and they did not interview other staff to see if they had concerns regarding this behavior. Based on the concern expressed by the two agency staff the resident was changed from one-person staff assist to two-person staff assist for all cares. Staff 1 and Staff 2 indicated there was no follow-up or monitoring regarding the incident.

1. Based on observation, interview and record review it was determined the facility failed to ensure Resident 8 was safe from sexual abuse for 1 of 5 sampled residents (#8) reviewed for abuse. This failure was determined to be an immediate jeopardy situation because the facility failed to prevent Resident 13 from sexually abusing Resident 8 three times in the past six months. Findings include: Resident 8 was admitted to the facility in 7/2022 with diagnoses including dementia. A 1/16/23 Quarterly MDS revealed Resident 8 was unable to be interviewed and the staff's cognitive assessment revealed Resident 8 had long term and short term memory problems. Resident 13 was admitted to the facility in 7/2022 with diagnoses including surgical amputation. Resident 13's 3/20/23 MDS identified resident with a BIMS score of 15; which indicated Resident 13 was cognitively intact. Resident 13's 10/11/22 Care Plan identified Resident 13 with a history of exhibited sexually inappropriate behaviors to residents and staff. A 10/31/22 Facility Reported Incident revealed Resident 13 inappropriately touched Resident 8's upper body. A 1/5/23 Public Compliant revealed Resident 13 inappropriately touched Resident 8's upper body. A 1/5/23 and 1/9/23 Communications Report revealed the Dallas Police Department responded to two separate incidents related to sexual advancements made by Resident 13 toward Resident 8. Resident 13 attempted to coerce Resident 8 into bed. Resident 13 was advised by the Officer on the scene that her/his actions were considered verbal and physical sexual harassment. A 3/16/23 Communication Note revealed Resident 13 was educated regarding the continued pattern of inappropriate sexual touching of Resident 8. On 4/27/23 at 10:20 AM Staff 17 (CNA) indicated Resident 13 continued to touch female residents' arms, legs, and back. On 4/27/23 at 10:25 AM Staff 7 (LPN) stated Resident 13 continued to have inappropriate conversations and engaged in inappropriate sexual behavior such as stating to female residents about getting married and having babies. On 4/27/23 at 10:53 AM Staff 3 (RNCM) stated that Resident 13 had a history of sexual comments and advancements toward to Resident 8. Staff 3 stated Resident 13's actions continued, and staff redirected her/his behavior on a routine basis. Staff 3 further stated there were five additional female residents with cognitive impairment on the second floor. On 4/27/23 at 11:11 AM, Staff 1 (Administrator) confirmed Resident 13 attempted to engage in sexual activity which included inappropriate touching and talking with Resident 8 on 10/31/22, 1/5/23, and 3/16/23. The Administrator stated no investigation or interventions were conducted to protect Resident 8 from Resident 13's sexual advancements. Staff 1 stated no changes to Resident 13 or Resident 8's care plan were completed to ensure Resident 8's safety from Resident 13's sexual advancements. A 4/27/23 email from Staff 1 (Administrator) to Witness 10 (Case Manager) revealed Staff informed Witness 10, Resident 13 was identified as a predator. On 4/27/23 at 1:44 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 4/27/2023 at 5:23 PM the facility submitted an acceptable immediacy removal plan. The immediacy removal plan included the following: All female residents with cognitive impairments were at risk for inappropriate sexual behaviors and comments. RN Unit Manager for E/F wings updated resident's care plan to reflect predatory behaviors, to include one-on-one supervision, which meant a CNA would monitor Resident 13 24/7 as well as follow her/him whenever she/he left her/his room and a behavior monitor was put in place as of 2:30 PM on 4/27/23. Thirty-minute checks were changed to one-on-one (1:1) supervision as of 2:30 PM on 4/27/23. Resident 13 would not be seated near female resident(s) at activities, dining, or at any other time when possible. All staff would be educated on this by 5:00 PM on 4/28/23. Interdisciplinary team (IDT) reviewed and revised Resident 13's care plan to identify patterns in resident's behaviors and implemented appropriate interventions which had been completed as of 4:30 Pm on 4/27/23. Care plan revisions and interventions would be communicated to the front line staff caring for the resident which would be completed by 5:00 PM on 4/28/23. Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident as of 4:30 PM on 4/27/23. All staff who worked with Resident 13 would be educated on her/his inappropriate sexual behaviors and when to report inappropriate sexual behaviors/abuse. This will be completed by 5:00 PM 4/28/23. Resident was on a one-on-one supervision 24/7 until there was a safe discharge plan. The CNA would follow Resident 13 when she/he left her/his room. If Resident 13 approached another female resident, staff would intervene and redirect her/him. The staff would also be educated on reporting any inappropriate behaviors to the charge nurse which would be completed by 5:00 PM on 4/28/23. The RN Unit Manager for E/F wings would educate nurse aides and licensed nurses on documenting behaviors by 5:00 PM on 4/28/23. In the event of any future resident to resident sexual abuse, the perpetrating resident would be placed on one one-on-one (1:1) supervision within thirty minutes of notification to the Administrator or DNS until primary care, nursing, or psychiatric evaluations could be completed. Outcomes of those evaluations would result in continued one-on-one (1:1) supervision or the initiation of discharge planning to a facility that focused on behavior management as of 2:30 PM on 4/27/23 for Resident 13. Residents with BIMS scores of 12 and below would be interviewed/assessed for potential abuse, which will be completed by 5:00 PM on 4/28/23. Reviewed/modifed current policies as applicable to ensure appropriate procedures we in place to prevent harm/potential harm by 5:00 PM on 4/28/23. New policies would be written/implemented when applicable to ensure additional serious harm would be prevented by 5:00 PM on 4/28/23, Educate all staff on facility abuse policies, as well as abuse prevention and reporting, with return demonstration, where applicable by 5:00 PM on 4/28/23. Abuse investigation procedure and documentation process reviewed and revised by 5:00 PM on 4/28/23. The current process was if physical abuse was reported, the charge nurse would do a skin assessment the same day. The victim resident would be interviewed, if able to, within 24 hours of the incident being reported. The victim resident would be put on alert monitoring the same day of the reported incident. Other interventions for the victim resident could include would be room moves, placement of stop signs, one-on-one for resident, location monitoring, etc. On 5/1/23 staff interviews verified re-education per the immediacy removal plan was completed. A review of all documention revealed all aspects of the immediacy removal plan was implemented. On 5/1/23 at 10:31 AM it was determined the IJ Immediacy was removed. 2. Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 5 sampled resident (#12) reviewed for abuse. This placed residents at risk for skin injuries. Findings include: Resident 12 was admitted to the facility in 5/2022 with diagnoses including cerebral infarction (stroke). A 10/31/22 Care Plan identified Resident 12 with displayed behaviors of crying, screaming, yelling, hallucinations, rejection of care, and suicidal ideation. A 4/13/22 Facility Incident Report revealed Staff 21 (CNA) held Resident 12's arm's down during performed care tasks. Staff 21 reported she attempted to place Resident 12 into bed which caused Resident 12 to become combative. Staff 21 confirmed she grabbed Resident 12 arms and held her/him down to provide care for the resident and scratched Resident 12's arm as a result. On 5/1/23 at 12:16 PM Staff 1 (Administrator) confirmed findings and stated Resident 12's scratch marks on her/his arm were caused by Staff 21.

1. Based on interview and record review it was determined the facility failed to ensure a resident's urine test and or results were communicated with the resident's physician in a timely manner for 1 of 3 sampled residents (#2) reviewed for change of condition. Resident 2 continued to show symptoms of an infection, was transferred to the emergency room to start antibiotics and was later admitted to the hospital and diagnosed with [CONDITION(S)] related to a UTI. Findings include: Resident 2 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 2/16/20 CAA indicated the resident had a Foley catheter which placed the resident at increased risk for UTIs. Progress Notes revealed on 4/2/20 the resident had a fever of 100.4 F. The resident did not have respiratory symptoms, the provider was notified, an order was obtained to provide Tylenol (over the counter medication to treat fevers) and to obtain a urine specimen for a dip test (Thin plastic stick with chemical strips on it. Urine is placed on the strip and the strip changes color. It is used as a preliminary test to detect abnormalities including UTIs.) The resident's record did not have the results of the urine dip test. Progress notes revealed from 4/3/20 through 4/7/20 the resident's urine was, at times, noted to be cloudy and her/his temperatures ranged from 99.0 to 100.9 F. The resident was administered Tylenol PRN. The 4/7/20 Progress Note by Staff 3 (LPN) indicated Witness 13 (Physician) called the facility and reported she saw the resident's urine dip results and said at this point by the time we get the C & S [Culture and Sensitivity] results for the ABX [antibiotic] [she]/he could be in much worse shape so you should send [her/]him out. The resident was transported to the local hospital and returned 4/8/20 at 12:20 AM on antibiotics. On 4/8/20 the resident's CBG was 473 and the physician was notified. Later the CBG was rechecked and was 476, the resident had a temperature of 102.5, was flushed, diaphoretic and more lethargic than baseline. The resident's physician was notified and the resident was sent to the hospital. The 4/9/20 hospital History and Physical indicated the resident was seen in the emergency roiagnom on [DATE], was started on antibiotics and was discharged back to the facility. The resident continued to have fevers and elevated blood sugars. The resident's urine culture was not responsive to the antibiotic started on 4/7/20 and the antibiotic was changed. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/21 at 1:14 PM Staff 3 (LPN) indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 3 did not recall the specific information related to the urine dip test. The 8/16/21 e-mail from Staff 4 (DNS) indicated she was not able to find the 4/2/20 urine dip test results. On 8/20/21 at 2:47 PM Staff 4 verified she was not able to find the results of the urine dip test in the resident's chart. Staff 4 indicated the facility had the urine test strips in the facility, the resident had a Foley catheter and the test was easy to obtain. Staff 4 indicated she was not sure when the results were sent to the physician. Staff 4 acknowledged if the results were sent on 4/2/20 the staff should have tried to get a response from the physician before 4/7/20 and if the results were not sent until 4/7/21 there was a delay in obtaining the urine dip test. On 8/18/21 at 3:45 PM Witness 12 (Witness 13's Office Assistant) indicated Witness 13 reported she recalled the 4/2/20 incident with Resident 2's urine and indicated Witness 13 was not able to say whether or not the resident's [CONDITION(S)] would have been prevented if treated sooner. 2. Based on interview and record review it was determined the facility failed to remove staples after surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . This placed residents at risk for delayed care and delayed wound healing. Findings include: Resident 1 was readmitted to the facility 11/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. Resident 1's 11/4/20 hospital Discharge Summary and orders indicated the resident had a leg amputation. The resident was to make a follow-up appointment with the surgeon as soon as possible for a visit. The resident's record did not have documentation to indicate a surgical follow up appointment was scheduled. The resident's 11/24/20 Progress Note indicated the resident had 32 staples intact to the right amputation site and it was more than 30 days after the resident's surgery. On 8/12/21 at 9:13 AM Witness 7 (Complainant) reported Resident 1 went to a primary physician appointment and the resident's skin was found to have grown over the staples. The staples were removed in the office. On 8/16/21 at 10:15 AM Staff 7 (RNCM) stated after surgery Resident 1 was admitted to the skilled nursing unit. When the resident returned to the non-skilled unit the nurses identified the resident to still have staples. The physician was notified, an appointment was made and the staples were removed at the physician's office. On 8/19/21 at 11:34 AM Witness 6 (Surgeon's Medical Assistant) stated after a resident had surgery the post-hospital appointment was usually made two weeks after the procedure and staples were removed within that time frame. b. The 8/28/20 CAAs indicated Resident 1 had vascular surgery to the right leg to assist with circulation and wound healing. The surgery was not successful and the resident had a right partial foot amputation. The resident was admitted to the facility post-partial foot amputation. The Skin and Wound Evaluation sheets for the right partial foot amputation indicated the staff monitored the wounds weekly. On 8/3/20, first assessment after readmission, the resident's foot wound had 20 percent granulation (new tissue which is formed during wound healing) and 80 percent slough (dead tissue). The area of the wound was initially assessed to be 21 centimeters. The wound decreased in size but the amount of granulation tissue, slough and eschar (black dead tissue) varied each week. On 9/11/20 the wound had 30 percent granulation and 70 percent eschar, on 9/15/20 the wound was identified to have a faint odor after cleansing and on 9/22/20 the skin around the wound was assessed to have intense redness and moderate odor after cleansing. On 9/29/20 there was slight odor after cleansing but the wound had seropurulent (clear drainage tinged with milky drainage-potential sign of infection) drainage. On 10/13/20 the wound had 90 percent slough and purulent drainage (indicative of infection). The sheets did not indicate the physician was notified of the wound status including the development of eschar, intense redness and purulent drainage. The August, September and October 2020 TARs indicated the treatment was not changed to potentially assist with slough debridement (removal) or to culture the wound for infection. The 8/1/20 through 10/17/20 Progress Notes did not indicate the physician was updated on the resident's partial foot amputation when the wound developed eschar on 9/11/20, intense redness on 9/22/20, an odor or seropurulent drainage on 9/29/20 and purulent drainage on 10/13/20. On 10/16/20 the Progress Note indicated the resident's foot was red, warm to touch, had foul drainage to the wound bed and was covered with 80 percent slough. On 8/19/20 at 4:05 PM Staff 7 (RNCM) indicated if a wound did not show signs of improvement after two weeks, the physician was to be notified and a treatment change would possibly be implemented. Staff 7 indicated the resident's wound did not have granulation tissue prior to the 10/16/20 hospitalization and Staff 7 and Staff 4 (DNS) did not find documentation in the resident's record to indicate the facility contacted the resident's physician.

Based on interview and record review it was determined the facility failed to prevent the development of a pressure ulcer and failed to demonstrate the resident's clinical condition made the development of a pressure ulcer unavoidable for 1 of 3 sampled residents (#12) reviewed for pressure ulcers. This resulted in Resident 12 developing an unstageable pressure ulcer. Findings include: Resident 12 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. The National Pressure Ulcer Advisory Panel defined the following pressure injury stages: Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident 12's 5/26/17 Pressure Ulcer CAA indicated the resident was at risk for pressure ulcers and the resident required extensive assistance with bed mobility. Risk factors included diabetes, pain and spending much of her/his time in bed. The assessment indicated the resident was repositioning and staff encouraged and assisted the resident to reposition every two hours. The resident did not have any pressure ulcers and was on a pressure redistribution mattress. A Clinical Notes Report dated 5/22/17 indicated Patient is corporative (sp) with care. A Clinical Notes Report dated 5/23/17 indicated .was cooperative with cares throughout the day. A Clinical Notes Report dated 5/25/17 indicated This LN used wedge to help position resident off of (sp) (her/his) bottom to help relieve pain and aide in comfort. Resident repeatedly removed the wedge after repositioning. A Clinical Notes Report dated 5/26/17 indicated Resident refuses to be repositioned off of (her/his) bottom. A Clinical Notes Report dated 6/8/17 indicated Resident 12's skin was pink, warm and dry with no new skin issues. An Event Report dated 6/9/17 indicated a 0.8 cm by 0.8 cm circular fluid filled area was found on Resident 12's left heel. The foot was elevated with a pillow and the resident was educated on compliance with keeping the heel floated (propped up to prevent the heel from being in contact with a surface). The report failed to indicate if the resident's care plan was followed. The root cause was indicated as stasis and non-compliance with repositioning. An attached Event Investigation dated 6/9/17 indicated the root cause was poor safety awareness and Resident 12 declined the use of a heel wedge. A Clinical Notes Report dated 6/10/17 indicated a 0.8 cm by 0.8 cm circular fluid filled area was found on the bottom of Resident 12's heel. The fluid filled area was dark blue and purple in the center. The note indicated Resident 12 was non-compliant with repositioning and floating her/his heels. The resident reported the wedge (cushion used for positioning) was uncomfortable and declined its use. The resident preferred to stay in bed most of the day. Resident 12 and her/his spouse were spoken to about the importance of repositioning and floating the heels. A Clinical Notes Report dated 6/12/17 indicated on 6/9/17 at 5:00 pm an unstageable pressure ulcer was found on the bottom of Resident 12's right heel. The wound was a 0.8 cm by 0.8 cm blood filled blister. The resident complained of pain from the wound. The note indicate Resident 12 often refused care and repositioning due to pain or no reason given. The root cause was believed to be self-inflicted related to poor safety awareness declining care and repositioning. Resident 12's heels were to be floated at all times and an order for [REDACTED]. A Wound Care Addendum dated 6/12/17 indicated Resident 12 had a 0.8 cm by 0.8 cm unstageable pressure ulcer on the right heel. A Wound Care Addendum dated 7/3/17 indicated Resident 12 had a 2.0 cm by 2.0 cm unstageable pressure ulcer on the right heel. A Wound Care Addendum dated 7/14/17 indicated Resident 12 had an unstageable pressure ulcer on the heel. The assessment failed to indicate which heel and did not provide measurements of the wound. The wound bed was described as black. A review of Resident 12's Clinical Notes Report from 5/19/17 through 6/8/17 revealed no documentation the resident refused to float her/his heels. A review of Resident 12's clinical record revealed no indication the resident was offered alternative treatments or staff educated the resident regarding the risks and benefits of floating her/his heels related to the resident's supposed non-compliance with floating her/his heels prior to the development of the unstageable pressure ulcer discovered on 6/9/17. On 11/27/17 at 11:03 am Staff 8 (RNCM) stated Resident 12's Clinical Notes Reports indicated the resident was non-compliant with cares but she acknowledged the notes did not specifically indicate the resident refused to float her/his heels. Staff 8 stated she was not aware the resident refused cares until after the resident developed the unstageable pressure ulcer on her/his heel. Staff 8 stated she believed Resident 12's clinical record demonstrated the resident was non-compliant with cares. Staff 8 was asked to provide documentation to indicate Resident 12 was non-compliant with floating her/his heels. No addition documentation to indicate Resident 12 was non-compliant with floating her/his heels prior to the identification of the unstageable pressure ulcer on the resident's heel on 6/9/17 was provided.

Based on interview and record review it was determined the facility failed to intervene related to a resident's change in condition for 1 of 7 sampled residents (#9) reviewed for death. This failure resulted in Resident 9 experiencing a noted decline in condition without medical intervention prior to the resident's death. Findings include: Resident 9 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. A Clinical Notes Report entered as a late entry for [DATE] at 9:30 pm by Staff 4 (LPN) indicated Resident 9 was reported by the previous shift as declining. Staff 4 assessed the resident at the start of her (evening) shift and the resident was breathing rapidly, had a very high heart rate and was ashen in color. Staff 4 checked on the resident throughout the shift and observed no improvement. The resident was unresponsive throughout the shift. The resident's medications were not administered per nursing judgement. At 7:15 pm the resident was observed by Staff 4 and the resident was still breathing. At around 7:20 pm a CNA requested Staff 4's assistance and the resident was not breathing and had no heartbeat. Staff 4 called the resident's family and later notified the resident's physician. A review of Resident 9's clinical record revealed no indication staff took any actions related to the resident's change in condition other than monitoring the resident through the shift. There was no evidence the physician or family were notified and given the opportunity to make informed healthcare decisions related to the change in condition prior to the resident's death. Resident 1's Face Sheet printed for this surveyor on [DATE] indicated the resident did not wish to be resuscitated. A review of Resident 9's Resident Vital Sign Report revealed the resident's vital signs were last documented on [DATE] at 11:03 am and were as follows: blood pressure ,[DATE], heart rate 84, respirations 16 and temperature 98.2 degrees. No vital signs were documented on [DATE], the day Resident 9 was reported as declining and subsequently died . On [DATE] at 11:38 am Staff 3 (RNCM) stated in [DATE] there was a meeting with the family to discuss hospice services for Resident 9. At that time the family refused hospice. The family felt the resident was not having pain issues and the facility was managing the resident's care. Staff 3 stated a family member visited the resident the day before she/he died . Staff 3 stated on [DATE] around 5:30 pm she told Staff 4 (LPN) to call Resident 9's physician and family because the resident was lethargic and not eating. On [DATE] at 11:08 am and [DATE] at 11:57 am Staff 4 (LPN) stated on [DATE] she came on duty (for evening shift) and received shift report which included Resident 9 was not having a good day. She stated she checked on the resident at the beginning of her shift and the resident was ashen with rapid labored breathing. The resident was in bed, non-responsive, not swallowing and not making eye contact. Staff 4 stated she listened to the resident's heart and lungs but did not do a full head-to-toe assessment. She said the nursing aides were providing routine care for the resident. She stated she kept checking on the resident and her/his color was more ashen as the evening progressed. At 7:25 pm an aide called her to the resident's room and the resident was not breathing and had no heartbeat. She stated the resident was still twitching. She stated she made sure the resident's code status was DNR (do not resuscitate), called the resident's family and physician, then performed post-mortem care. Staff 4 acknowledged the resident was breathing rapidly and became more ashen during the shift. Staff 4 acknowledged she did not call the resident's physician prior to her/his death because she thought the resident was having a down day.

Based on interview and record review it was determined the facility failed to ensure Staff 4 (LPN) adhered to professional standards related to a resident's change in condition for 1 of 7 sampled residents (#9) reviewed for death. This failure resulted in Resident 9 experiencing a noted decline in condition without appropriate intervention prior to the resident's death. Findings include: OAR 851¿045¿0040 Scope of Practice Standards for All Licensed Nurses indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. OAR 851¿045¿0050 Scope of Practice Standards for Licensed Practical Nurses indicated the following: (2) Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation. Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care, and applying practical nursing knowledge drawn from the biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Licensed Practical Nurse shall: (a) Conduct and document initial and ongoing focused nursing assessments of the health status of clients by: (A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; (B) Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data; (D) Anticipating and recognizing changes or potential changes in client status; Identifying signs and symptoms of deviation from current health status; and (C) Selecting appropriate nursing interventions and strategies; (d) Implement the plan of care by: (A) Implementing treatments and therapy, appropriate to the context of care, including, but not limited to, medication administration, nursing activities, nursing, medical and interdisciplinary orders; health teaching and health counseling. OAR 851¿045¿0070 Conduct Derogatory to the Standards of Nursing Defined indicated the following: Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: (1) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. (2) Conduct related to other federal or state statute/rule violations: (b) Neglecting a client. The definition of neglect includes, but is not limited to, carelessly allowing a client to be in physical discomfort or be injured. (3) Conduct related to communication: (h) Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse co¿worker) in an ongoing and timely manner; and (i) Failing to communicate information regarding the client's status to other individuals who need to know; for example, family, and facility administrator. Resident 9 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. A Clinical Notes Report entered as a late entry for [DATE] at 9:30 pm by Staff 4 (LPN) indicated Resident 9 was reported by the previous shift as declining. Staff 4 assessed the resident at the start of her (evening) shift and the resident was breathing rapidly, had a very high heart rate and was ashen in color. Staff 4 checked on the resident throughout the shift and observed no improvement. The resident was unresponsive throughout the shift. The resident's medications were not administered per nursing judgement. At 7:15 pm the resident was observed by Staff 4 and the resident was still breathing. At around 7:20 pm a CNA requested Staff 4's assistance and the resident was not breathing and had no heartbeat. Staff 4 called the resident's family and later notified the resident's physician. A review of Resident 9's clinical record revealed no indication Staff 4 took any actions related to the resident's change in condition other than monitoring the resident through the shift. There was no evidence the physician or family were notified and given the opportunity to make informed healthcare decisions related to the change in condition prior to the resident's death. Resident 1's Face Sheet printed for this surveyor on [DATE] indicated the resident did not wish to be resuscitated. A review of Resident 9's Resident Vital Sign Report revealed the resident's vital signs were last documented on [DATE] at 11:03 am and were as follows: blood pressure ,[DATE], heart rate 84, respirations 16 and temperature 98.2 degrees. No vital signs were documented on [DATE], the day Resident 9 was reported as declining and subsequently died . On [DATE] at 11:38 am Staff 3 (RNCM) stated in [DATE] there was a meeting with the family to discuss hospice services for Resident 9. At that time the family refused hospice. The family felt the resident was not having pain issues and the facility was managing the resident's care. Staff 3 stated a family member visited the resident the day before she/he died . Staff 3 stated on [DATE] around 5:30 pm she told Staff 4 (LPN) to call Resident 9's physician and family because the resident was lethargic and not eating. On [DATE] at 11:08 am and [DATE] at 11:57 am Staff 4 (LPN) stated on [DATE] she came on duty (for evening shift) and received shift report which included Resident 9 was not having a good day. She stated she checked on the resident at the beginning of her shift and the resident was ashen with rapid labored breathing. The resident was in bed, non-responsive, not swallowing and not making eye contact. Staff 4 stated she listened to the resident's heart and lungs but did not do a full head-to-toe assessment. She said the nursing aides were providing routine care for the resident. She stated she kept checking on the resident and her/his color was more ashen as the evening progressed. At 7:25 pm an aide called her to the resident's room and the resident was not breathing and had no heartbeat. She stated the resident was still twitching. She stated she made sure the resident's code status was DNR (do not resuscitate), called the resident's family and physician, then performed post-mortem care. Staff 4 acknowledged the resident was breathing rapidly and became more ashen during the shift. Staff 4 acknowledged she did not call the resident's physician prior to her/his death because she thought the resident was having a down day. Refer to F-684

Based on interview and record review it was determined the facility failed to notify the physician and the family of a resident's significant change in condition for 1 of 7 sampled residents (#9) reviewed for death. This failure resulted in Resident 9 experiencing a noted decline in condition without an opportunity for the physician or responsible party to make informed healthcare decisions prior to the resident's death. Findings include: Resident 9 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. A Clinical Notes Report entered as a late entry for 10/17/17 at 9:30 pm by Staff 4 (LPN) indicated Resident 9 was reported by the previous shift as declining. Staff 4 assessed the resident at the start of her (evening) shift and the resident was breathing rapidly, had a very high heart rate and was ashen in color. Staff 4 checked on the resident throughout the shift and observed no improvement. The resident was unresponsive throughout the shift. The resident's medications were not administered per nursing judgement. At 7:15 pm the resident was observed by Staff 4 and the resident was still breathing. At around 7:20 pm a CNA requested Staff 4's assistance and the resident was not breathing and had no heartbeat. Staff 4 called the resident's family and later notified the resident's physician. A review of Resident 9's clinical record revealed no evidence the physician or family were notified and given the opportunity to make informed healthcare decisions related to the change in condition prior to the resident's death. On 10/30/17 at 11:38 am Staff 3 (RNCM) stated on 10/17/17 around 5:30 pm she told Staff 4 (LPN) to call Resident 9's physician and family because the resident was lethargic and not eating. Staff 3 acknowledged the resident's physician and family should have been notified. On 10/25/17 at 2:17 pm Staff 2 (DNS) acknowledged Resident 9's physician should have been notified. On 10/26/17 at 11:08 am and 11/8/17 at 11:57 am Staff 4 (LPN) acknowledged she did not call the resident's physician prior to her/his death because she thought the resident was having a down day. Refer to F-684

Based on interview and record review it was determined the facility failed to ensure medications had adequate indications for use and were not given in excessive doses for 1 of 4 sample residents (# 2) and to ensure adequate monitoring of medications for 1 of 4 sample residents (# 3) whose medications were reviewed. Resident 2 had a decline in ADL function, a narcotic overdose and was hospitalized . Resident 3 had a fall with fractures and was hospitalized . The residents were reviewed as closed records. Findings include: 1. Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Clinical Notes, physician's orders [REDACTED]. Routine pain medications included: a. [MEDICATION NAME] (for neuropathic pain) was gradually increased from 100 mg BID and 300 mg HS on [DATE], to 300 mg QID on [DATE]. b. [MEDICATION NAME] (opioid narcotic) 25 mcg/hour [MEDICATION NAME] every 3 days was added/started on [DATE] and increased to 50 mcg/hour on [DATE]. The PRN pain medications included [MEDICATION NAME] (narcotic [MEDICATION NAME]) ,[DATE] mg, which was increased from 1 tablet BID PRN on [DATE] to 2 tablets QID PRN on [DATE]. A physician consultant's note dated [DATE] indicated the resident had a history of [REDACTED]. The pain level varied between ,[DATE] and ,[DATE]. After the resident started taking [MEDICATION NAME] (for neuropathic pain), she/he developed swelling in both hands, possibly related to use of the [MEDICATION NAME]. "With the pain and swelling in the hands, the (resident) has actually regressed in terms of (her/his) level of functioning. Prior to the onset of ... hand problems, (she/he) says that (she/he) was able to feed himself... (She/he) is no longer able to feed (her/himself).... (She/he) is going to have difficulty making progress in therapy until ... hand pain and swelling diminish." Clinical Notes dated [DATE] to [DATE] indicated the resident was having difficulty swallowing liquids. There was no assessment of the swollen hands related to use of [MEDICATION NAME], and no assessment of the resident's fluid status related to swallowing difficulty, inability to feed her/himself and increased opiates/narcotic use. There was no documented assessment of the need of the narcotic and opioid pain medications related to the increased neuropathic pain in the resident's hands. MARs dated [DATE] to [DATE] showed administration of the following: a. [MEDICATION NAME] 300 mg QID. b. [MEDICATION NAME] 50 mcg/hour [MEDICATION NAME] every 3 days, placed on [DATE] and [DATE]. c. [MEDICATION NAME] ,[DATE] two tablets PRN given one time on [DATE], [DATE] and [DATE]. Clinical Notes dated [DATE] indicated the resident had a change of orientation and was unable to follow commands. When the resident was taken to her/his room her/his blood pressure was found to be 60/palp (palpable diastolic blood pressure) and "911" was activated. The resident was put to bed with legs elevated and blood pressure came up to ,[DATE]. EMS arrived and removed the [MEDICATION NAME] 50 mcg/hour patch and gave [MEDICATION NAME] (to remove narcotics from the system), and the resident responded. The resident was taken to the hospital. The hospital Admission History and Physical dated [DATE] indicated the resident was unconscious on arrival. The resident responded and revived with [MEDICATION NAME] administration. It was concluded the resident had a narcotic overdose. Decreased fluid intake may have worsened the "inadvertent narcotic overdose..." versus the resident being "chronically over narcotized". On [DATE] at 2:30 pm Staff 1, DNS stated there was no pain assessment/pain management plan found related to the increased use of narcotic/opioid medications and was unable to provide information related to whether the pain in the hands would be best managed by [MEDICATION NAME] or another medication for neuropathic pain. There was no further information provided related to adequate monitoring and assessment of fluid status and the increased risk of narcotic/opioid overdose in the presence of dehydration. 2. Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. There were physician's admission orders [REDACTED]. According to the 2012 Nursing Drug Handbook [MEDICATION NAME] has adverse reactions which include ataxia, dizziness, [MEDICAL CONDITION], blurred vision, and respiratory depression. An Initial Psychopharmacological Drug and Behavior Review dated [DATE] did not include the onset, duration or frequency of anxiety, and safety issues including the resident's poor eyesight (legally blind) or the increased risk of falls. The dose of [MEDICATION NAME] remained the same as at admission. Clinical Notes and MARs dated [DATE] indicated the resident received her/his regularly scheduled dose of [MEDICATION NAME]. At 10:00 am the resident was found on the bathroom floor with head beside toilet and lying on the her/his right side. The resident had a bloody nose, bruises on the right shoulder, left knee and right hand. The resident complained of pain in the shoulder and back, pupils were sluggish and blood pressure was ,[DATE]. There was blood in the resident's hair and staff were unable to find the source of bleeding. There was a skin tear on the right elbow and she/he had left leg abduction. The resident was sent to the hospital. The hospital admission history and physical dated [DATE] indicated the resident had a ground level fall. She/he was "apparently down for some time before (she/he) was found, it is not clear if (she/he) lost consciousness." The resident had a fractured humerus, a UTI, facial bone fractures, knee pain, and [MEDICATION NAME] hemorrhage. There was no assessment of the resident's increased risk of falls from [MEDICATION NAME] use and no behavioral monitoring of the anxiety symptoms found. On [DATE] at 2:30 pm, Staff 1, DNS was unable to provide an assessment and ongoing behavioral monitoring of the resident's anxiety. Staff 1 stated no recommendations were made in ,[DATE] related to reducing or discontinuing the [MEDICATION NAME], as they were waiting for four months after admission to try a dose reduction.

Based on interview and record review it was determined the facility failed to provide pain assessments and management; and assessments of fluid status and management for 2 of 4 sample residents (#'s 1 & 4) reviewed for changes in condition. The residents were reviewed as closed records. Resident 1 had [MEDICAL CONDITION], was hospitalized and received IV fluids. Resident 4 had [MEDICAL CONDITION] and was hospitalized . Findings include: 1. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Physician's admission orders [REDACTED]. There was no initial pain assessment related to restless leg syndrome and the continued need/use of two pain medications which were used to treat an acute condition in the hospital. Clinical Notes from 8/15/13 to 8/19/13 included the resident had poor food/fluid intake and had symptoms of UTI. Intake and output records showed the resident had excessive output related to fluid intake on 8/15/13 and 8/18/13. (8/15/13 Intake: 360 ml Output: 500 ml 8/18/13 Intake: 480 ml Output: 850 ml). There was no assessment of the intake and output related to decreased fluid intake, dehydration and symptoms of UTI. Clinical Notes dated 8/19/13 indicated the resident was declining, had increased weakness, was withdrawn and had no interest in eating. The resident was taken by family to a clinic for a blood transfusion, and was admitted to the hospital. A hospital Discharge Summary dated 8/23/13 indicated the resident was admitted on [DATE], through the emergency department after arriving at a clinic for a blood transfusion. The resident was not responding normally and was found to have a blood pressure of 64/44. The resident received IV fluids for [MEDICAL CONDITION] and the blood pressure rose over several hours to a normotensive state. The resident also [MEDICAL CONDITION] related to a UTI and was treated with antibiotics. Clinical Notes dated 8/23/13 indicated the resident returned to the nursing facility with the same medications for pain related to restless leg syndrome. The resident was very tired and fatigued and had a blood pressure of 98/58. On 8/25/13 a FAX to the physician included the family's concern that [MEDICATION NAME] and ropinirole doses were increased in the hospital and the increased doses were continued at the nursing home. The concern was the increased dosages were related to the resident's increased drowsiness. On 8/26/13 the physician ordered to decrease the doses of the two medications. On 8/27/13 the resident went to a physician's appointment and returned with physician's orders [REDACTED]. Intake and Output records from 8/23/13 to 8/29/13 continued to show excessive output related to intake without evidence of assessment for dehydration, [MEDICAL CONDITION] and UTI. Clinical Notes dated 8/29/13 indicated the resident went a physician's appointment and did not return to the facility. On 10/25/13 at 10:15 am Resident 1's family member stated the resident was admitted to the hospital twice in 10 days. After the second hospitalization the resident did not return to the facility. The family stated the first hospital visit was for UTI [MEDICAL CONDITION], and for low blood pressure of 64/40. The family felt the continued use of the [MEDICATION NAME] and ropinirole had increased the resident's drowsiness. The second hospital admission was for pneumonia. On 11/4/13 at 2:30 pm a discussion with Staff 1, DNS included the lack of assessment of the resident's fluid status, dehydration, [MEDICAL CONDITION] and symptoms of UTI. Staff 1 acknowledged the lack of an initial pain assessment which included restless leg syndrome and the need/use of continuing the two medications used to treat an acute condition in the hospital. 2. Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Physicians admission orders [REDACTED]. There were also orders for [MEDICATION NAME] 325 mg, 2 tablets PRN every 4 hours and [MEDICATION NAME] (similar in action to [MEDICATION NAME]) HCL 50 mg PRN TID for moderate pain of 4-6/10 on the pain index. Clinical Notes dated 10/1/13 indicated the resident was found on the toilet non-responsive with agonal respiration, very pale skin and fixed pupils. When the resident was put in bed, she/he became responsive. On 10/1/13 a fax to the physician included a report of the non-responsive episode. However, there was no documented assessment of the non-responsive episode. On 10/2/13 blood pressure records showed a blood pressure of 98/62 at 6:16 am. Clinical Notes dated 10/2/13 indicated a significant decrease in blood pressure and fluid intake was minimal. Clinical Notes dated 10/3/13 indicated the resident had very low intake of fluids. On 10/3/13 during the night the resident requested a sleeping pill or a pain pill, and reported she/he was "achy all over". MARs indicated [MEDICATION NAME] was given at 3:15 am for a pain index of 3/10. There was no rationale given for not following the physician's orders [REDACTED]. (The MARs also showed [MEDICATION NAME] was given twice on 10/1/13 for pain indexes of 5/10 and 8/10 and the pain level improved to 3/10 both times). On 10/4/13 in the morning the resident was confused and had a blood pressure of 88/54 and 80/50 on recheck. The resident was having minimal fluid intake and was weak. The resident was sent to the hospital. There was no assessment of the resident's fluid status related to [MEDICAL CONDITION] and continued use of two anti-hypertensive medications. There was no assessment of pain and no rationale given for using [MEDICATION NAME] for minimal pain, when [MEDICATION NAME] was effective for moderate pain. On 11/4/13 at 2:30 pm Staff 1, DNS stated there was no pain assessment/pain management plan and no further information was provided related to use of the pain scale and administration of pain medications. There was no further information provided related to assessment of fluid status and continued use of two anti-hypertensive medications in the presence of low fluid intake and [MEDICAL CONDITION].

Based on interviews and record review it was determined the facility failed to provide an evaluation to assess the safety of the resident's wheelchair and to provide adequate supervision to prevent a fall from a wheelchair for 1 of 2 sampled residents (#1). Resident 1 sustained a fractured left fibula. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 1/8/13 Rehabilitation Screen form indicated "Nursing states they could use recommendations for positioning and safety ...." The 1/10/13 physician's orders [REDACTED]. The 1/12/13 Clinical Note written by Staff 3 (LPN) indicated the resident attempted to slip out of her/his wheelchair. Staff 3 expressed concern to PT about the need for a different wheelchair. The 1/19/13 Clinical Notes written by Staff 3 (LPN) indicated Resident 1 was found sitting on her/his wheelchair foot rests. The resident was assessed with [REDACTED]. The 1/20/13 Clinical Notes written by Staff 3 (LPN) indicated the resident complained of left knee pain. The on-call physician was contacted and directed the facility to monitor the resident's condition. On 1/21/13 there was Nursing Therapy Communication Form to indicate PT/OT was requested. The 1/22/13 Clinical Notes indicated an x-ray was taken of the resident's left knee and ankle. The 1/23/13 x-ray results were faxed to the facility and indicated the resident had a "recent fracture involving left proximal fibula with no displacement. The joint shows no dislocation. There is associated joint effusion ...." The 1/23/13 Clinical Notes indicated the x-ray report was faxed to the resident's primary care physician. The Notes indicated the resident did not complain of pain. The 1/25/13 Clinical Notes indicated the resident was transported to the local hospital emergency department for treatment of [REDACTED]. The 1/28/13 facility investigation conducted by Staff 7 (RNCM) indicated Resident 1 was found sitting on her/his wheelchair leg rests on 1/19/13. The staff reported her/his "left lower extremity was bent at the knee, on the ground and she/he was partially sitting on it with the majority of her/his weight on the right buttock which was on the wheelchair leg rests. Resident 1 had no complaint of pain or injury noted at the time. She/he was in her/his room and had just been assisted to her/his wheelchair approximately 15 minutes prior ..." Staff 3 (LPN) reported she asked Staff 6 (CNA) to have the resident seated in the dining room and not to leave her/him in her/his room. Staff 3 (LPN) counseled Staff 6 (CNA) at time of fall and he was made aware of the importance of Resident 1 being in the line of sight for supervision. The resident's care plan was updated to include the need for the resident to be in the light of sight. Staff 3 (LPN) was counseled on the necessity of updating the resident's care plan The investigation indicated Resident 1 complained of pain on 1/20/13. The on-call physician was contacted and orders received to monitor the resident's left knee pain. An x-ray was obtained on 1/22/13 as Resident 1 continued to complain of left knee pain. The x-ray showed a recent fracture of the left fibula. The resident's primary care physician was contacted for more information on the fracture as the x-ray report did not indicate the fracture was acute. The 2/1/13 local hospital discharge summary indicated the resident's left fibula fracture did not require surgery and the resident was fitted with a soft cast. A Daily Individual Treatment Note signed 2/14/13 indicated on 1/28/13 OT was to conduct an evaluation for Resident 1 and the resident was hospitalized . An interview on 2/14/13 at 10:00 am with Staff 3 (LPN) revealed Resident 1 was found on the wheelchair foot rests on 1/19/12 at 1:20 pm. Staff 3 stated the resident attempted to stand up for a few minutes after lunch. Staff 3 (LPN) stated she told Staff 6 (CNA) not to leave the resident alone. Staff 3 indicated there were no signs and symptoms the resident was injured. Staff 3 stated the on-call physician was contacted and indicated the facility should continue to monitor the resident. Staff 3 stated on Tuesday (1/23/13) the x-ray-revealed the resident sustained [REDACTED]. Staff 3 stated she did not change the resident's care plan because she had been told this was the responsibility of Staff 7 (RNCM). Staff 3 stated Staff 7 was aware Resident 1 had a tendency to slip out of the wheelchair and needed supervision when seated in the wheelchair. Staff 3 stated she thought the therapy department assessed Resident 1's wheelchair after she identified the resident was slipping out of the wheelchair on 1/12/13. An interview on 2/14/13 at 12:00 pm with Staff 2 (RNCM) revealed there was no documentation the resident was evaluated by PT/OT after the physician's orders [REDACTED]. Staff 2 stated the resident was to be evaluated by OT on 1/28/13 when the resident was hospitalized . On 2/14/13 at 12:13 pm Staff 4 (PT) was asked about the facility's process for the evaluation of the resident's wheelchair. Staff 4 reviewed the 1/8/13 therapy screening evaluation which identified the request for an evaluation. Staff 4 stated there was a 1/10/13 physician's orders [REDACTED]. Staff 4 reviewed the 1/12/13 Clinical Notes to indicate the resident had issues regarding sliding in the wheelchair and PT was informed. Staff 4 stated he was the PT who worked on 1/12/13 and did not remember being told of Resident 1's slide out of the wheelchair. Staff 4 stated there was no documentation of OT/PT treatment. Staff 4 stated the system usually worked very well. Staff 4 stated once the physician's orders [REDACTED]. Staff 4 (PT) recommended Staff 5 (Rehabilitation Manager) be interviewed. Staff 4 (PT) stated there usually was documentation of a wheelchair evaluation conducted by the therapy staff. An interview on 2/14/13 at 12:44 pm with Staff 5 (Rehabilitation Manager) revealed no additional information could be provided. Staff 5 stated it was possible for a new wheelchair to be obtained for the resident without documentation though it was not likely. An interview on 2/20/12 at 11:00 am with Staff 7 (RNCM) revealed she was aware the resident had a tendency to slip out of the wheelchair on 1/14/13 and requested the resident be evaluated by OT/PT. Staff 7 stated on 2/20/12 Staff 5 (Rehabilitation Manager) told her of an attempt by OT to examine the resident on 1/22/13 and the resident refused. Staff 7 stated she conducted the investigation of the resident's 1/19/13 fall out of the wheelchair. Staff 7 stated she interviewed Staff 3 (LPN) and Staff 6 (CNA) and learned Staff 3 directed Staff 6 to have the resident in the line of sight of the staff. Four attempts to interview Staff 6 (CNA) on 2/14/13, 2/15/13 and 2/20/13 were unsuccessful.