Every finding on record at Franklin Nursing Home

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or a centralized staff work area from each resident's bedside for 4 of 12 residents (Residents # 1, # 2, #3 and # 4) reviewed for call lights.The facility failed to ensure Resident # 1 had an operating call light system. The facility failed to ensure the call light system was accessible to Residents # 2, # 3 and # 4. These failures could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of injury, pain, hospitalization, and a diminished quality of life.Findings include:Record review of a face sheet dated 12/3/2025 indicated that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia (confusion due to aging with inability to remember), muscle weakness, difficulty ambulating, and muscle wasting and chronic kidney disease stage 3 (the kidney's function has been cut by half). Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated that she had a BIMS score of 10, indicating that she had a moderate cognitive impairment. Resident # 1 needed supervision when transfers from bed to chair.Record review of Resident # 1's comprehensive care plan with a revision date 11/10/2025, revealed the resident needed a safe environment with adequate, glare-free light, a working and reachable call light, and the bed in low position at night. Resident # 1 was a risk for falls.During an observation/ interview on 12/03/2025 at 9:34 a.m., Resident #1's call light did not turn on when the button was pressed by Resident # 1. Resident stated that she did not know that the call light was not working, and she would like to be sure that staff will respond to her calls for assistance. Record review of a face sheet dated 12/3/2025 indicated that Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Down Syndrome (a genetic disorder), dementia (confusion due to aging with inability to remember), muscle weakness, and Dysphagia (difficulty swallowing). Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated that her BIMS score could not be determined. The MDS assessment of Resident # 2's mobility indicated she required extensive assistance.Record review of the Care Plan dated 09/04/2025, for Resident #2 indicated the resident's call light was to be within reach and staff were to encourage the residents to use it for assistance as needed.During an observation and attempted interview of Resident # 2 on 12/03/2025 at 1:14 PM the resident was lying in her bed, and a flat call button was out of the resident's reach. It was located under Resident #2's pillow. DON entered Resident # 2's room and resituated Resident # 2's call light button from under the pillow to above the resident's blanket next to Resident # 2's left hand. Record review of Resident # 3's face sheet dated 12/03/2025 indicated that Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease (form of dementia that affects memory), congestive heart failure (heart unable to pump blood effectively) and Atherosclerotic Heart Disease (hardening of the arteries). Record review of a Quarterly MDS assessment dated [DATE] for Resident #3 indicated a BIMS score of 8 indicating she had moderate cognitive impairment. The assessment of Resident #3's mobility indicated she was independent, and she needed no assistance from a helper. Record review of the Care Plan dated 09/03/2024, for Resident # 3 indicated the resident's call light was to be within reach and encourage the residents to use it for assistance as needed.In an observation and attempted interview of Resident # 3 on 12/03/2025 at 9:34 am Resident # 3's call light button was resting on the arm of the easy chair which was located over 3 feet way from the resident. Resident was sleeping and was not able to be interviewed.Record review of Resident # 4 's Face sheet dated 12/03/2025 indicated that Resident #4 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Dementia (confusion due to aging with inability to remember), Diabetes (high levels of glucose in the blood), and Dysphagia (difficulty swallowing).Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated a BIMS score of 8 indicating he had moderate cognitive impairment. The assessment of Resident #4's mobility indicated he needed partial/moderate assistance and the helper did less than half the effort.Record review of the Care Plan dated 05/05/2025, for Resident # 4 indicated the staff was to be sure the resident's call light was within reach and encourage the resident to use it.During an observation and interview of Resident #4 on 12/03/2025 at 9:43 AM, the resident could not reach the call button due to the button hanging off the right side of the bed. Resident said he was not sure how often the staff came into his room and checked on him.During an interview on 12/03/2025 at 9:39 AM, CNA A said she did not know the last time she saw a call light on for Resident # 4's room. During an observation, CNA A tested Resident # 4's call light button and it was determined that the light was not working. CNA A stated, she did not know Resident # 1's call light was not working. CNA A replaced Resident #4's call light button with another working call light button. During an interview on 12/03/25 at 2:03 pm, the Maintenance Supervisor said the call lights in the bedrooms needed to be working because if a resident were to fall, they needed to be able to use it to call for help. He said he was responsible for making sure the call light system was working. He stated the call lights were checked for functionality every week. He stated the senior staff did Champion Rounds daily. He stated, Champion Rounds are when each member of the senior staff is assigned to check in on all the residents on an assigned hallway and daily all departments got together, and they reported to him if something was not working. He stated he checked the call light buttons in Resident #4's room and both were functioning.During an interview on 12/03/2025 at 2:25 PM, the ADON said the call button was always supposed to be within the resident's reach. She stated, CNAs, Nurses, everyone on staff is responsible for making sure the resident can reach the call light button.During an interview on 12/03/2025 at 3:16 pm, the DON stated, everyone on staff is responsible for checking the call light button locations. The DON stated, even if the resident was not in the room at a given time, it was important to know where the call light was. She stated, it may be wrapped up in the sheets and not visible so when they come back into the room, they may not be able to find it. The DON stated, We don't test the call lights during the Champion Rounds. DON stated her expectation was that her staff check to see that each resident had a call light button within reach. She stated, she did not know why a resident's call light was not working, and they may have missed it. DON stated, the ADM did most of the all-staff in-service training such as call light buttons were to be within reach of the residents. During an interview on 12/03/25 at 11:41 am, the Administrator said a call light must be within reach, wherever the resident was, in an easy chair or in their bed. The call light button was for a resident to get assistance if there was an emergency. The Administrator said if a resident were to fall, they needed to be able to reach the call light button to call for help. He said he would expect his staff to follow proper policy and procedure. Record review of an undated facility policy titled Call Lights indicated a call light training involves the patient using the light to request assistance and the staff responding promptly and courteously. Key components include placing the call light within reach, demonstrating its use to patients, and establishing clear response protocols. For Staff promote understanding: when a new resident arrives, explain what the call light is for and demonstrate how to use it. Including the call button in the bathroom.Ensure Accessibility: Verify that the call light is plugged in and positioned within the resident's easy reach. Systemic RequirementsFunctionality: All call systems must be in operating order, with both visible and audible signals that are easy for staff to see and hear at the nurses' station.Reporting: A procedure for reporting and correcting malfunctions is crucial to prevent common problems like non- functioning equipment.Staffing and Training: Facilities should have clear expectations for staff to ensure timely call light responses.Compliance: Regulations require functioning call system to ensure resident safety, and response times are often monitored as a key performance indicator.

Based on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 2 (Resident #1) reviewed for respiratory care.Findings included: Record review of Resident #1's undated Face Sheet printed on [DATE] revealed a [AGE] year old, male admitted to the facility on [DATE]. Diagnoses included Down Syndrome (genetic disorder), Seizures, and Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit). Record review of Resident #1's Annual MDS, dated [DATE], reflected Resident #1 was sometimes able to make himself understood and sometimes able to understand others. BIMS score for Resident #1 reflected 00 (severe cognitive impairment). Record review of Resident #1's Physician's orders printed on [DATE] at 1:09 PM reflected an order for Full Code dated [DATE], indicating a need for emergency care and resuscitation. There were no current orders for oxygen equipment or specialized respiratory care. Record review of Resident #1's Care Plan printed on [DATE] at 1:11PM reflected a Focus Area stating, Resident is Full Code. Date Initiated: [DATE]. Related Interventions/Tasks stated, Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify EMS (emergency medical services) Date Initiated: [DATE], and, Consult with nursing staff on changes in health. Date Initiated: [DATE]. Interventions for a Focus Area regarding Resident #1's seizure disorder reflected, SEIZURE PRECAUTIONS: Do not leave resident alone during a seizure, Protect from injury, If resident is out of bed, help to the floor to prevent injury, Remove or loosen tight clothing, Don't attempt to restrain resident during a seizure as this could make the convulsions more severe, Protect from onlookers, draw curtain etc. Date Initiated: [DATE]. Record review of Resident #1's Progress Notes [DATE] at 10:45AM reflected a note from LVN A stating, Res up in lobby initially noted having tremors. Res began vomiting then having seizure activity lasting 3-4 minutes. Lung sounds also significantly worsened, Spo2 dropped to 52 during seizure activity. Sent to [hospital] via RCEMS ([NAME] County Emergency Medical Services). at time of transfer res was continuing to have tremors, sats up to 72 on 5L O2(liters of oxygen). [Family member] called, informed of all, already at hospital for [Resident #1's other family member]. In an interview on [DATE] at 2:13PM, LVN A stated he was present on [DATE] when Resident #1 was sent out to the hospital. He stated Resident #1 was in the lobby when he started convulsing. He stated Resident #1 was breathing, but his oxygen levels were low, and he was sent out quickly. He stated prior to the incident the resident did not show any signs of respiratory changes or decline. He stated a crash cart was bought out during the episode. He stated emergency medical services were notified right away. He stated the ambulance was just down the road when they called and came very quickly. He stated the resident's oxygen improved some before the ambulance arrived. He stated he was not sure of the exact numbers for Resident #1's oxygen levels during the episode or prior to leaving the facility. He stated after the resident was sent out to the hospital, he notified the doctor, family, and the administration of the episode. He stated he thought he used a non-rebreather mask for the resident. He stated the proper oxygen flow for a non-rebreather was 8-10 LPM . He stated the bag attached to the oxygen mask does not need to fill. In an interview on [DATE] at 8:23 AM, the DON stated staff had monthly care related trainings and continuing education topics. She stated the nursing staff recently received a training regarding respiratory care. She stated that nurses in the facility are BLS Certified. She stated she expected the nurses to bring out the crash cart for a resident with a seizure or one showing signs of respiratory distress. She stated she expected one nurse to stay with the resident during an emergency, while the other calls for EMS (emergency medical services) and/or the physician. She stated a non-rebreather mask should be used during respiratory distress. She stated she did review the incident with Resident #1 on [DATE]. She stated that the proper oxygen flow level for a non-rebreather mask should be 5-10 LPM. She stated that she could not recall an interview with LVN A after the incident. She stated that she was not sure what type of oxygen supplies he used based on the note in the chart. She stated that she does look over the documentation and perform interviews, as needed, for discharges, but does not document those investigations unless there was a concern. She stated she had no additional investigation documentation for this event. She stated the EMS station was just around the corner and she knew that he was picked up very quickly. She stated that without effective oxygenation equipment and care a resident in respiratory distress would continue to decline. Observation on [DATE] at 09:02 AM of staff demonstration of the use of non-rebreather oxygen mask with LVN C and ADON revealed LVN C set the oxygen tank to 4 LPM with the non-rebreather mask and applied to ADON with the bag not inflated. She stated that she thought that residents with chronic lung conditions might be harmed by too high of a flow rate. She then stated that she may be wrong about the flow rate for chronic lung conditions and that during an emergency where a resident is in active respiratory distress, the oxygen flow rate should be turned up all the way. She stated that she had her BLS certification and had received respiratory skills training about a month prior. She stated that she does not use a non-rebreather mask often. ADON at that time stated she would use a non-rebreather with a starting flow rate of 10-15 LPM and make sure the bag was inflated prior to placing it on a resident. In an interview on [DATE] at 9:55AM, LVN A stated that he went back to look at the progress note he wrote about the incident. He stated that he must have used a nasal cannula rather than a non-rebreather mask for Resident #1 on [DATE]. He stated that a nasal cannula is not ideal for the situation, but that was what he grabbed first. He stated that he should have used a non-rebreather on high flow rate. He stated that the bag should inflate when the oxygen is turned on and prior to placing on the resident. He stated that the DON had in-serviced him on the use of a non-rebreather mask and emergency respiratory care that morning. He stated that he was BLS certified. He stated that he had attended a respiratory training about a month ago. He stated that there was a demonstration portion to the BLS course he attended. He stated that the potential impact to the resident of using the wrong oxygenation device or using the device improperly were that they could continue to decline. In an interview on [DATE] at 9:56AM, the ADON stated that she had BLS certification. She stated a NRB should be used with 10-15 LPM of oxygen and the bag on the mask should be filled when it is placed on the resident. In an interview on [DATE] at 09:58AM, the DON stated there was a skills demonstration component of the BLS class. She stated that the class is provided for nursing at the facility. She stated that given the status of Resident #1 at the time of the incident, from the documentation and interviews with staff, that a non-breather mask would have been the best choice, given his oxygen saturations were in the range of 50% when oxygen was started. In an interview on [DATE] at 10:04AM, the RNC stated during an emergency involving respiratory distress she expected the nurses to assess the residents and send them out. She stated that a non-rebreather mask would be the best choice for a resident in respiratory distress with low oxygen levels. She stated that you turn the oxygen flow rate to 10 or more liters and place the mask on the patient. She stated that the mask will fill on its own with the oxygen on and should be full during its use. She stated that the mask does not work if the bag is not full of oxygen to her knowledge. She stated that she would not use a nasal cannula for a resident in respiratory distress. She stated she was not aware of the incident on [DATE] when Resident #1 was sent out to the hospital. She stated it was the responsibility of the DON to review all discharges the next day. She stated that she should also have been notified if she was present in the building at the time of the incident. She stated that the last respiratory training for the nurses at the facility was about a month ago. She stated that she expected all nurses to know how to use a non-rebreather mask. She stated that if we do not provide effective oxygenation supplementation to residents in distress that the distress could continue. The facility's policy regarding seizure care or emergency care was requested. RNC stated that there was not a policy for seizure care or emergency care other than the facility policy for Notification of Physician for Change in Condition. In an interview on [DATE] at 11:05AM, the ADMIN stated his expectation regarding emergency care was that staff respond as quick as possible to get the resident the level of care needed. He stated that he expected nurses to follow the CPR training certification guidelines regarding care for respiratory distress. In a telephone interview on [DATE] at 11:40AM, the NP stated for the correct use of a non-rebreather mask the oxygen flow rate should be set to 10-15 LPM and the bag should be full. She stated that she would use a nasal cannula for a resident in respiratory distress if that was all she had, but standards of practice would indicate a non-rebreather mask should be used for respiratory distress. She stated that the resident could continue to decline if adequate oxygen was not provided during respiratory distress episodes. She stated she has confidence in the nurses at the facility and is informed well of care. She stated that the priority for Resident #1 in the situation on [DATE] was to be transferred to a higher level of care and that was done. She stated that the respiratory decline that occurred in hospital was unlikely to be related to the brief care the facility provided during the emergency. She stated that the resident was being treated for a respiratory infection at the time of the incident. She stated that it was normal to have a drop in oxygenation after a seizure. Record review of facility policy on [DATE] at 11:25AM for Notifying the Physician of Change in Status (no date) reflected that the policy does not give any indication of steps of care for a resident in an emergency situation or during respiratory distress.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of eight residents (Resident # 9, and Resident #37) reviewed for activities. The facility failed to provide Resident #9, and Resident #37 in room activities on the dates of 8/11/2025 thru 8/31/2025. This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings included:Record review of Resident # 9's face sheet, dated 09/10/2025, reflected a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Resident #9 had diagnoses which included major depressive disorder, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder ( a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), other lack of coordination ( the body's movements are not smooth, controlled, or precise resulting in unsteadiness, and difficulty with everyday tasks) and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( a condition where individuals experience cognitive decline consistent memory loss, impaired thinking, etc. without behaviors). Record review of Resident #9's annual MDS Assessment, dated 06/16/2025, reflected Resident #9 had a BIMS score of 5, indicating severely impaired cognition. -Further review reflected Resident #9 indicated going outside to get fresh air was very important to him. The following activities was somewhat important such as reading books, being around pets, listening to music, keeping up with the news, and doing favorite activities. Record review of Resident #9's Comprehensive Care Plan, dated 07/20/2025, reflected Resident #9 had dementia. Interventions included: engage resident in simple, structured activities that avoid overly demanding tasks and provide a program of activities that accommodates the resident's abilities. Resident #3 had a communication problem related to cognitive communication deficit (caused by underlying problems with thinking processes, not a speech or language impairment) Interventions included be conscious of resident position when in groups, activities, dining room to promote proper communication with others. and provide a program of activities that accommodates the resident's communication abilities. Resident #9 needed out of room social, spiritual, and stimulus activities and mental stimulation. Intervention included the activity director will encourage and remind the resident of current activities. Resident is at risk for falls. Intervention: Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Resident#9 needed activities that minimize the potential for falls while providing diversion and distraction. Record review of Resident #9's Participation Record, dated August 2025, reflected Resident # 3 did not receive in room activities from 08/11/2025 thru 08/25/2025. During an interview on 09/09/2025 at 11:45 AM, the Activity Director stated Resident # 9 did not want to attend very many group activities and changed his activity program the first week of August 2025 to receive in room activities 3 times per week. She stated her plan was to begin in room activities with Resident #9 on 08/11/2025. The Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if residents were not coming out of their room, the residents were to be provided in room activities. The Activity Director stated she provided in room activities at least twice a week. She stated there was not an excuse why Resident #9 did not receive in room visits. The Activity Director stated if a resident was not receiving activities on a consistent basis there was a potential a resident may become bored, depressed, or have a decline in their quality of lifeDuring an observation and interview on 09/09/2025 at 10:50 AM, Resident #9 was lying in bed staring at the wall in front of him. His television was not on in his room. Resident #9 was not interview able . Resident #9 did not respond to questions. Resident#9 cognition is severely impaired. Record review of Resident # 37's face sheet, dated 09/10/2025, reflected a [AGE] year-old male, admitted on [DATE]. Resident #37 had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition where individuals experience cognitive decline consistent memory loss, impaired thinking, etc . without behaviors), legal blindness, as defined in USA (an eye which has limitation in the field of vision so that the widest diameter of the visual field was at an angle no greater than 20 degrees was considered to have a central visual acuity of 20/200 or less), age-related nuclear cataract, bilateral (clouding or hardening of the central part of the eye's lens of both eyes), and primary osteoarthritis in right and left shoulder (a degenerative condition where the protective cartilage in the shoulder joint wears away, leading to bones rubbing against each other, causing pain, stiffness, and loss of motion). Record review of Resident # 37's Annual MDS Assessment, dated 02/09/2025, reflected Resident #37 had a BIMS score of 5, which indicated his cognition was severely impaired. Further review reflected Resident #37 indicated listening to music was very important to him. with the following activities were somewhat important: being around pets, l keeping up with the news, and doing favorite activities. Record review of Resident#37's Quarterly MDS Assessment, dated 08/29/2025, reflected Resident #37 had a BIMS score of 3, which indicated his cognition was severely impaired. Record review of Resident #37's Comprehensive Care Plan, reflected Resident #37 (date initiated on 05/13/2024) had little or no activity involvement related to resident wishes not to participate. Resident #37 would participate in activities of choice 2 to 3 times per week. An intervention was to explain to the resident the importance of social interaction, leisure activity time, and encourage the resident's participation. Resident risk for weight loss. Intervention: Encourage food related activities. Record review of Resident #37's Participation Record, dated August 2025, reflected Resident #3 did not receive in room activities from 08/11/2025 thru 08/25/2025. During an observation on 09/09/2025 at 10:17 AM, Resident #37 was sitting in a wheelchair in his room. He was wearing sunglasses. Resident #37 was looking downward. He stated he did talk to his roommate, but he did not do any activities. Resident #37 stated he enjoyed music and would enjoy having music in his room. He stated he enjoyed all types of music except country. Resident #37 stated his roommate watched tv and he would try something go in his ears to listen to music. He stated he did not want to be in a group, and he rather do activities in his room. He did not respond if activity director visited him in his room or offered him music. Interview on 09/09/2025 at 11:45 AM, the Activity Director stated Resident # 37 did not want to attend group activities due to his impaired vision. She stated he preferred to receive activities in his room. The Activity Director stated she added Resident #37 to in room activities on 08/11/2025. She stated Resident #37's activity plan was adding him on the in-room activity program 2-3 times per week. The Activity Director stated she did not have an explanation of why Resident #37 did not receive in room activities during the time frame of 08/11/2025 thru 08/25/2025. Interview on 09/11/2025 at 9:40 AM, the Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if residents were not coming out of their room, had a decline of attending group activities, the residents were to be provided activities in their room. She stated if a resident was not receiving activities there was a possibility the resident may have become isolated, have a decline in their mental status, or become depressed. She stated it was her responsibility to provide in room activities. The Activity Director stated she forgot to visit Resident # 9 and Resident #37 during the month of August when she added both residents to the in-room activity program. Interview on 09/11/2025 at 11:00 AM, the Administrator stated he expected in room activities be provided to the residents needing these types of activities. He stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored and isolated. He stated the Activity Director was responsible for all activities in the facility. He stated the Administrator would be responsible for monitoring the Activity Director. Record review of the Activity Director's personnel file revealed she was a certified Activity Profession through NCCAP (National Certification Council of Activity Professionals). Record review of The Facility's Activity Programming, dated 2019, revealed Activity programs are to be designed based on resident's leisure interest and implemented to meet the needs (physical, cognitive, social, spiritual, community, independent, and sensory) of the residents. Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation, or physician ordered bed rest. Record review of The Facility's Activity Documentation-General Guidelines, dated 2019, The following areas are considered documentation responsibilities of the Activity Director and staff and should be completed in a comprehensive and timely manner. Resident participation records.

Based on observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 9, and Resident #37) reviewed for ADL care. The facility failed to ensure Resident #9's and Resident # 37's nails were cleaned, and did not have any rough edges. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.Findings included: Record review of Resident #9's face sheet, dated 09/10/2025, reflected a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Resident #9 had diagnoses which included major depressive disorder, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), other lack of coordination (the body's movements are not smooth, controlled, or precise resulting in unsteadiness, and difficulty with everyday tasks) and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition where individuals experience cognitive decline consistent memory loss, impaired thinking, etc . without behaviors). Record review of Resident#9's Annual MDS Assessment, dated 06/16/2025, reflected Resident #9 had a BIMS score of 5, which indicated his cognition was severely impaired. Resident #9 required partial/moderate assistance - helper does more than half the effort with the following: personal hygiene, upper body dressing, and oral hygiene. He required substantial/maximal assistance - helper does more than half the effort with the following: lower body dressing, showers, and putting on/taking off footwear. Record review of Resident #9's Comprehensive Care Plan, dated 07/20/2025, reflected Resident #9 had an ADL self-care performance deficit. Interventions: Resident #9 required assistance with personal hygiene and bathing. Check nail length and trim and clean on bath day and as needed. Report any changes to the nurse. During an observation and interview on 09/09/2025 at 10:50 AM, Resident #9 was in his room lying in bed. He had a blackish/ brownish substance underneath the middle and ring fingernails on his right hand. Resident #9's middle fingernail on his right hand was uneven around the edges. Resident #9 did not respond to questions or conversation about his nails. He was not interviewable. Record review of Resident #37's face sheet, dated 09/10/2025, reflected a [AGE] year-old male, admitted on [DATE]. Resident #37 had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition where individuals experience cognitive decline consistent memory loss, impaired thinking, etc . without behaviors), legal blindness, as defined in USA (an eye which has limitation in the field of vision so that the widest diameter of the visual field was at an angle no greater than 20 degrees was considered to have a central visual acuity of 20/200 or less), age-related nuclear cataract, bilateral (clouding or hardening of the central part of the eye's lens of both eyes), and primary osteoarthritis in right and left shoulder (a degenerative condition where the protective cartilage in the shoulder joint wears away, leading to bones rubbing against each other, causing pain, stiffness, and loss of motion). Record review of Resident#37's Quarterly MDS Assessment, dated 08/29/2025, reflected Resident #37 had a BIMS score of 3, which indicated his cognition was severely impaired. Resident #37 required partial/moderate assistance (helper does less than half the effort) with the following: personal hygiene, lower and upper body dressing, showers, and oral hygiene. Record review of Resident #37's Comprehensive Care Plan, reflected Resident #37 (date initiated on 05/01/2024) had an ADL Self Care Performance Deficit. Interventions: he needed assistance with personal hygiene and bathing. During bathing check Resident #37's nail length, trim and clean on bah day and as needed. Report any changes to the nurse. Observation and interview on 9/09/2025 at 10:17 AM, revealed Resident #37 was in his room sitting in his wheelchair. He had a blackish/ brownish substance underneath the middle ring and fore fingernails on his right hand. Resident #37's ring and middle fingernail on his right hand were uneven around the edges. Resident # 37 stated he could not see his fingernails. He stated he was blind. Resident #37 stated if his nails needed to be cut and cleaned, he wished someone would do it for him. In an interview on 06/19/2025 at 9:00 AM, LVN C stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. She stated the CNAs were responsible for all other residents' nail care. LVN C stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill such as stomach problems nausea and vomiting. LVN C stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. She stated Resident #9 and Resident #37 did not refuse care. She stated no one had reported to her Resident #9 or Resident #37 refused nail care. She stated she had been in- serviced on nail care, however, she did not recall the date. In an interview on 06/19/2025 at 9:20 AM, CNA D stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA D stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. She stated a resident may cause a skin tear if their fingernails were not smooth. CNA D stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 9 and Resident #37, and they did not refuse nail care . She stated if any resident refused care it was reported to the nurse and the nurse would document the refusal in the nurses note. She stated he was in-serviced on nail care. CNA D stated she did not recall the date of the nail care in-service. In an interview on 06/19/25 at 10:30 AM, Treatment Nurse RN E stated the nurses, and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNAs' responsibility to clean and trim all other residents' nails during showers or as needed. She stated if there was a blackish substance underneath the resident's nails, there was a possibility the substance had bacteria. Treatment Nurse RN E stated if a resident swallowed the bacteria there was a possibility a resident may become ill with stomach problems such as vomiting. CNA C stated she was in-serviced on nail care; however, she did not recall the date. She stated she had given care to Resident #9 and Resident #37. She stated she was not aware of Resident #37 or Resident #9 refusing nail care. In an interview on 06/19/25 at 09:36 AM, the Assistant Director of Nurses stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and diarrhea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes (a disease that occurs when your blood sugar, is too high). She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The Assistant Director of Nurses stated the nurse supervisor was responsible for monitoring CNAs giving ADL care including nail care and she was responsible for monitoring the nurse supervisors.Record review of the facility policy on Nail Care, not dated, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common.

Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 (Resident #9 and Resident #37) of 6 residents reviewed for care plans. The facility failed to update Resident #9's and Resident #37's care plan to reflect current activity needs for in room activities. This failure could place residents at risk for not receiving necessary services or having important needs identified and met. Findings included:Record review of Resident #9's face sheet, dated 09/10/2025, reflected a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Resident #9 had diagnoses which included major depressive disorder, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), other lack of coordination (the body's movements are not smooth, controlled, or precise resulting in unsteadiness, and difficulty with everyday tasks) and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition where individuals experience cognitive decline consistent memory loss, impaired thinking, etc . without behaviors).Record review of Resident #9's annual MDS Assessment, dated 06/16/2025, reflected Resident #9 had a BIMS score of 5, indicating severely impaired cognition. -Further review reflected Resident #9 indicated going outside to get fresh air was very important to him. The following activities was somewhat important such as reading books, being around pets, listening to music, keeping up with the news, and doing favorite activities. Record review of Resident #9's Comprehensive Care Plan, dated 07/20/2025, reflected no revisions of activity preferences and needs assessed in August 2025. Resident #9 was identified first week of August as needing in room activities 2-3 times per week related to a decline in attending group activities. Record review of Activity in Room Resident List, not dated, on 09/09/2025 reflected Resident #9's name was on the list to receive in room activities 2 to 3 times per week. During an observation and interview on 09/09/2025 at 10:50 AM, Resident #9 was lying in bed staring at the wall in front of him. His television was not on in his room. Resident #9 was not interviewable . Record review of Resident #37's face sheet, dated 09/10/2025, reflected a [AGE] year-old male, admitted on [DATE]. Resident #37 had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition where individuals experience cognitive decline consistent memory loss, impaired thinking, etc . without behaviors), legal blindness, as defined in USA (an eye which has limitation in the field of vision so that the widest diameter of the visual field was at an angle no greater than 20 degrees was considered to have a central visual acuity of 20/200 or less), age-related nuclear cataract, bilateral (clouding or hardening of the central part of the eye's lens of both eyes), and primary osteoarthritis in right and left shoulder (a degenerative condition where the protective cartilage in the shoulder joint wears away, leading to bones rubbing against each other, causing pain, stiffness, and loss of motion). Record review of Resident # 37's Annual MDS Assessment, dated 02/09/2025, reflected Resident #37 had a BIMS score of 5, which indicated his cognition was severely impaired. Further review reflected Resident #37 indicated listening to music was very important to him with the following activities were somewhat important: being around pets, l keeping up with the news, and doing favorite activities. Record review of Resident#37's Quarterly MDS Assessment, dated 08/29/2025, reflected Resident #37 had a BIMS score of 3, which indicated his cognition was severely impaired. Record review of Resident #37's Comprehensive Care Plan, reflected Resident #37 (date initiated on 05/13/2024) had little or no activity involvement related to resident wishes not to participate. Resident #37 would participate in activities of choice 2 to 3 times per week. An intervention was to explain to the resident the importance of social interaction, leisure activity time, and encourage the resident's participation. Resident risk for weight loss. Intervention: Encourage food related activities. Record review of Activity in Room Resident List, not dated, on 09/09/2025 reflected Resident #37's name was on the list to receive in room activities 2 to 3 times per week. Interview on 09/11/2025 at 9:05 AM MDS Coordinator stated any time there was a change in a resident's physical condition, cognition, or activity preferences. The residents care plan was expected to be revised to reflect any changes with the resident. She stated if a resident needed in room activities after the comprehensive care plan was completed, the Activity Director was expected to revise the activity care plan and inform the IDT of the changes. She stated the Activity Director had opportunity to inform the IDT in morning meetings. The MDS Coordinator stated any residents in the facility she was not aware of any changes in their activity level or preferences. Interview on 09/11/2025 at 9:40 AM, the Activity Director stated Resident # 9's and Resident #37's care plans were not revised in August 2025 to reflect their changes in activity needs such as being provided in room activities. She stated anytime a resident's activity preference or activity abilities changed; the residents care plan was expected to be revised to reflect these changes. She stated if a resident was having behaviors or was depressed and staff reviewed the care plan; the staff would not know the accurate activities interventions to provide for the resident. She stated she had been in-serviced on care plans but did not recall the date. She stated she did not recall why the care plan was not revised. Interview on 09/11/2025 at 10:00 AM, the Assistant Director of Nurses stated all care plans was expected to be revised anytime there was a change of physical condition, mental status, or activity preferences. She stated if a resident activity level changed and needed different type of activities, such as in room activities, the residents care plan was expected to be revised to reflect resident activity needs and preferences. She stated the care plan was a tool the staff used to know how to treat a resident's physical needs, cognitive needs, interventions of any type of behaviors, activity preferences, etc. She stated a care plan could be revised at any time. She stated if there were any changes in activity level or activity preferences with a resident the Activity Director was expected to revise the care plan to reflect their current activity needs. Record review of the Facility's Comprehensive Care Planning, not dated, reflected Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

Based on observations, interviews, and record reviews the facility failed to ensure that residents received housekeeping services to maintain a sanitary and comfortable interior for 1 of 8 residents (Resident #22). The facility failed to ensure that housekeeping attendants cleaned and sanitized the interior of the bathroom cabinet in Resident #22's bathroom. This failure could result in potential cross contamination and illness for residents. Findings included: Record review of Resident #22's undated face sheet, printed on 9/09/2025, reflected a [AGE] year old female admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), cognitive communication deficit (problem with communication caused by cognition rather than a language or speech deficit), and paranoid schizophrenia (condition in which the mind creates a highly detailed alternate reality that feels completely real, causing suspicion and fear). Record review of Resident #22's quarterly MDS, dated [DATE], reflected a BIMS score of 9 (moderate cognitive impairment). Record review of Resident #22's care plan reflected a Focus Area indicating, [Resident #22] has an ADL Self Care Performance Deficit at times r/t Schizophrenia, depression and dementia. Date Initiated: 01/07/2014 with a related intervention of , TOILETING: the resident is independent and continent of bowel and bladder. Date Initiated: 01/07/2014. Revision on: 12/10/2014. During an observation and interview on 9/09/2025 at 09:54 AM, Resident #22, stated there were roaches in the bathroom. She stated the facility has treated for roaches. She stated there was evidence of the roaches in the bathroom cabinet. The bathroom was observed to be clean with no evidence of pests. An observation of the inside of the bathroom cabinet in Resident #22's room revealed a collection of a dry, black substance scattered on the inside of the cabinet and the wall inside the cabinet. She stated the black substance in the cabinet was roach excrement. During an observation of Resident #22's bathroom on 9/10/2025 at 11:47AM, revealed a clean bathroom with a collection of a dry, black substance scattered on the inside of the cabinet and the wall inside the cabinet. There was no observable change to the soiled areas inside the cabinet from the previous day. Resident #22's room was observed to be clean with no evidence of pests. During an interview on 9/10/2025 at 12:11PM, Resident #22 stated she had not told the facility about the suspected roach excrement in the bathroom cabinet. She stated she thought they would just fix it, but they had not. During an interview and observation with Housekeeper B on 9/10/2025 at 1:03PM, he stated he believed Resident #22 was the only room with a bathroom cabinet He stated he mostly cleaned the floors and had not cleaned Resident #22's bathroom in a long time. He stated the other housekeeper on staff would have cleaned that room, but she was on break He stated the housekeeping department does deep cleaning of resident rooms on a rotation. He stated he thinks Resident #22 was due for a deep cleaning soon. During an observation of Resident #22's cabinet, Housekeeper B stated, That's not good. That is roach feces. He stated he was not sure why the inside of the cabinet was not cleaned. He stated he would clean it right away. He stated the risk to the resident of not cleaning her environment adequately was she could become very sick. In an interview on 9/10/2025 at 1:11 PM with the Housekeeping Director, she stated she thought the black substance in Resident #22's cabinet was something called track marks by their Pest Control Technician. She stated track marks were described to her as evidence of pests walking over an area. She stated she was not sure if it was roach excrement. She stated she and the housekeeping staff were responsible for the cleaning and sanitation of the facility. She stated there were no other bathroom cabinets in the facility except Resident #22's. She stated the Pest Control Technician treated and inspected the facility that morning on 9/10/2025. She stated he was treating for reports of flies. She state that it was normal to have more flies during this season. She stated she knew Hall 2 had an issue with pests within the last two months, but she stated she was not aware there was an issue with Resident #22's room at this time. She stated she was not aware the inside of Resident #22's cabinet was not being cleaned. She stated that there is a monthly deep cleaning done for all resident rooms. She stated that she believed that Resident #22 was due to be cleaned for the month. She stated she sent out daily messages to staff after the morning meeting regarding any known areas of concern for the building. She stated a portion of the roof of the building was blown off in a storm recently and the facility was working to treat for any pests and repair any holes that were noted during inspection by the staff or pest control. She stated that since that time there had been reports of roaches in the facility, but the staff had been in regular communication with pest control services to treat regularly monitor the building for any new access points for pests or vermin. She stated she had observed large roaches, but had not seen any rodents. She stated she did not know if the housekeeper checked the cabinet to see the black substance inside. She stated that staff probably know that the inside of the cabinet is not in use. She stated that the department does a deep clean once a month for all resident rooms. She stated she expected staff to look inside the cabinet when they were cleaning the bathroom. She stated she expected housekeeping staff to look under, over, and through things as they are cleaning. She stated she would make a note to herself to check the cabinet daily and ensure it was cleaned in the future. She stated she would add that room number to the list of rooms for the Pest Control Technician to look at when he visited. She stated she would do an in-service right away to alert staff to the issue. During an interview on 9/10/2025 at 1:23 PM, the DON stated, I don't know why she has a cabinet. They probably don't think to clean it because there are no other cabinets. She stated that she expected the bathrooms to be cleaned daily, including the bathroom cabinet for Resident #22. She stated she would add it to the morning rounds and discuss it during the morning meeting in the future. She stated pest control had been in the facility that morning on 9/10/2025. She stated she was not aware of black substance scattered in the bathroom cabinet for Resident #22. She stated that, If [Resident #22] touched it, she could get an infection. She stated the facility called pest control yesterday to treat for flies. She stated that anytime the [pest control technician] was in the facility, the staff would tell him any areas to focus on or where insects were seen. She stated that the facility was working to declutter trash and unwanted personal items for residents in addition to their pest control visits to minimize opportunities for food and housing of pests and/or vermin. In a telephone interview on 9/10/2025 at 2:07PM, the Pest Control Technician stated it was probably roach feces in the bathroom cabinet from the description, but that he could not be sure. He stated he has been coming more than monthly to the facility. He stated they had more problems since the incident with the portion of the roof was damaged recently and being an older building in the country was challenging. He stated that he primarily treated for flies and was monitoring for signs of vermin in the kitchen area and possible entry points for pests and vermin into the building on 9/10/2025. He said he felt the facility was staying on top of their communication with him and trying to keep things under control. He stated the pest situation at the facility was definitely improving. He stated he had not see the bathroom cabinet when he was in the facility earlier that day. He stated he did not treat that room for roaches or inspect it during the visit on 9/10/2025. He stated he was not aware there was a continued problem in that resident room specifically. In an interview on 9/11/2025 at 10:04 AM with RNC, she stated housekeeping should be cleaning the bathrooms daily. She stated pest control was out more than monthly lately. She stated she felt like the facility was doing everything they could to manage pests inthe building. She stated the condition of the cabinet for Resident #22's bathroom was not an acceptable level of cleanliness. She stated that the potential risk to the resident if they got into the cabinet was it could cause some sort of illness. During an interview on 9/11/2025 at 11:05 AM, the ADMIN stated he ensured they deep cleaned Resident #22's room after the cabinet was brought to the attention of the housekeeper by surveyor on 9/10/2025. He stated the facility planned to remove the cabinet in her room and install a sink like the other rooms in the facility. He stated he was not aware the inside of the cabinet for Resident #22 was soiled. He stated the bathroom should be cleaned daily by housekeeping. He stated that he would have the staff check the cabinet in the future during morning rounds. He stated that even though it is the only bathroom cabinet in the facility, it was expected that it should be cleaned and decluttered. He stated that from the look of the cabinet and knowing the history of the building, he thought the black substance was roach related. He stated that the effect on the resident of having a unclean bathroom would be that it could contribute to contamination or illness for the resident. Record review of Service Inspection Report from Pest Control Technician visit dated 9/01/2025, reflected, The medical records office. She mentioned seeing some American cockroaches in [Resident #22's room]. Resident was unable to be moved. I did find 3 live American cockroaches in the closet and bathroom. These cockroaches were disposed of. Resident was unable to be moved. Bait and monitors were applied. As I pulled up to the facility. The first thing I noticed was the missing roof. This facility has lost half of the roof over the 400 hallway, from a storm that hit about 2 weeks ago. The old damaged roof is still there.,but the tin has blown off.I checked in with the [Maintenance Director] and he said that he didn't know of any issues. The dietary staff said that they had been doing good. They hadn't seen anymore rodent activity, since I was there last. A liquid spot residual was applied to the kitchen, dining room,common areas, offices, nurses station,entranceways, and exits. The fly light glue boards were replaced. Record review of facility policy printed on 9/11/2025 at 11:54PM for Resident Rights (undated) reflected: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, the facility stored all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of one nurses' treatment cart reviewed for medication storage. The facility failed to ensure Resident #1's prescription shampoo was stored in the locked treatment nurse cart and instead was stored in the open shower room. This failure could place residents at risk of misuse of medications leading to harm . Findings include: Record review of Resident #1's face sheet, dated, 03/25/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included need assistance for personal care (assistance with basic daily activities like bathing, dressing, eating, toileting, and grooming), chronic obstructive pulmonary disease ( a group of lung diseases that cause ongoing damage to the airways in the lungs), and pain unspecified ( an unpleasant sensory and emotional experience, the specific location not clearly identified). Record review of Resident #1's Admission MDS Assessment, dated 01/15/2025, reflected the resident had a BIMS score of 12, which indicated his cognition was moderately impaired. Resident #1 required substantial/maximum assistance with showers (helper does more than half the effort). He required partial/moderate assistance (helper does less than half the effort) with personal hygiene, lower body dressing, and toileting hygiene. Resident #1 required supervision with upper body dressing. Record review of Resident #1's Comprehensive Care Plan, with a start date of 01/22/2025 and a completion date of 03/25/2025, reflected Resident #1 had an ADL self-care performance deficit. Interventions: Assist with personal hygiene as required such as hair, shaving, oral care as needed. Bathing with one staff assistance. Avoid scrubbing and pat dry due to sensitive skin. Resident #1 had chronic obstructive pulmonary disease. Record review of Resident #1's physician order reflected ketoconazole external shampoo 2% was ordered on 01/15/2025. Medication class antifungal ( organisms that can live on or in the human body), dermatological ( these can range from common skin rashes and acne to more serious issues such as: skin cancer and eczema ( a dry skin condition characterized by itching and scaly skin). Apply to head topically one time a day every Monday, Wednesday, and Friday for dry flaking skin. Order type: wound treatment (with med ). Route of Administration topically ( apply to the surface of the body particularly the skin). Record review on 03/25/2025 at 12:05 PM of the facility's shower schedule located at the nurse's desk reflected Resident #1 received a shower on Monday, Wednesday's and Fridays. Record review on 03/25/2025 at 2:45 PM of the facility's in-service on medication cart locks was conducted on 08/15/2025. There was not any information provided of what was reviewed during this in-service. Treatment Nurse B did attend the in-service. The Director of Nurses was the instructor of the in-service. Observation on 03/25/2025 at 8:35 AM revealed the 400-hall shower door was unlocked. There was a prescription of medicated shampoo located on a shelf in the shower room . Observation on 03/25/2025 from 8:35 AM to 3:00 PM there was not any residents wandering on the 400 hall. Interview on 03/25/2025 at 9:20 AM, CNA/Shower Aide A stated she did not lock the door when she left the shower room. She stated she was not aware there was prescription shampoo for Resident #1 in the shower room . CNA/Shower Aide A stated Resident #1 received a shower Monday, Wednesday, and Friday. She stated she was off on Monday and she was not going to give Resident #1 a shower today (03/25/2025). CNA/Shower Aide A stated the treatment nurse kept the prescription shampoo locked in the treatment nurse's cart. She stated when it was time for Resident #1's shower the shower aide would ask for the prescription shampoo from Treatment Nurse B and she would bring the prescribed shampoo to the shower room or the shower aide would go to the treatment nurse and she would give it to them at the treatment cart. She stated when the shower aide was finished with the prescribed shampoo it was expected for the shower aide to return the shampoo to the treatment nurse or the treatment nurse would come to the shower and get the prescribed shampoo. She stated CNA C gave showers in her place on 03/24/2025. CNA/Shower Aide A did not reveal how she knew CNA C gave showers on 03/24/2025 on Resident #1. She stated she was in serviced to keep the shower doors locked. CNA /Shower Aide A did not recall the date of the in-service. She stated she had not witnessed any residents on 400 hall wandering. CNA/Shower Aide A stated she worked on 400 hall several times a week. Interview via phone, attempted on 03/25/2025 at 10:30 AM with CNA C. A voice message was left for CNA C to return the phone call and a text message was also sent to CNA C asking for her to return the phone call. CNA C did not return phone call. Interview on 03/25/2025 at 9:45 AM, Treatment Nurse B stated Resident #1 was prescribed shampoo. She stated the shampoo was expected to be locked on the treatment nurse cart. She stated she delivered the prescribed shampoo to CNA C on 03/24/2025. She stated it was after 12:30 PM. Treatment Nurse B stated either the CNA/Shower Aide would return the prescription shampoo to her when they were finished or she would go to the shower room and get the prescribed shampoo and place it in the locked treatment cart. She stated she observed Resident #1 receiving a shower on 03/24/2025. She stated it was her responsibility to ensure the prescribe shampoo was returned to her and locked in the treatment nurses' cart. She stated she forgot to check on the prescribed shampoo and CNA C did not return it to her on 03/24/2025. Treatment Nurse B stated if a resident ingested the shampoo she would call the doctor and follow the doctors' orders. She stated she could not comment if there would be any adverse effect on a resident if the resident ingested the shampoo or if the shampoo was in the residents' eyes. She stated she did not know if she was in serviced on locking medications. Treatment Nurse B stated there was not any residents who wandered on the 400 hall ( hall where the unlocked shower was located). She stated she would answer the question if she was in-serviced on storing medications after she reviewed the in-services. Treatment Nurse B did not report prior to exit if she received in-service on medication storage and locking medications. Interview on 03/25/2025 at 10:33 AM, the Director of Nurses stated her expectations was all prescribed medications which included prescribed shampoo was to be locked in a medication cart or treatment nurses' cart when not in use. She stated leaving prescribed shampoo in the shower room was not acceptable. She also stated the shower room was to be locked at all times. The Director of Nurses stated the protocol for the shower aides to have the prescribed shampoo was the treatment nurse would give it to the shower aide and when the shower aide was finished with the prescribed shampoo, the shower aide would return it to the treatment nurse to be locked in the treatment cart. The Director of Nurses stated they did not have a shower schedule it would be under each resident's name in the electronic medical records beside the shower log. She stated if there was any suspicion of a resident ingested the prescribed shampoo, a nurse would contact the physician and the poison control. The Director of Nurses stated there was not any residents who wandered on the 400 hall (where the shower room was not locked). She stated she was not aware of any in-services in the past year of ensuring prescribed medications required to be locked. Interview on 03/25/2025 at 11:03 AM, the Medical Director stated the prescribed shampoo (ketoconazole external shampoo 2%) for Resident #1 would not cause harm to a resident. He stated it was a fungal type of shampoo. The Medical Director stated if there was any question if resident ingested the shampoo, the poison control could be called for guidance and he would suggest observing the resident. Interview on 03/25/2025 at 11:49 AM, CNA/Shower Aide D stated the shower doors was expected to be locked at all times. She stated she worked on 03/24/2025 but not as a shower aide. CNA/Shower Aide D stated she was assigned to work on the floor instead of giving showers. She stated CNA E gave showers on the residents she gave showers to and CNA C gave showers on the residents CNA A was assigned to give showers. CNA /Shower Aide D stated she did not give Resident #1 a shower. Resident #1 was not on her shower list. She stated when anyone had prescribed shampoo the protocol was to ask Treatment Nurse B for the prescribed shampoo and when finished with the prescribed shampoo the shower aide was expected to return the prescribed shampoo to the treatment nurse to lock it in the treatment nurse cart. She stated she was in-serviced on keeping the shower door locked but did not recall the date. She stated she was not aware of any residents who wandered on 400 hall where the unlocked shower was located. Interview via phone attempt, to call CNA E on 03/25/2025 at 1:20 PM. CNA E did not return phone call after a voice and text message was left for CNA E. Record review of the facility's Storage of Medications, dated 2003, reflected medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked and attended by persons with authorized access. 2. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area.

Based on observation, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of eight (Resident #17, Resident #31, and Resident #46) residents reviewed for ADL care. The facility failed to ensure Resident #17, Resident # 31, and Resident #46 nails were cleaned and smooth around the edges. These failures placed residents at risk of a decline in their hygiene, at risk of skin breakdown, loss of dignity and decline in quality of life. Findings included: 1. Record review of Resident # 17's Face Sheet dated, 08/14/2024, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes mellitus with other circulatory complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified (a metabolic disorder in which the body had high sugar levels for prolonged periods of time and a type of nerve damage that occur if you have diabetes most often damages nerves in the legs and feet), lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), muscle weakness (when your body can not contract its muscle properly, causing a reduction in strength), and pain in unspecified joint ( a general diagnosis that a patient is experiencing joint pain, but the specific joint has not yet been identified). Record review of Resident #17's Quarterly MDS Assessment, dated 06/02/2024, reflected the resident had a BIMS score of 03 reflected his cognition was severely impaired. Resident #17 required assistance with personal hygiene, dressing, transfers, and showers/bathing. Record review of Resident #17's Comprehensive Care Plan, dated 06/05/2024 reflected Resident #17 had an ADL self-care deficit. Intervention: Bathing: check nail length, trim and clean on bath day and as needed. Report any changes to the nurse. Observation on 08/13/2024 at 9:45 AM Resident #17 was lying in bed watching television. His nails were jagged and had blackish substance underneath all nails on his right hand. He also had blackish/ brownish dried substance on the tip of the middle, forefinger, and ring finger on his right hand. The substance did have an odor of feces. There were two small scratches on his left arm. In an interview on 08/13/2024 at 9:47 AM Resident #17 stated he asked someone last night to clean his nails and the young lady stated someone would clean them the next day. Resident #17 did not remember the young lady's name. He also stated he had a difficult time trying to eat breakfast today (08/13/2024) due to not wanting to get what smelled like cow manure on his food. He stated he hoped no one could smell the stuff ( referring to feces) on his hands. He stated there are sometimes a man had an itch and needs to scratch his bottom. He also stated he his nails needed to be cut or something because he has scratched his arm when it was itching. He stated it did cause a little scratch on his arm; he stated it was this arm (he pointed to his left arm). Record review of Resident # 31's Face Sheet dated, 08/14/2024, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] diagnoses of : combined forms of age-related cataract, bilateral (a common eye condition that occurs when the lenses of the eyes thicken and cloud over due to aging), muscle weakness (when your body can not contract its muscle properly, causing a reduction in strength), and Alzheimer's disease with early onset (a person's symptoms are often relatively mild and not always easy to notice). Record review of Resident #31's Quarterly MDS Assessment, dated 08/04/2024, reflected Resident #31 had a BIMS score of 15 indicated his cognition was intact. He required assistance from staff with personal hygiene, dressing, transfers, and bathing. Record review of Resident #31's Comprehensive Care Plan, dated 08/13/2024, reflected Resident #31 had impaired visual function related to cataracts ( a condition in which the lens of the eye becomes cloudy). Intervention: encourage use of glasses. Resident #31 had impaired cognitive function or impaired thought process related to diagnosis of Alzheimer's (a brain disorder that slowly destroys memory and thinking skills). Intervention: keep Resident #31's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #31 had an ADL self-care performance deficit. Intervention: during bathing check nail length, trim and clean on bath day and as necessary. Report any changes to the nurse. If resident was diabetic the nurse will provide toenail care. Observation on 08/13/2024 at 9:56 AM Resident #31 was sitting on his bed in his room watching television. His fingernails were long and not smooth around the edges on his forefinger, middle finger, and his ring finger on his right hand. His fingernails were long and not smooth on his ring finger and middle finger on his left hand. Resident #31 had blackish/ brownish substance underneath his middle and ring fingernails on his right hand. Interview on 8/13/2024 at 9:58 AM Resident # 31 stated his fingernails was rough on both hands. He stated he scratched his leg over the weekend, and he thought the scratch on his right leg bled a little. Resident #31 also stated he asked a staff worked in nursing on Saturday or Sunday to cut and file his nails. He stated the person told him someone would cut and clean his nails next week. He stated he did not want to scratch himself and cause a big problem with his skin. Resident #31 stated no one had offered to clean or trim his nails and he did not want to ask anyone again because he had already reported his nail concerns to staff. Resident #31 stated he would do it himself, but he couldn't see very well to cut his nails or to make them smooth where he wouldn't scratch himself. Record review of Resident # 46's Face Sheet, dated 06/01/2024 reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), need assistance with personal care (personal care for elders is the support and supervision of daily personal living tasks and private hygiene and toileting, along with dressing and maintaining personal appearance such as bathing, hair washing, shaving , oral hygiene and nail care), type 2 diabetes mellitus with other specified complications (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), muscle weakness (when your body can not contract its muscle properly, causing a reduction in strength), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder that causes a person to lose the ability to think, remember, learn, make decisions, and solve problems, but without any symptoms of behavioral disturbances). Record review of Resident #46's Quarterly MDS Assessment, dated 06/01/2024, reflected Resident #46 had a BIMS score of 15 indicated his cognition was intact. Resident #46 required set up or clean up assistance with eating, oral hygiene, toileting hygiene, upper and lower dressing. Resident # 46 required partial/moderate assistance with personal hygiene. He required maximal assistance with showers. Resident #46 required moderate assistance with walking. Resident #46 was assessed to require a manual wheelchair for ambulation. Record review of Resident #46's Comprehensive Care Plan dated 08/13/2024 reflected Resident #46 had diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Intervention: check all body for breaks in skin and treat promptly as ordered by doctor. Monitor, document, and report to MD as needed for any signs or symptoms of infection to any open areas: redness, pain, heat, swelling or pus (a thick yellowish or greenish liquid in infected tissue, consisting of dead while blood cells and bacteria) formation. Resident #46 had impaired cognitive function, dementia (a mental disorder that causes a person to lose the ability to think, remember, learn, make decisions, and solve problems), or impaired though processes. Intervention: Communicate with the resident regarding residents' capabilities and needs. Keep Resident #46 routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #46 had ADL self-care performance deficit. Interventions: bathing, bed mobility, and walking -needed supervision. He uses a cane for ambulation. Observation on 08/13/2024 at 10:57 AM Resident #46 was in his room lying in bed. His nails were long and not even around the edges on his right and left hand. There was a blackish/ brownish substance on the edge of his ring finger and middle finger on his right hand. Observed the scent of feces when Resident #46 held up his right hand. Resident #46 had blackish hard substance underneath his ring finger, middle finger, and forefinger on his right hand. Interview on 08/13/2024 at 11:00 AM Resident #46 stated he did ask someone over the weekend to clean his nails and trim his nails. He stated the person he asked to clean and trim his nails stated someone would do it next week that they did not do nail care on the weekends. Resident #46 did not recall the name of the person he asked to help him with his nails. He stated he did not want to try and clean his nails because he was afraid he would get his fingernails or skin around his nail infected since he was a diabetic. He stated he tried to clean his nails and cut his nails few years ago and his skin around his nails became infected and he almost lost one of his fingers. Resident #46 stated he did have poop (a word for feces) on his fingers he was trying to clean himself and he did not realize it was on his fingers until someone came in and he saw it and asked for his fingernails to be cleaned and cut. In an interview on 08/14/2024 at 11:10 AM LVN A stated the nurses and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN A stated it was the CNAs responsibility to clean and trim all other residents' nails. She stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria underneath the residents' nails. She also stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with e coli (a bacteria that is commonly found in the lower intestine of warm-blooded organisms) issues such as diarrhea and vomiting. LVN A stated if a resident scratched themselves with rough nails there was a potential a resident may develop a skin tear and the skin tear had a potential of becoming infected. She stated she was not aware of Resident# 17, Resident # 31 or Resident #46 refusing nail care. In an interview on 08/14/2024 at 11:20 AM CNA B stated the nurses completed all diabetic (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) fingernails, and the CNAs were responsible for all other residents' nails. She stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails during showers. CNA B stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day, the staff were expected to do any type of nail care as needed. She stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria such as bowel movements. She stated if a resident swallowed bacteria it was a potential the resident may become ill with E. coli (a bacteria that is commonly found in the lower intestine of warm-blooded organisms) and may develop major stomach problems such as diarrhea. CNA B stated if a resident became severely ill the resident may need to be transferred to emergency room for more care. She stated she worked with Resident #17 and Resident #31, and she was not aware of them refusing nail care. CNA B stated sometimes Resident #46 would refuse to shave but she was not aware of him refusing nail care. She stated if a resident's nails were rough there was a possibility the resident may scratch themselves and develop a skin tear, or possibly scratch their eye and cause a tear on their eyeball. She stated she had been in-service on nail care but did not remember the date of the in-service. She stated it had been about a year. In an interview on 08/14/2024 at 11:43 AM LVN C stated the Treatment Nurse D was responsible for all nail care. He stated if a resident had blackish substance underneath their nails there was a possibility the substance was some type of bacteria. LVN C stated if a resident swallowed the blackish substance, he did not know what type of symptoms the resident may have if the blackish substance was bacteria such as feces. LVN C stated the resident may develop vomiting or diarrhea if they did get sick from the blackish substance according to what type of bacteria. He stated he was not aware of when the residents' nails were to be cleaned or trimmed it was according to the treatment nurses schedule. LVN C stated he did not clean or trim nails. He stated he did not recall if he had or had not been in-service on nail care. In an interview on 08/14/2024 at 11:55 AM CNA E stated the CNAs was responsible for cleaning, trimming, and filing all residents' nails except for the residents with diagnosis of diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). She stated the nurses was responsible for all residents' nails with diagnosis of diabetes. CNA E stated residents nails were usually cleaned , filed, and trimmed on their shower days. She stated if a resident had a hang nail or their nails were dirty, nail care was expected to be completed as needed. She stated if a resident had nails that were rough around the edges, there was a possibility a resident may scratch themselves or another resident. CNA E stated the scratch may develop into a skin tear. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues such as vomiting or diarrhea. CNA E stated there were also a possibility a resident may become severely dehydrated and may need to be transferred to emergency room to determine what type of bacteria was underneath the residents' fingernails. CNA E stated she had been in-serviced on cleaning, filing and trimming residents' nails but she did not recall the date. In an interview on 08/14/2023 at 12:15 PM Treatment Nurse D stated she did help with trimming and cleaning the diabetic nails; however, she was not responsible for all resident's nail care in the facility. She stated a resident may become ill such as stomach issues if the resident ingested some type of bacteria. The treatment nurse D stated if resident had rough nails around the edges there was a possibility a resident scratch themselves, staff, or other residents. She stated residents' nails were given care during showers and as needed. She stated the CNAs was responsible for all residents' nails except for resident with diagnosis of diabetes and this was the nurse's responsibility. She stated she had been in-service on nail care; however, she did not recall the date of the in-service. In an interview on 08/15/2024 at 7:50 AM The Director of Nurses stated the Treatment Nurse D was not responsible for all the residents' nails in the facility. She stated the Treatment Nurse D was expected to assist with nail care especially the residents with diagnosis of diabetes. The Director of Nurses stated if a resident had rough edges around the nail there was a possibility the resident may scratch themselves and develop a skin tear. Director of Nurses stated if a resident ingested blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated a resident may develop a type of illness. She stated it was according to what the bacteria was to determine if a resident would become ill. The Director of Nurses stated the resident may become ill with hepatitis. She stated all residents was expected to receive nail care during showers and as needed. She stated it was the nurse supervisor responsibility to monitor nail care. Record review of the Facility's Policy on Nail Care, dated 2003, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails all occur in the elderly with some frequency. Nail care especially trimming, is performed by a podiatrist in those with diabetes and peripheral vascular disease. Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions. The resident will be free from infection.

Based on observation, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for one (Resident # 53) of eight residents reviewed for resident rights. The facility failed to treat Resident #53 with respect and dignity when the staff was standing while feeding Resident #53 on 08/13/2024. This failure could place residents at risk for decreased quality of life, increased anxiety, and unmet needs. Finding included: Record review of Resident # 53's Face Sheet, dated 08/14/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of down syndrome ( a genetic condition that can affect how their brain and body develop), anxiety disorder (a condition in which a person has excessive worry and feelings of fear. Symptoms may include irritability, dizziness, fast heartbeat and/or restlessness), cognitive communication deficit (mental process of thinking, learning, problem-solving. Can affect both verbal and non-verbal communication such as speaking, listening, and social interaction skills), and need assistance with personal care ( hands-on services that assist a person with critical day-to day activities that they are unable to perform on their own such as dressing, bathing, eating, and maintaining their appearance). Record review of Resident # 53's MDS Quarterly Assessment, dated 05/19/2024, reflected Resident #53 had a BIMS score of 0 indicated her cognition was severely impaired. Resident #53 required assistance with eating, dressing, toileting, bathing, and personal hygiene. Record review of Resident #53's Comprehensive Care Plan, dated 07/15/2024, reflected Resident #53 had impaired visual function. Intervention: Resident #53 utilizes glasses. Resident used anti-anxiety medication for diagnosis of anxiety. Intervention: Monitor/ record occurrence for target behavior symptoms such as: pacing, wandering, aggression towards staff/others and inappropriate response to verbal communication. Resident had impaired cognitive function related to downs syndrome (a genetic condition that can affect how their brain and body develop), anxiety disorder (a condition in which a person has excessive worry and feelings of fear. Symptoms may include irritability, dizziness, fast heartbeat and/or restlessness). Intervention: Use the residents preferred name her first name), identify yourself each interaction. Face the resident when speaking and make eye contact. Reduce any distractions such as turn off television and radio. Resident #53 understands, consistent, simple , directive sentences. Keep her routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #53 had a communication problem. Intervention: be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Resident #53 had an ADL Self Care Performance Deficit. Observation on 08/13/2024 at 12:40 PM reflected Resident #53 was sitting at the feeders table in the dining room. Staff delivered her meal tray to her. LVN J walked toward Resident #53 and stood partially behind Resident #53 and partially beside Resident #53's right side. She was not facing Resident #53. LVN J began to feed Resident # 53 at an angle. Resident #53 attempted approximately 4 times turn her head to see the person feeding her. Resident #53 was unable to see the silverware coming toward her mouth until the silverware was in front of her mouth. Resident #53 began to move more frequently while sitting in the chair. She was moving her head side to side and was attempting to see who was feeding her. LVN J did not introduce herself to Resident #53 or explain she was going to be feeding her. Interview on 08/13/2024 at 1:05 PM LVN J stated she was standing while feeding Resident #53. She stated she did not introduce herself or explain she was going to be feeding Resident #53. LVN J stated she was not facing Resident #53 and it was difficult for Resident #53 to see her where she was standing when feeding her. She stated she was required to sit and face Resident #53 when she was feeding her. LVN J stated she did not feed Resident #53 correctly and she had been in serviced when staff was feeding a resident to introduce yourself, explain what you were going to be doing, and face the resident. She stated this was a dignity issue for someone to stand and feed a resident. LVN J stated Resident #53 may become anxious if she was unable to see who was feeding her. Interview on 08/15/2024 at 7:50 AM the Director of Nurses stated the staff was expected to sit when feeding a resident. She stated if staff was standing when feeding a resident this was a dignity issue for the resident. The Director of Nurses did not respond to any other questions about feeding residents in the dining room such as: Is there a possibility this could have a negative outcome with Resident #53 if she was unable to see who was feeding her. Record review of the Facility Policy on Resident Rights, dated 2003 and revised on 11/28/2016, reflected a facility must treat each resident with respect and dignity of care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals, were in locked compartments and inaccessible to unauthorized staff, visitors , and residents for 3 of 3 medication carts reviewed for medication storage. The facility failed to prevent Medication Cart #1 and Medication Cart #2 being unattended and unlocked near the nurse's desk and one medication cart unlocked and unattended approximately 15 feet away from the right side of nurse's desk on 08/15/2024 between 1:30 AM to 1:43 AM . This failure could allow residents unsupervised access to prescription and over-the-counter medications. Findings included,-: Observation on 08/15/2024 at 1:30 AM LVN H was standing at the entrance door to the facility when Surveyor I was walking toward the door to enter the facility. LVN H opened the door for Surveyor I and when entered the facility. LVN H was walking very fast toward Medication cart #1 on the right side of the nurse's desk and locked the medication cart. She asked CNA J to lock Medication Cart #2 on the left side of the nurse's desk. Observation on 08/15/2024 at 1:35 AM observed Resident #28 walked into the lobby and sat in a chair near nurse's desk. Observation on 08/15/2024 at 1:38 AM observed Resident # 7 was propelling self in her wheelchair to the lobby from 400 hall. She stopped approximately 10 feet from the nurse's desk and sat approximately 5 minutes and propelled self toward her room on 400 hundred hall. Observation on 08/15/2024 at 1:43 AM there was a third medication cart #3 located approximately 15 feet from the nurse's desk toward the hall on the right side of the nurse's station where the activity room was located. Surveyor I opened the medication cart drawers, and the Medication Cart #3 (Med Cart #3) was unlocked. In an interview on 08/15/2024 at 1:45 AM LVN H stated she was not aware of the third medication cart being unlocked. She stated she knew the other two medication carts by the nurse's desk was unlocked. LVN H stated she thought she had locked the third medication cart, but she did not recall how long the third medication cart had been unlocked. She stated the two medication carts by the nurse's desk had been unlocked approximately 1 hour. She stated she gave one resident some medications out of the medication cart on the left side of the nurse's desk approximately 40 minutes prior to Surveyor I entered the facility and she forgot to lock the three carts. She stated staff that was not authorized to open medication carts did have access to all medications except for narcotics. She stated the narcotics was locked in a box inside the medication cart. LVN H stated if a resident was wandering during the night the resident would have opportunity to open the medication cart and get any medications out if the cart and swallow the medication or drink some of the liquid medications. She stated there was a potential for a resident to die if the resident ingested a medication, they could be allergic to or it interacted with their own medications. LVN H stated all medications carts were to be locked at all times except when the nurse was dispensing medications from the medication cart to give to a resident. She stated she had been in-service to keep medication carts locked at all times unless administering medications to a resident. LVN H stated she did not follow the facility protocol and she was aware she was wrong not to check the medication carts to ensure they were locked. In an interview on 08/15/2024 at 1:55 AM CNA J stated she was sitting behind the nurse's desk when LVN H walked from the front door toward the medication cart. She stated LVN H asked her to lock the medication cart. CNA J stated the medication cart located to the left of the nurse's desk was unlocked and she did lock the medication cart. She stated only the nurses was allowed to lock and unlock the medication cart. CNA J stated she did not think about asking Nurse H she did not feel comfortable locking the medication cart. She stated LVN H had given a resident some medication approximately 45 minutes prior to Surveyor I entered the facility. In an interview on 08/15/2024 at 7:50 AM the Director of Nurses stated all three medication carts were expected to be locked on the night shift unless the nurse was standing at the cart administering medications. She stated if the medication carts were opened on the night shift there was no possibility of a resident getting any medications. The Director of Nurses stated no residents would be up during the night. She stated if there were residents awake when Surveyor I was in the facility the staff would stop them from taking medications. The Director of Nurses did not respond to any other questions of the possibility if staff was not around the medication carts there was a possibility the residents would have access to the medication carts without the staff knowledge. She stated she did not know the facility policy or protocol for the medication carts. She stated she would find out and inform Surveyor I of the protocol and her opinion after she read the facility medication cart policy. The Director of Nurses did not discuss the medication policy or protocol with Surveyor I prior to exiting on 08/17/2024. In an interview on 08/15/2024 at 8:09 AM the Administrator stated it was ideally for the medication carts to be locked when the nurses were not administering medications from the carts. He stated there was a possibility a resident may get medications out of the medication cart. He stated if a resident did take the medications by mouth there was a possibility a resident may have an allergic reaction and may cause some type of physical harm. He stated he was not a nurse and did not know all the risks of a resident taking another residents medication. Record review of the Facilities Medication Cart Policy, dated 2003, reflected the medication carts shall be maintained by the facility. The carts are to be locked when not in use or under the direct supervision of the designated nurse. Carts must be secured.

Based on observation, interview and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure the Maintenance Supervisor K wore a hair net and beard net and the Administrator wore a hair net while standing over large bowl of approximately 15 uncooked chicken breasts in the sink on 08/13/2024. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illness, and decreased quality of life. Findings included: Observation on 08/13/2024 at 9:15 AM the Administrator and the Maintenance Supervisor K walked into the kitchen without donning (the act of putting on gloves or a hair net) hair net and beard net. The Maintenance Supervisor was checking the temperature of the water in the sink. A large bowl of approximately 15 uncooked chicken breasts being defrosted was in the sink. The Maintenance Supervisor K and the Administrator was standing over the sink without wearing hair net or beard net. The maintenance supervisor K had approximately 8-inch growth of hair on his chin. His hair was twisted; however, his hair was long almost to his shoulders. The Administrator hair was long between his neck and his shoulders. In an interview on 08/13/2024 at 9:25 AM Maintenance Supervisor K stated he was expected to place hair net on his head and a beard net over his hair on his chin. He stated he was standing directly over the chicken. He stated there was a possibility hair could have fallen onto the chicken. The Maintenance Supervisor K stated if a resident did have hair on their chicken there was a potential a resident may become sick with some type of illness from the hair. He stated the hair may have chemicals on it and cause the resident to become ill with stomach issues. He stated had been in serviced on wearing hair net and beard net when entering the kitchen. He did not recall the date of the in-service. He stated the hair net and beard net was available at the door prior to entering the kitchen. In an interview on 08/15/2024 at 8:09 AM the Administrator stated he was expected to wear hair net when entering the kitchen and the Maintenance Supervisor K was also to wear a hair net and a beard net. He stated the both of them maintenance supervisor K) did enter the kitchen without wearing hair net and the Maintenance Supervisor did have hair on his chin and he was to wear a beard guard. The Administrator stated the Maintenance Supervisor K was standing directly over the uncooked chicken being defrosted in the sink. He stated he was standing toward the side, however, there was one time he was standing over the same chicken as Maintenance Supervisor K. He stated there was a possibility a resident potentially may ingest hair and become ill with some type of foodborne illness. He stated his expectation was any staff entering the kitchen was expected to wear hair net and if males had beard growth, they were expected to wear a beard guard. The Administrator stated he knew he was required to wear hair net prior to entering the kitchen and the hair nets was available at the kitchen door prior to entering the kitchen. In an interview on 08/15/2024 at 11:55 PM the Dietary Manager L stated all staff in the facility was expected to wear a hair net and if a male had a beard the male staff was expected to wear a hair net and beard net prior to entering the kitchen. She stated there was a possibility hair could have fallen onto the chicken being defrosted in the sink. Dietary Manager L stated it would be easy for hair to stick to wet uncooked chicken. She stated hair was considered contaminated and if a resident ate some hair which was located on the chicken there was a possibility the resident may become physically ill from the bacteria on the hair. She stated a resident may become ill with stomach issues such as vomiting and diarrhea. Dietary Manager L stated her staff is in-service on this on a regular basis and the non-dietary staff was verbally informed no one was to enter the kitchen without wearing hair net. She stated the staff was also informed they could not enter the kitchen if the staff had facial hair. They were to place beard guard over their facial hair. She stated the beard guard and hair nets were located at the door entering into the kitchen from the dining room. Record review of the Facility's Policy on Infection Control, dated 2012, reflected clean hair was required. It is to be covered with an effective hair restraint. Facial hair was to be closely trimmed and was to be covered with a hair restraint.

Based on observations, interviews, and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by staff in the direct care of one ( Resident #1) of four residents reviewed for infection control. The facility failed to ensure CNA F sanitized or washed her hands prior to touching contaminated surfaces (floor and chair) prior to touching Resident #1's food and prior to feeding Resident #1 on 08/13/2024. These failures could place residents at risk of cross contamination which could result in physical illness. Findings included: Record review of Resident #1's face sheet, dated 08/14/2024, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of transient cerebral ischemic attack, unspecified ( a medical emergency that occurs when the blood flow to the brain is temporarily disrupted, causing a lack of oxygen), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder that causes a person to lose the ability to think, remember, learn, make decisions, and solve problems, but without any symptoms of behavioral disturbances), legal blindness, as defined in USA (having central visual acuity of 20/200 or worse in the better eye with the best possible correction, or a visual field of 20 degrees or less), cognitive communication deficit (It can involve problems with cognitive skills such as memory, concentration, reasoning, and problem-solving. These deficits can affect verbal and nonverbal communication, including speaking, listening, reading, writing, and social interaction skills), age-related nuclear cataract, bilateral cataracts (a common eye condition that affects both eyes and causes blurred vision), and muscle weakness (when your body can not contract its muscle properly, causing a reduction in strength). Record review of Resident #1's Admission MDS Assessment, dated 05/07/2024 reflected Resident #1 had a BIMS score of 5 indicated his cognition was severely impaired. Resident #1 required maximal assistance ( helper does more than half the effort) of staff with eating, oral hygiene, dressing and personal hygiene. He was dependent on staff for toileting hygiene and showers. Resident #1 required mechanically altered diet. Record review of Resident #1's Comprehensive Care Plan, dated 05/01/2024 and revised on 08/13/2024 reflected Resident #1 had impaired cognitive function or impaired thought process (It can involve problems with cognitive skills such as memory, concentration, reasoning, and problem-solving. These deficits can affect verbal and nonverbal communication, including speaking, listening, reading, writing, and social interaction skills). Interventions: Keep Resident #1's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. He had impaired visual function related to legal blindness; age related nuclear cataract- bilateral. Intervention: arrange consultation with eye care practitioner as required. Ensure appropriate visual aids are available to support resident. Monitor , document, and report to MD the following signs and symptoms of acute eye problems: ability to perform ADLs and sudden visual loss. Resident #1 was at risk for malnutrition ( lack of proper nutrition, caused by not having enough to eat, not eating enough of the right foods, or being unable to use the food that one does eat. Resident #1 had an ADL self-care performance deficit. Intervention: Resident #1 required one person staff assistance with eating. Observation on 08/13/2024 at 12:45 PM reflected CNA F bent over and picked up approximately four stacked cups off the dining room floor. Her middle, forefinger, and ring fingers from the knuckle to the tip of the fingers touched the floor when she picked up the stacked cups. She placed the plastic cups on the table near Resident #1. CNA F grabbed the arms of a chair and pulled the chair next to Resident #1 immediately after she placed the plastic cups on the table. She did not sanitize or washed her hands. CNA F sat in the chair and turned Resident #1 plate around between her and Resident #1. When she pulled Resident #1 plate the top part of her middle finger and fore finger touched inside his plate and touched the mashed potatoes. CNA F continued to feed Resident #1 and never sanitized or washed her hands. She picked up the napkin with her small finger, middle finger, and ring finger on her right hand and wiped Resident #1's mouth. She then wiped his mouth her middle finger and ring finger on her right hand from her knuckle to the tip of her finger touched the right side of Resident #1's mouth. In an interview on 8/13/2024 at 1:30 PM CNA F stated she did pick up some cups off the floor and the tip of her fingers did touch the floor. She stated she pulled up a chair and touched the arms of the chairs. CNA F stated she pulled Resident #1's plate around to feed him and she did touch the inside of the plate and she may have touched the mashed potatoes. She stated she did not wash or sanitize her hands. CNA F stated there was a possibility she may have cross contaminated Resident #1's plate and his food with her hands. She stated it was expected to wash or sanitize hand prior to feeding any resident and she did not wash or sanitize her hands. She stated she had been in serviced on sanitizing hands prior to feeding a resident, however, she did not recall the date of the in-service. In an interview on 08/14/2024 at 11:10 AM LVN A stated if staff picked up anything off the floor and their fingers touched the floor the staff was expected to wash or sanitize their hands immediately. She stated if staff touched the arms of a chair while moving the chair to the table next to a resident, the chair was considered contaminated, and the staff was expected to wash or sanitize their hands prior to feeding a resident. LVN A stated if the staff hand touched the resident's food with her hands after she touched the chair and the floor the staff cross contaminated the food from the bacteria on the staff's hands. She stated there was a possibility the resident could become ill such as food borne illness with symptoms of vomiting or diarrhea. She stated she had been in-service on hand hygiene and wash or sanitize your hands prior to feeding a resident. LVN A stated she did not recall when she had been in-serviced on washing hands when in the dining room feeding residents. In an interview on 08/15/2024 at 11:20 AM CNA B who stated if someone picked anything up off the floor and their fingers touched the floor, she stated the staff was to wash or sanitize hands prior to feeding a resident. She stated if staff pulled up a chair and sat in chair the chair would be considered contaminated. She stated the staff must sanitize or wash hands prior to feeding any resident even if they did not touch the floor or chair. She stated there was a possibility if the food was touched the food would be contaminated from the germs from the floor and the chair. She stated a resident could become sick if they swallowed any type of bacteria from the staff hands if the hands were not sanitized. She stated the resident could become ill with vomiting stomach issues and may have diarrhea. CNA B stated she had been in-service on hand hygiene when feeding did not recall the date and had been in-service on feeding residents and during the in-service was discussed to always sit and never stand when feeding she did not recall when this in-service was given. In an interview on 08/15/2024 at 7:50 AM the Director of Nurses stated the staff was expected to sanitize their hands prior to feeding a resident. She stated if the staff touched the floor, or anything contaminated the staff hands were considered contaminated and was expected to sanitize their hands. She stated she did not know what type of illness a resident may get from bacteria. She stated the facility never had a resident to become ill from any type of bacteria. ( common infectious diseases caused by bacteria is the following: strep throat ( a disease that causes a sore throat), urinary tract infection ( an infection in any part of our urinary system: kidneys and/ or bladder), E. Coli ( bacteria normally lives in your intestines can get it from the environment, food and water), clostridiodes diffcile (infection of the colon)She stated there was always a possibility of someone becoming ill from bacteria. The Director of Nurses stated the staff had been in-service to wash or sanitize their hands prior to feeding a resident. She stated she did not recall the date of the in-service. Record Review of the Facility Policy on Hand Hygiene, not dated, reflected you may use alcohol-based hand cleaner or soap/water for the following before and after assisting a resident with meals.

Based on interview, observation, and record review the facility failed to request Nursing Facility Specialized Services for habilitative therapies for two (Resident #1 and Resident #2) of three residents reviewed for PASRR services. The facility failed to provide specialized services to Resident #1 and Resident #2. due to the facility not submitting the Nursing Facility Specialized Services (NFSS) request form in the LTC Portal. This failure could place residents at risk of not receiving specialized PASRR services to enhance the resident's highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: 1. Review of Resident #1's face sheet dated, 12/19/2023 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of : other psychotic disorder not due to a substance or know physiological condition ( a mental disorder that cause abnormal thinking and perceptions, and make a person lose touch with reality), difficulty with walking ( multiple medical conditions that affect the bone, joints, muscles or the brain), abnormalities of gait and mobility ( occurs when the body systems that control the way a person walks do not function in the usual way), muscle wasting and atrophy, not elsewhere classified, unspecified site ( thinning of muscle mass), history of falling ( a has fallen numerous times in the past), and unspecified lack of coordination ( uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements). Review of Resident #1's Quarterly MDS assessment dated , 11/04/2023 reflected Resident #1 had a BIMS score of one indicating his cognition was severely impaired. He had functional limitation in Range of Motion with upper and lower extremities. Resident #1 required assistance with ADLs. He had received physical therapy (restore the normal function of the body), occupational therapy (helps people with physical, emotional, or social problems), and speech therapy (helps people improve their communication skills and help with eating and drinking problems). Review of Resident #1's Comprehensive Care Plan, dated, 11/20/2023 reflected Resident #1 was at risk for falls. He had an unspecified intellectual disability. Resident also had ID (intellectual disabled, developmentally disabled) and was PASRR positive. He was also assessed of having poor balance and an unsteady gait. Resident #1 had an ADL self-care performance deficit related to limited range of motion and limited mobility. He had limited use of his left hand. Observation of Resident #1 on 12/19/2023 at 9:50 AM, he was sitting near the ADON office leading into the lobby area. He was sitting in a specialized wheelchair. He was wearing a soft helmet on his head. He made eye contact and did not speak. An attempted interview on 12/19/2023 at 9:52 AM revealed Resident #1 was not interview able. He would turn his head toward the wall when attempting to communicate with him. Review of an email on 12/19/2023 at 2:40 PM, reflected the Rehab Director emailed the MDS Coordinator on 10/5/2022 with subject Resident #1's PASRR (this assessment helps decide if a nursing facility was the best place for a person with a behavioral, intellectual or developmental disability) . The attachment to the email was the completed NFSS (nursing facility specialized services) for Habilitative Therapies form of the information from physical therapy, speech therapy, and occupational therapy. 2, Review of Residents #2 face sheet dated 12/19/2023 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of: down syndrome (causes lifelong intellectual disability and developmental delays), muscle wasting and atrophy (thinning of muscle mass), cognitive communication deficit, (difficulty with thinking and how someone uses language), muscle weakness (when full effort does not produce a normal muscle contraction or movement), difficulty with walking, abnormalities of gait and mobility (occurs when the body systems that control the way a person walks do not function in the usual way), ataxic gait (unsteady and uncoordinated way of walking. A person may feel they need to hold onto something as they walk), cerebral palsy (affects movement, muscle tone, balance and posture), dysphagia (difficulty with swallowing food or liquid). (and stiffness of right and left knee (tightness in and around knee joint that can make it hard to move the joint). Review of Resident #2's Quarterly MDS dated , 09/23/2023, reflected Resident #2 had a BIMS score of five indicated his cognition was severely impaired. Resident #1 required assistance with ADLs. He had received physical therapy (restore the normal function of the body), occupational therapy (helps people with physical, emotional, or social problems), and speech therapy (helps people improve their communication skills and help with eating and drinking problems). Review of Resident #2's Comprehensive Care Plan dated, 09/15/2023 reflected Resident #2 had cerebral palsy (affects movement, muscle tone, balance and posture), limited range of motion to knees and ankles. He had impaired cognitive function related to down syndrome (causes lifelong intellectual disability and developmental delays). Resident #2 was assessed to be at risk for falls. He had DD (development disability) and was PASRR positive. Resident #2 had contracture to left elbow. He also required assistance with ADLs. He had a swallowing problem related to dysphagia (difficulty with swallowing food or liquid). Observation on 12/19/2023 at 10:04 AM, Resident #2 was in his room and lying in bed. Resident #2 was smiling and counting how many times he had completed the exercise on each arm. In an interview on 12/19/2023 at 10:06 AM, Resident #2 stated he did arm exercises every day. He stated he was feeling good. He asked, can you come back tomorrow. There is things I need to do today and do not have time for people to visit me today? Review of Email on 12/19/2023 at 2:48 PM reflected the Rehab Director emailed the MDS Coordinator on 10/5/2022 with subject Resident #2's PASRR. The attachment to the email was the completed NFSS for Habilitative Therapies form of the information from physical therapy, speech therapy, and occupational therapy. Review of Email on 12/19/2023 at 3:10 PM reflected the PASRR Representative (through the state HHSC) sent an email to the MDS Coordinator dated 01/26/2023. A follow-up to a compliance phone call - PASRR information of high importance. The email reflected as discussed on the phone, you (MDS Coordinator) will need to submit a NFSS request form from PASRR Specialized Services (therapies and assessments OT, PT and ST) by 01/31/2023 through the Texas Medicaid and Healthcare Partnership Long Term Portal (the link to this portal was provided in the email). The email also reflected the directions on how to complete a Nursing Facility Specialized Service Form, the new security access to submit the Nursing Facility Specialized form, and a telephone number if there were any questions. Review of Email from the PASRR Representative to the MDS Coordinator and the Administrator on 12/19/2023 at 3:15 PM reflected the email was dated 02/07/2023. A follow up to a compliance phone call - PASRR information and avoiding denials. The full email was not provided at time of exit. Review of electronic medical records on the MDS Coordinator Computer reflected Resident #1 and Resident #2 was approved for OT, ST and PT on 02/23/2023. Review of Resident #1's and Resident #2's Physical Therapy, Speech Therapy, and Occupational Therapy on 12/19/2023 at 3:10 PM reflected both men continued their therapy per physician orders during the time period the NFSS was not submitted and the facility was waiting on the approval of therapies for both me. In an interview on 12/19/2023 at 12:15 PM, the MDS Coordinator stated she did not submit Resident #1's or Resident #2's NFSS forms by the due date. She stated she did speak with someone from the PASRR office and explained to the person that she did not have the time to complete the NFSS forms. The MDS Coordinator stated the Rehab Director did email her the NFSS forms in October 2022 on Resident #1 and Resident #2. She stated between October 2022 and the due date of the NFSS on 01/31/2023 was sufficient time to submit the NFSS forms. She stated OT, PT, and ST did fill out the NFSS form correctly when it was emailed to her in October 2022. She stated she could not remember the exact date in October. She stated if therapy had quit seeing Resident #1 and Resident #2 until the services was approved by the PASRR department, there was a possibility that Resident #1 and Resident #2 may have had a decline in their physical condition, range of motion, and cognition. She stated it was her responsibility to submit the NFSS forms. She stated she became busy and did not submit the NFSS forms by the due date of 01/31/2023. In a phone interview on 12/19/2023 at 1:19 PM, the Rehab Director stated she emailed the completed NFSS forms to the MDS Coordinator in October 2022. She stated she did not know the exact date. The Rehab Director stated Resident #1 and Resident #2 never went without therapy according to their physician orders during this time. She stated it was time for their therapy to be approved by the PASRR for Rehabilitation Office. She also stated she remembered talking about therapy and the NFSS in a meeting but she would need to be in the office to recall which meeting and the date of the meeting. She stated she remembered the MDS Coordinator being in the meeting due to discussing renewing the NFSS forms with the PASRR specialized services office. She stated the approval was sometime in February. The Rehab Director stated when anyone was on therapy through PASRR services, the residents never miss any of their therapy if they are waiting on forms to be approved. She stated to look through Resident #1's and Resident #2's therapy records during that time period and the records would indicate these two men (Resident #1 and Resident #2) received OT, PT, and ST. In an interview on 12/19/2023 at 1:40 PM, the ADON stated he was not familiar with the process of the NFSS forms. He stated he was aware of PASRR when a resident was admitted to the facility. He also stated if there was a due date for the NFSS to be submitted and the Specialized Service Representative emailed a deadline for the NFSS to be submitted the MDS Coordinator was expected to submit the NFSS by the due date documented in the email from the Specialized Service for PASRR office. The ADON stated he reviewed the therapy documentation during the time period of October 2022 and February 2023. He stated Resident #1 and Resident #2 continued receiving OT, PT, and ST . He also stated there was more than enough time for the MDS Coordinator to submit the NFSS form when the Rehab Director sent her the email in October 2022 (he did not know the exact date) and by the due date of 01/31/2023 documented in the email from the Specialized Service Representative from PASRR to the MDS Coordinator. In an interview with MDS Coordinator on 12/19/2023 at 2:00 PM requested records of the IDT meetings when Resident #1's and Resident #2's therapy was discussed during these meetings. The records were not available at time of exit. In an interview on 12/19/2023 at 3:45 PM, the Administrator stated the NFSS forms were to be completed and submitted to the PASRR Representative before the due date. He stated the MDS Coordinator was responsible for submitting the NFSS and completing the PASRR. He stated there was no reason why the MDS Coordinator did not submit the NFSS form on time. He stated he was not aware prior to today (12/19/2023) that the NFSS forms on Resident #1 and Resident #2 were not submitted. He stated when the second email was sent by the NFSS Specialized Office he informed the MDS Coordinator to submit the NFSS form on time. He did not respond to any other questions of who was responsible to monitor the MDS Coordinator. The facility's policy on PASRR Nursing Facility Specialized Services dated 03/06/2019 reflected the NFSS forms are submitted timely and accurately. Utilize the following resources: 1. HHSC Companion Guide for completing the NFSS forms. 2. HHSC Detailed Item Guide for NFSS forms. 3.TMHP Manual: Long Term Care Guide for PASRR for Nursing Facilities. 4. HHSC Detailed Item Guide for PCSP Forms. The NFSS will be submitted in the electronic site for NFSS within 24 hours of receipt of the Assessment/Service from therapy and will be monitored daily for approval/denial.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for sanitation. The Director of Food and Nutrition failed to ensure all food items were labeled, dated, and properly stored. CK H failed to wash her hands after handling dirty dishes. These failures could place residents at risk of foodborne illness. Findings included: An observation of the reach-in refrigerator in the kitchen on 7/12/2023 at 7:08 a.m. revealed an opened container of mayonnaise dated 12/02/2022, a container of opened pickles dated 4/12/2023, and a plastic storage container filled with an unknown substance that was not labeled or dated. During an interview on 7/12/2023 at 7:10 a.m., CK H stated the dates on the mayonnaise and pickles were received dates and not opened dates. CK H stated food items needed to be labeled with an opened date when they were opened. CK H stated the unknown substance was chili and said, it needs a date. During an interview on 7/12/2023 at 7:12 a.m., the Director of Food and Nutrition stated she had a lot of new staff in the kitchen and everyone was in training. During an interview on 7/12/2023 at 7:14 a.m., the Director of Food and Nutrition stated food items should be dated when they were opened. An observation of the reach-in freezer on 7/12/2023 at 7:16 a.m. revealed a bag of frozen white rectangular items dated 7/07/2023 but not labeled. The plastic bag was ripped and open to air. There was also a blue bag of unknown substance tied shut with no label or date. During an interview on 7/12/2023 at 7:18 a.m., the Director of Food and Nutrition stated the blue bag contained hamburger patties and stated yes that everything should be covered. The Director of Food and Nutrition stated, it's a battle but did not clarify what this meant. An observation on 7/12/2023 at 11:36 a.m. revealed CK H pureed pork chops, washed the food processor in the three compartment sink, and did not wash her hands. CK H then proceeded to puree broccoli. During an interview on 7/12/2023 at 11:49 a.m., CK H stated she had not washed her hands after cleaning the food processor because she had rinsed her hands off in dishwasher and sanitizer water. During an interview on 7/12/2023 at 1:49 p.m., the Director of Food and Nutrition stated she had not had any problems in the kitchen and the RD had told her she did not need to look because she knows it's good. The Director of Food and Nutrition stated the RD had not completed any kitchen sanitation audits. During an interview on 7/13/2023 at 7:57 a.m., the Administrator stated kitchen sanitation audits were not something the RD did at that facility. The Administrator stated the RD monitored the kitchen via walk throughs with the Director of Food and Nutrition when she came in and stated the RD discussed any issues with the Director of Food and Nutrition. The Administrator stated the RD did that once a month. The Administrator stated the facility also had unannounced white glove audits which were completed yearly by members of the facility's corporate office. The Administrator stated the facility recently had a white glove audit of the kitchen. During an interview on 7/13/2023 at 2:25 p.m., the Director of Food and Nutrition stated yes all foods should be covered, labeled and dated. The Director of Food and Nutrition stated yes she expected staff to wash their hands after handling dirty dishes and before preparing a food item but stated she felt washing, rinsing and sanitizing them in the three compartment sink while washing a dish was good enough. The Director of Food and Nutrition stated staff could hardly stand her because she was consistently in the kitchen and was always monitoring them. The Director of Food and Nutrition stated she monitored for food storage by looking in the refrigerators and freezers every morning around 7:30 a.m.-8:00 a.m. The Director of Food and Nutrition stated she trained staff on food storage verbally and visually by showing them. The Director of Food and Nutrition stated the RD came in once a month to look around but had not written anything down because she hasn't found any issues. The Director of Food and Nutrition stated if the RD did find issues, she would tell her and it would be corrected right then. When asked what a potential negative outcome was if food were not stored or handled properly, the Director of Food and Nutrition stated she did not give residents bad food and what I don't eat, I'm not going to let them eat. During an interview on 7/13/2023 at 3:06 p.m., the RD stated yes all foods should be covered, labeled and dated with an opened date. The RD stated she expected staff to wash hands with every change in task and although no she did not believe washing hands in the three compartment sink was a substitute, she could see why dietary staff might be confused and said she could do an in-service. The RD stated she had not done any formal in-services with dietary staff yet and stated the Director of Food and Nutrition trained dietary staff. The RD stated she completed walk throughs every month but these were not documented. When asked what a potential negative outcome was if food that was improperly handled or stored were served to residents, the RD stated it would be a food safety concern. During an interview on 7/14/2023 at 10:15 a.m., the Administrator stated foods needed to be labeled if they were opened and stored items needed to be labeled and dated. The Administrator stated hands needed to be washed when contaminated and based on their policy, the three compartment sink was not a substitute for handwashing. The Administrator stated dietary staff were trained by shadowing the Director of Food and Nutrition. The Administrator stated the Director of Food and Nutrition was responsible for ensuring compliance of dietary polices. The Administrator stated if hands were not washed when soiled and food was not handled properly, it could result in food contamination and they could get sick. A record review of the facility's [NAME] Glove Dietary assessment dated [DATE] reflected NO next to Food Rotation Dates and a note reflected Multiple open bags. A record review of the facility's policy dated 2012 titled Hand Washing reflected the following: We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below. Procedure: 1. Hand washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispensers, and paper towels, and should have a sign posted conspicuously near or above wash basin. 5. Food preparation sinks are not to be used for hand washing. A record review of the facility's policy dated 2012 titled Storage Refrigerators reflected the following: Procedure: 5. Food must be covered when stored, with a date label identifying what is in the container. A record review of the 2017 FDA Food Code reflected the following: (B) Except as specified in [paragraph] (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in [paragraph] (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 2-301.12 Cleaning Procedure. (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under S 5-202.12 and Subpart 6-301.

Based on observation, interviews, and record review the facility failed to place most recent survey readily accessible to residents in a place most frequented by most residents have the most recent survey for 5 of 5 residents reviewed for resident group meeting. The facility failed to have the survey manual readily accessible for the residents to view the survey manual. This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history. Findings included: Observation on 07/13/2023 at 9:30 AM revealed the state survey manual was located behind the nurse's desk on the medical chart rack. There were 28 manuals located on the chart rack and it was difficult to locate the survey manual. Where the medical chart rack was located the resident would need to go behind the nurse's station to view the survey manual. It was not readily accessible for residents to view the survey. The survey manual was not placed in an area where the resident had easy access to it. The area where the survey manual was located was not easily for a resident in a wheelchair to obtain the survey manual The sign on the wall stated a copy of the most recent survey conducted by the Texas Department of Aging and Disability Services can be reviewed at the nurse's station. This sign was in a picture frame with sixteen other signs in a picture frame. Record review on 07/13/2023 at 9:40 AM of the sign on the wall reflected a copy of the most recent survey conducted by the Texas Department of Aging and Disability Services can be reviewed at the nurse's station. The information is for reference only. The binder will contain survey information covering at least one year. Please do not remove the binder or any part of the binder. The sign was on a wall with approximately sixteen other picture frames with different information. In a confidential group interview on 07/13/2023 at 10:00 AM through 10:30 AM, five residents stated they did not know where or how to access the survey results in the facility. They did not understand or have knowledge this existed in the facility. The residents in the group stated they would like to have access to this information, because the staff did not tell them anything about visits from the state. Two of the residents stated they did not know the state sent a report to the facility of any type of visits. The other three residents agreed. Two residents stated if there was a sign about the survey book on the wall they did not know it was there due to there were a lot of signs on one wall and it was very confusing attempting to read and understand all the signs. There were two residents who stated there were approximately 25 or more signs on the wall. The residents stated most of the signs were confusing. The residents stated if there was a sign saying Texas Department of Aging and Disability survey can be reviewed at the nurse's station, they would believe it was how to apply for Medicaid or to receive forms about disability. The residents stated if the survey manual was behind the nurse's station they were not allowed to go behind the nurse's station. Two residents stated if they were allowed to go behind the nurse's desk to look at the survey manual their wheelchairs would not fit behind the nurse's station. The residents also stated they would not feel comfortable to ask the staff to get the survey for them because they would not want the staff to know they were looking at what the state survey said about the facility. The residents stated they would prefer to review the report from the state in an area where it was private, and they could take their time reviewing the survey. The residents stated they never saw a sign about a survey book. The residents stated behind the nurse's station was not a good place for them to be able to look at the surveys anytime they wanted to without request to ask for the book. In an interview on 07/14/2023 at 10:57 AM the Administrator stated the resident's rights were reviewed with the residents upon admission. He stated the survey book was located behind the nurse's desk. He stated the resident did have a right to have access to the last survey. He also stated the resident would need to ask someone for the survey manual. The Administrator also stated behind the nurse's desk may not be the best place for the survey book due to not being accessible for the residents. He stated he thought it would be better to move the survey book to another area where the residents were able to look at it without having to ask someone for the manual. He stated the residents were not able to go behind the nurse's desk to obtain the survey book. He also stated having the survey manual behind the nurse's desk was not an ideal place . He also stated he did not know if it was a resident right for the residents to have access to surveys. He did not respond to the question of who was responsible to review resident rights and explain the survey book to the residents. He did not respond to the question about the sign posted about the survey book could be confusing to the residents such as: Texas Department of Aging and Disability survey. Record review of the Facility Policy on Resident Rights dated 11/28/2016 reflected the facility post in a place readily accessible to the residents, family members and legal representatives of residents, the results of the most recent survey of the facility.

Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of 15 residents (Resident #23, Resident #28, Resident #45, and Resident #48) reviewed for quality of life. The facility failed to ensure Resident#23's, Resident #28's, Resident #45's, and Resident #48's fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life. Findings included: 1. Record review of Resident #23's face sheet, dated 07/13/2023, reflected an 86 -year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus without complications ( your body does not use insulin properly), unspecified lack of coordination ( uncoordinated movement), need for assistance with personal care (day- to- day activities people are unable to perform on their own), cognitive communication deficit (difficulty with thinking), and muscle weakness ( lack of strength in muscles). Record review of Resident #23's Significant Change MDS assessment, dated 06/05/2023, reflected Resident# 23 had a BIMS score of 1 which indicated residents' cognition was severely impaired. Resident #23 was assessed to require assistance with ADLs. Resident #23 did not reject care. Record review of Resident #23's Comprehensive Care plan, dated 07/05/2023, reflected resident had impaired cognitive function or impaired thought processes. Resident had impaired visual function. Observation on 07/12/2023 at 7:30 AM revealed Resident #23 was awake and lying-in bed. Resident #23 had a blackish/brownish substance underneath the nails on her ring finger, middle finger, and fore finger on the right hand. In an observation and interview on 07/12/2023 at 7:33 AM Resident #23 stated that looks awful (when she was looking at the blackish/brownish substance underneath her nail). She stated she did not know anything about cleaning her nails. She stated she was not able to clean her nails or do anything, she was sick and could not do anything for herself. 2. Record review of Resident #28's face sheet, dated 07/13/2023, reflected a 75 -year-old male admitted to the facility on [DATE] with diagnoses which included need assistance for personal care (day- to- day activities people are unable to perform on their own), cognitive communication deficit (difficulty with thinking), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side ( paralysis on the right side of the body due to tissue damage to the brain or spinal cord). Record review of Resident #28's Quarterly MDS assessment, dated 06/28/2023, reflected Resident # 28 had a BIMS score of 14 which indicated resident's cognition was intact. Resident required assistance with ADLs. Resident #28 did not refuse care. Resident was frequently incontinent of bowel. Record review of Resident #28's Comprehensive Care plan, dated 05/31/2023, reflected Resident #28 had hemiplegia, and hemiparesis related to CVA. Resident had poor vison. Resident had hearing deficit. Resident had a communication problem related to stroke. Resident had impaired cognitive function/dementia and impaired thought processes. Resident required assistance with personal hygiene. Intervention: resident required one person staff assistance with personal hygiene and oral care. Observation on 07/12/2023 at 7:24 AM, revealed Resident #28 was in his room sitting in a wheelchair waiting on breakfast. Resident #28 had a blackish/brownish substance underneath the fingernails on the following fingers on both hands: middle finger, ring finger and fore finger. His middle fingernail on his right and the ring fingernail on his left hand were long and jagged. In an interview on 07/12/2023 at 7:24 AM, Resident #28 stated he had asked someone three days ago to clean and trim his nails. He stated the person he asked stated they would come back and clean and trim his nails and they never came back to his room. He stated he did not remember the staff's name. He stated sometimes he gets bowel stuff on his nails almost every night. Resident #28 stated he did not want to discuss this any further. 3. Record review of Resident #45's face sheet, dated 07/13/2023, reflected a 56 -year-old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis on the right side of the body due to tissue damage to the brain or spinal cord), muscle weakness generalized (decreased strength of the muscles), and cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #45's Quarterly MDS Assessment, dated 05/04/2023, reflected Resident #45 had a BIMS score of a 9 which indicated resident's cognition was moderately impaired. Resident #45 was assessed she did not exhibit behavior problems such as rejecting care. Resident #45 required supervision with one person assist with ADLs except for personal hygiene and bathing. Resident #45 required extensive assistance with personal hygiene and required physical assistance with part of her bathing. Resident was occasionally incontinent of bowel. Record review of Resident #45's Comprehensive Care Plan, dated 05/10/2023, reflected Resident #45 had hemiplegia/ hemiparesis related to CVA. Intervention: assist with ADLs. Resident #45 had ADL self-care performance deficit. Intervention: check nail length, trim, clean on bath day and as necessary. Observation on 07/12/2023 at 7:40 AM, revealed Resident #45 was in her room lying in bed. Resident #45's nails were long, and the nail polish was peeling from her fingernails. She had a blackish /brownish substance underneath the fingernails of the fore finger, the ring finger, the little finger, and the middle finger on her left hand. In an interview on 07/12/2023 at 7:40 AM, Resident #45 stated she asked the same staff two times to clean her fingernails. Resident #45 stated she accidentally touched some bowel stuff on her hand. She stated she removed the bowel stuff from her hand; however, she could not clean the bowel stuff underneath her fingernails. Resident #45 stated she did not remember the staff's name. 4. Record review of Resident #48's face sheet, dated 07/13/2023, reflected an 82 -year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified lack of communication (persistent problems in language and speech), unspecified lack of coordination (uncoordinated movement) and, muscle weakness (decreased strength of the muscles). Record review of Resident #48's Quarterly MDS Assessment, dated 05/01/2023, reflected Resident #48 had a BIMS score of a 3 which indicated resident's cognition was severely impaired. Resident #48 did not reject care. She required assistance with ADLs. Resident #48 required supervision with eating. Resident #48 was frequently incontinent of bowels. Record review of Resident #48's Comprehensive Care Plan, dated 05/10/2023, reflected Resident #48 had a communication problem related to Alzheimer's disease. Intervention: anticipate and meet needs. Resident #48 had an ADL self-care performance deficit. Intervention: check nail length, trim, and clean on bath day and as necessary. Observation on 07/12/2023 at 8:14 AM, revealed Resident #48 was in the dining room eating breakfast. Resident #48 was feeding herself, and she placed the ring finger and middle finger on her right hand in her mouth. Resident had a blackish/brownish substance underneath the nails of her forefinger and middle finger on her right hand. In an interview on 07/12/2023 at 8:17 AM, it was determined Resident #48 was not interviewable. She smiled and would mumble. In an interview on 07/14/2023 at 8:31 AM the Director of Nurses stated the CNAs were responsible of cleaning and trimming/cutting residents' nails except the residents with a diagnosis of diabetes. She stated for any resident with or without a diagnosis of diabetes the treatment nurse was responsible for all nail care including trimming and cleaning when she completed the weekly skin assessments. She stated if a resident had dirty nails there was a possibility bacteria could be on their fingers and/or underneath the resident's nails. She stated there was a potential a resident could ingest bacteria from their fingernails into their mouth. She stated it depended on the type of bacteria of what type an illness a resident could receive from the bacteria. The Director of Nurses also stated a resident potentially could become ill with stomach issues or any type of infection. She stated it depended on what was underneath the residents' nails. She also stated a resident had a potential to scratch themselves and may develop a skin concern such as a skin tear and may develop an infection if the residents' nails were not trimmed properly. She stated it was the nursing administration responsibility to monitor nursing staff to ensure residents were receiving proper nail care. In an interview on 07/14/2023 at 8:48 AM RA C stated the residents were expected to have their nails trimmed and cleaned on their shower days. She stated if a resident was a diabetic it was the Nurses' responsibility. She also stated nail care was expected to be taken care of when nails were visibly dirty or needed to be trimmed. RA C also stated if it was a certain type of bacteria a resident may become physically ill. She stated if a resident had dirty nails there was a possibility bacteria could be on their fingers and/or underneath the resident's nails. RA C stated if the resident was eating food with their hands there was a potential a resident could ingest bacteria transferred from their hands and/or fingernails onto their food. She stated it depended on the type of bacteria of what type an illness a resident could receive from the bacteria. She also stated a resident could become ill with stomach issues and develop diarrhea or vomiting. She also stated a resident had a potential to scratch themselves and may develop a skin concern such as a skin tear and may develop an infection. She stated she had never heard that it was treatment nurses' responsibility to trim and clean residents' nails. In an interview on 07/14/2023 at 8:52 AM CNA G stated the CNAs were responsible to clean and trim the residents' nails except for the residents with diagnosis of diabetes. She stated the charge nurse was responsible to clean and trim diabetic residents' nails. She also stated any staff was expected to clean and trim non-diabetic residents' nails if they observed the residents' nails needed to be trimmed or cleaned. She also stated she never was in serviced or informed it was the treatment nurses' responsibility to complete nail care weekly on the residents. CNA G stated several of the residents had feces underneath their nails. She also stated if a resident swallowed bacteria from their fingernails there was a possibility a resident develops some type of stomach infection and need to be hospitalized for further medical treatment. In an interview on 07/14/2023 at 8:57 AM the Treatment Nurse stated she trimmed and cleaned certain residents' nails. She stated there were certain residents who preferred her to trim and clean their nails. She stated any nurse can trim and clean diabetic resident's nails and the CNAs were responsible for trimming /cleaning non-diabetic residents' nails. She stated she had not been instructed by anyone that it was her responsibility to trim and clean nails during skin assessments. She stated if she sees a residents' nails dirty or needed to be trimmed she would clean /trim residents nails. She stated it was an effort on all the nursing staff to ensure the residents' nails were clean and trimmed. She also stated if any non-nursing staff viewed residents' nails dirty or needed to be trimmed the staff was expected to report it to the nurse. She also stated if residents' nails are jagged there was a potential a resident may scratch themselves and receive a skin tear. The Treatment Nurse stated a resident may become physically ill if ingested any type of bacteria. She stated it was difficult to know exactly the symptoms until the bacteria was identified. She stated it was a possibility a resident may need medical care from the hospital depending on what type of symptoms the resident may develop after ingesting bacteria. She stated it was the Nurse supervisor's responsibility to monitor the CNAs on completing nail care. In an interview on 07/14/2023 at 9:10 AM LVN A stated CNAs and shower aide had responsibility of cleaning and trimming resident's nails of non-diabetic residents. She stated all diabetics nail care was the duty of an LVN or RN. She stated she had not been in serviced or informed by anyone it was the treatment nurses' responsibility to complete nail care. For a resident with a diagnosis of diabetes with long/dirty nails, they were expected to notify any nurse. LVN A stated a resident had potential of ingesting bacteria and according to what type of bacteria the resident ingested may cause severe GI problems such as vomiting, diarrhea and possibly a resident may become dehydrated and need to be evaluated at the hospital. She stated it was the nursing supervisor's responsibility to monitor the job tasks assigned to the CNAs. In an interview on 7/14/2023 at 10:57 AM the Administrator stated residents' nail care was the CNAs' responsibility. He stated if a resident was a diabetic it was the Nurses' responsibility. He stated nail care was expected to be taken care of when nails were visibly dirty or needed to be trimmed. He also stated if it was a certain type of bacteria a resident may become physically ill. He also stated there was a possibility a resident may require medical care from the hospital and that depended on what type of bacteria a resident may ingest. The Administrator stated it was the nurse supervisor's responsibility to monitor residents' nail care. Record review of the facility's Policy on Nail Care, dated, 2003 reflected the policy was used during an in-service on nail care on 07/11/2023 and reflected nail management is the regular care of the fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails. It includes cleansing, trimming, and smoothing. Nail care usually done during the bath. Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions. The resident will be free from infection. Procedure as follows: 1. Immerse hands in a basin of warm soapy water to cleanse and soften the nails for ease in cleansing and trimming. 2. Use a soft brush if necessary to cleanse under and around the nails. 3. Remove debris from under the nails with an orange stick while soaking. 4. When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident.

Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 2 of 12 residents (Resident # 45, and Resident #23) reviewed for call lights in that Resident #45's and Resident #23's call lights were on the floor and not in reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1. Record review of Resident #45's face sheet, dated 07/13/2023, reflected a 56 -year-old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (Paralysis on the right side of the body due to tissue damage to the brain or spinal cord), muscle weakness generalized (decreased strength of the muscles), unsteadiness on feet (problems with walking can be due to disease or injury to the legs, feet, spine, or brain), and cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #45's Quarterly MDS Assessment, dated 05/04/2023, reflected Resident #45 had a BIMS score of a 9 which indicated resident's cognition was moderately impaired. Resident #45 required assist with ADLs. Resident #45 was not steady transferring from surface-to-surface or from seated to standing position. She required to be stabilized with staff assistance. Resident #45 had impairment on one side of upper and lower extremity. Resident #45 used mobility device of a wheelchair. Record review of Resident #45's Comprehensive Care Plan, dated 05/10/2023, reflected Resident #45 had hemiplegia/ hemiparesis related to CVA. Intervention: assist with ADLs. Resident #45 had ADL self-care performance deficit. Intervention: encourage Resident #45 to use bell to call for assistance. She was assessed to be at risk for falls related to poor balance and poor coordination. Intervention: be sure the resident's call light was within reach and encourage the resident to use the call light for assistance as needed. Resident #45 had a communication problem related to aphasia (a language disorder that makes it hard for a person to read, write and say what they mean. It is a symptom of damage to the parts of the brain that controls language). Observation on 07/12/2023 at 7:44 AM, revealed Resident #45 was in her room lying in bed. Resident #45's call light was lying on the floor. The call button was partially under the bed. In an interview on 07/12/2023 at 7:45 AM, Resident #45 stated the call light was just laying on her bed last night and was not attached to anything on her bed. She stated she thought it fell off sometime during the night. She stated if she needed help with anything it would be difficult for her to yell for help because she cannot speak clearly or very loudly. Resident #45 also stated if she attempted to reach the call light from her bed she would probably fall. She is afraid of falling related to having fell in the past. 2. Record review of Resident #23's face sheet, dated 07/13/2023, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified lack of coordination ( uncoordinated movement), need for assistance with personal care (day- to- day activities people are unable to perform on their own), cognitive communication deficit (difficulty with thinking) abnormal posture (rigid body movements and chronic abnormal positions of the body) unsteadiness on feet (losing your balance while walking), and muscle weakness ( lack of strength in muscles). Record review of Resident #23's Significant Change MDS, dated [DATE], reflected Resident# 23 had a BIMS score of 1 which indicated residents' cognition was severely impaired. Resident #23 was assessed to require assistance with ADLs. She required to be stabilized with staff assistance during surface-to-surface transfer, and when she moved from seated to standing position. Resident #23 did not walk. She used a wheelchair for mobility. Record review of Resident #23's Comprehensive Care plan, dated 07/05/2023, reflected resident had impaired cognitive function or impaired thought processes. Resident had impaired visual function. Resident #23 was at risk for falls related to general body weakness, poor balance, and unsteady gait. Interventions: anticipate and meet the resident's needs. Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Observation on 07/12/2023 at 7:45 AM revealed Resident #23 was awake and lying-in bed. Her call light was on the floor beside her bed. In an observation and interview on 07/12/2023 at 7:46 AM Resident #23 stated that is a cord on the floor. She stated that does not need to be there. She pointed to the call light. Resident #23 closed her eyes and stated she was going to sleep, and for everyone to leave. In an interview on 07/14/2023 at 8:31 AM the Director of Nurses stated she expected the call lights be within reach of all residents. She stated if a call light was not in reach when a resident was in their room, the residents would not have any device to use if they needed any type of assistance. She stated some residents were able to yell, however, this was not the appropriate protocol for residents to yell for help. She also stated it was a greater risk for harm if the residents did not have the call light within reach. The Director of Nurses stated ensuring the call lights were within reach of a resident was all staffs' responsibility. She did not elaborate of what type of harm a resident may endure if the resident required assistance from staff and did not have their call light within reach. In an interview on 07/14/2023 at 8:52 AM CNA G stated all staff were responsible to check call lights when they entered a resident's room. She stated if the call light was not in reach the resident may fall attempting to reach the call light or try to find the call light. She also stated a resident may have any type of an emergency and would not have a device to call for assistance. CNA G stated some residents would be able to yell for help but there were some residents who would not be heard if they attempted to yell. She stated she had been in serviced on call lights within the past few months. In an interview on 07/14/2023 at 8:57 AM the Treatment Nurse stated if a resident's call light was not in reach a resident had potential to fall attempting to reach the call light or attempting to assist self out of their bed or wheelchair and fall trying to get help. She stated if the resident had an emergency, they may be able to yell for help but there were some residents would not be able to yell very loud and it would be difficult to hear those residents. She stated it was the responsibility of all staff in the facility to check call lights when they entered a resident room to ensure the call light was attached to something where the resident had easy access to the call light. She also stated staff had been in serviced on call lights within the past few months. In an interview on 07/14/2023 at 9:10 AM LVN A stated all residents' call lights were expected to be within reach. She stated a resident may need assistance with any type of physical problem and would not be able to call for assistance. She stated a resident may attempt to assist self out of bed or their wheelchair if they were needing something and fall. LVN A stated if the resident had their call light in reach the resident would use the call light for assistance instead of trying to transfer themselves to get help, go to the bathroom or try to get anything in their room. She stated there were some residents who would not be able to yell for help. LVN A also stated if staff was in another resident's room or was at the end of the hall from their room it would be difficult to hear a resident yell for assistance. She stated the staff had been in serviced on call lights within the past few months. In an interview on 7/14/2023 at 10:57 AM the Administrator stated all staff were responsible for checking call lights when they entered a resident's room. He stated he expected all call lights to be within reach of the residents. The Administrator if the resident was lying in bed and the call light was on the floor the resident had a potential of falling if attempted to reach for the call light. He also stated a resident may need immediate help from the staff and would not be able to call for help by using the call light. He stated not all residents could yell for assistance. Record review of the facility's in-service dated 03/01/2023 reflected anyone can answer a call light and reposition the call light to make sure it is in reach of the resident. This applies whether the resident is in a geri-chair (a large, padded chair that is designed to help elderly with limited mobility, wheelchair, or in bed. If staff is unable to assist resident due to need for direct care, notify charge nurse. Make sure all call lights are answered in a timely manner.

Based on observation, interview and record review, the facility failed to ensure all residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #37) of eight residents reviewed for pressure ulcers. The facility failed to promptly assess the size of Resident t#37's pressure ulcers. The facility failed to promptly input orders for would care for Resident #37's pressure ulcers. These failures could place residents at risk of worsened pressure ulcers. Findings included: A record review of Resident #37's face sheet dated 7/13/2023 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of chronic kidney disease (loss of kidney function), anemia (unhealthy red blood cells), atrial fibrillation (irregular heartbeat), cognitive communication deficit (problems with communication), dementia (symptoms affecting memory and thinking), heart failure, and major depressive disorder (depression). A record review of Resident #37's MDS assessment dated [DATE] reflected she did not have any unhealed pressure ulcers. A record review of Resident #37's care plan last revised on 7/10/2023 reflected she had stage III pressure ulcers to the left inner buttock and right lower buttock. A record review of Resident #37's BIMS assessment dated [DATE] reflected a BIMS score of 0, which indicated severe cognitive impairment. A record review of Resident #37's progress note dated 6/30/2023 authored by LVN I at 5:23 p.m. reflected Resident #37 arrived at the facility via ambulance transport. A record review of Resident #37's Initial Skin assessment dated [DATE] authored by LVN I reflected yes Resident #37 had a pressure, venous (affecting the veins), arterial (affecting the arteries), or diabetic ulcer. This assessment did not include measurements or staging of pressure ulcer(s) and it reflected If yes, complete the Ulcer Assessment. A record review of Resident #37's Ulcer assessment dated [DATE] authored by the Treatment Nurse reflected Resident #37 was admitted with an unstageable pressure ulcer on the right lower buttock measuring 2x7 cm and a stage III pressure ulcer on the left inner buttock measuring 6x4x0.2 cm. A record review of Resident #37's physician orders reflected orders dated 7/04/2023 for wound care for the pressure ulcers on Resident #37's left inner buttock and right lower buttock. The wound care orders reflected staff were to cleanse, pat dry and apply dressing to wounds. A record review of Resident #37's WAR for June 2023 reflected no orders or treatments documented for wound care to Resident #37's pressure ulcers on the right lower buttock and left inner buttock. A record review of Resident #37's WAR for July 2023 reflected wound care to Resident #37's pressure ulcers on the right lower buttock and left inner buttock were not signed off as having been completed on 7/04/2023. A record review of Resident #37's progress notes from June and July 2023 reflected no documentation indicating wound care was completed for her left inner buttock and right lower buttock pressure ulcers from 6/30/2023-7/04/2023. During an observation on 7/12/2023 at 8:33 a.m., Resident #37 was observed lying in bed with oxygen on and a catheter hanging below her bed. Resident #37 was non-interviewable. During an interview on 7/13/2023 at 10:08 a.m., the Treatment Nurse stated Resident #37 came to the facility on Friday 6/30/2023 and she did her ulcer assessment on Monday 7/03/2023. During an interview on 7/13/2023 at 11:39 a.m., LVN I stated she worked on 6/30/2023 when Resident #37 was readmitted to the facility. LVN I stated I would have to backtrack to tell you the policy on admitting residents with pressure ulcers. LVN I stated, I know that we have a treatment nurse and wound care coordinator but as far as the absolute policy goes, I would have to look that up. LVN I stated if a resident came in with a new pressure ulcer, she would have to let an RN or wound care doctor stage it. LVN I stated yes that measuring the ulcer was expected of nurses but at the same time, in the back of my head, I'm thinking we are being told the way one person measures is different than the way the other person measures. LVN I stated that over the years she had heard that it was better to have one person measuring wounds but she had not heard that from that facility. LVN I stated she did not complete weekly ulcer assessments and that those were completed by the Treatment Nurse. When asked why she had not completed an Ulcer Assessment on 6/30/2023 as prompted by indicating yes on the Initial Skin Assessment, LVN I stated she would have to look back at her notes to see what else was going on. LVN I then stated she remembered feeding Resident #37 dinner on 6/30/2023 while completing her admission assessment when she was summoned to the dining room because another resident had fallen and needed immediate medical attention. LVN I stated she had to triage and prioritize what was going on for the remainder of the shift. When asked if the weekly ulcer assessment should begin when the ulcer is first identified, LVN I stated, that's a good question. LVN I stated Resident #37 was on hospice and she expected the hospice RN to stage the ulcers and measure them. LVN I stated yes ma'am that hospice typically measured ulcers. During an interview on 7/13/2023 at 1:12 p.m., the Treatment Nurse stated she had worked in the facility for ten years and had been in her current position for seven years. The Treatment Nurse stated she believed the skin assessment policy was the same as the ulcer assessment policy but she would have to look at the policies and procedures. The Treatment Nurse stated normally the admitting nurse would do the initial skin assessment and then Monday when I come in I relook at the residents' skin to know what they look like with my own eyes. The Treatment Nurse stated she completed all of the weekly ulcer assessments and other nursing staff did not complete ulcer assessments unless she was out. The Treatment Nurse stated no that staff were not required to notify her of newly identified pressure ulcers when she was off work. The Treatment Nurse stated residents' pressure ulcers should be assessed for size the day they came in. The Treatment Nurse stated in the skin assessment, there was a box where staff should document the size of pressure ulcers. When asked what a potential negative outcome was of not measuring Resident #37's ulcers on the day she was readmitted with them, the Treatment Nurse stated it could get worse and if I didn't see it I wouldn't be able to know whether it got better or worse. During an interview on 7/13/2023 at 1:49 p.m., the DON stated ulcer assessments were done weekly and skin assessments were completed upon admission and readmission. The DON stated new wounds should be assessed whenever they were identified. The DON stated typically the Treatment Nurse was responsible for completing ulcer assessments but if she was not there, it was the charge nurse's responsibility. When asked how staff were trained on assessing wounds and measuring wounds, the DON stated, they're aware of the admission process. The DON stated the size of wounds should be documented in the skin assessment and the nurse completing the initial skin assessment should measure the wound. The DON stated she monitored the Treatment Nurse and the Treatment Nurse monitored nurses to ensure staff were completing skin and ulcer assessments accurately and in a timely manner. When asked how not immediately measuring Resident #37's wounds had the potential to negatively affect her, the DON stated, you don't have a baseline and you don't know if it got better or worse. An observation on 7/14/2023 at 11:00 a.m. revealed Resident #37 was in bed. The Treatment Nurse removed dressing from Resident #37's right buttock to reveal a stage III pressure ulcer approximately 2 cm long and 7 cm wide. The wound bed consisted of granulation (formation of new connective tissue and blood vessels on the surface of a wound during the healing process) tissue and the wound was without drainage or signs of infection. The Treatment Nurse then removed a dressing from her left buttock to reveal a stage III pressure ulcer that was 4 cm by 5 cm with granulation (formation of new connective tissue and blood vessels on the surface of a wound during the healing process) tissue and no signs of infection were noted. During an interview with the DON on 7/14/2023 at 11:41 a.m., when asked how she should know whether wound care was completed if it were not documented, the DON stated she would expect there to be an order and for staff to document on the WAR. The DON stated she spoke to the RN supervisor (RN J) who worked the weekend after Resident #37 was admitted and RN J said she did wound care that weekend (7/01/2023-7/02/2023). The DON stated the nurse who admitted a resident was responsible for putting in orders for wound care. The DON stated LVN I was the one who admitted Resident #37 and she was not sure why LVN I did not put in orders or measure the wounds. During an interview on 7/14/2023 at 11:50 a.m., the Treatment Nurse stated she entered Resident #37's wound care orders on 7/03/2023 and the system automatically set the start date to be 7/04/2023. The Treatment Nurse stated she had completed Resident #37's wound care on Monday 7/03/2023 and on Tuesday 7/04/2023, and she was not sure why she had not documented it. A record review of the facility's policy dated 8/12/2016 titled Pressure Injury: Prevention, Assessment and Treatment reflected the following: Procedure: 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems. 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. 6. Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: Note: Add any interventions to care plan. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through State IV). Staging of pressure injuries is an important part of wound documentation, but it is only one part of the wound and resident assessment. Assessment of the pressure injury should also include the site, size, and W x L x D, of the injury. A record review of the facility's policy dated 8/15/2016 titled Skin Assessment reflected the following: It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner. Procedure: 1. All new admits and residents returning from a hospital stay will have a head-to-toe skin assessment completed. If the facility Treatment Nurse/designee is available he/she should complete the assessment within four (4) hours of the resident's arrival at the facility. If the Treatment Nurse/designee isn't available then the charge nurse should complete the assessment within four (4) hours of the resident's arrival at the facility. The charge nurse will then notify the Treatment Nurse/designee of any skin problems noted. Complete the appropriate attachments/assessments.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Residents #7 and #9) reviewed for infection control. A) CNA E and F failed to practice appropriate hand hygiene and infection control techniques during incontinent care for Resident #7 B) CNA G and D failed to practice appropriate hand hygiene and infection control techniques during incontinent care for Resident #9 These failure could place residents at risk for developing infections. Findings included: A) Review of Resident #7's Face sheet dated 07/13/2023 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over time.), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control.) and vascular disorder of intestine (is a condition that happens when narrowed or blocked arteries restrict blood flow to your small intestine). Review of Resident #7's Quarterly MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 7 indicating moderate cognitive impairment. Resident #7 was assessed to require extensive assist with toilet use. Resident #7 was further assessed to be always incontinent of bowel and bladder. Review of Resident #7's Comprehensive Care Plan reflected a focus area dated 11/23/2021 The resident has bladder incontinence. Interventions included incontinent care at least every 2 hours .monitor/ document for signs and symptoms of UTI . Observation on 07/13/2023 at 9:49 AM revealed CNA E and CNA F in Resident #7's room to perform incontinent care. Both CNAs washed hands prior to the procedure and donned gloves. CNA E was holding Resident #7 over and CNA F cleaned Resident #7's perineal area (private areas below the waist) in the front and changed gloves (no hand hygiene). CNA F then cleaned Resident #7's buttock and changed gloves with no hand hygiene to apply a new brief. In an interview on 07/13/2023 at 11:14 AM CNA E stated she did not use hand sanitizer or hand hygiene between glove changes when doing perineal area care with Resident #7. She stated CNA F did not perform hand hygiene between glove changes. In an interview on 07/13/2023 at 12:20 PM CNA F stated I changed my gloves, but I did not sanitize my hands when I changed my gloves. She further stated Looking back yes i should have sanitized by my, and I did not while doing perineal care for Resident #7. B) Review of Resident #9's Face Sheet dated 07/13/2023 reflected she was admitted on [DATE] with the following diagnoses Chronic Obstructive Pulmonary Disease (persistent respiratory symptoms like progressive breathlessness and cough.) and Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) Review of Resident #9's Annual MDS assessment dated [DATE] reflected Resident #9 was assessed to have a BIMS score of 6 indicating moderate cognitive impairment. Resident #9 was further assessed to require extensive assist with ADLs and to be always incontinent of bowel and bladder. Review of Resident #9's Comprehensive care plan reflected a focus area dated 05/15/2022 The resident has bladder incontinence. Interventions included .incontinent care at least every 2 hours and apply moisture barrier after each episode .Monitor/ document for signs and symptoms of UTI: pain, burning . Observation on 07/13/2023 at 9:27 AM revealed CNA G and CNA D in Resident #9's room to perform incontinent care. CNA G and CNA D both washed hands and donned gloves. CNA G was performing incontinent care and CNA D assisted. CNA G cleaned Resident #9's front perineal area performing the procedure correctly. CNA G then removed her gloves and without hand hygiene she donned new gloves and cleaned the back perineal area. CNA G removed her gloves again and without hand hygiene donned new gloves and applied barrier cream to Resident #9. CNA G then changed gloves and without hand hygiene donned new gloves and applied Resident #9's clean brief. In an interview on 07/13/2023 at 12:17 PM CNA D stated she was trained to sanitize hands between gloves changes. She stated she did not when doing care for Resident #9. In an interview on 07/13/2023 at 12:21 PM CNA G stated she did not recall in training if she should sanitize her hands between glove changes and stated she did not when doing care for Resident #9. In an interview on 7/13/2023 at 12:23 PM the Nurse Consultant stated it was the facility's policy that staff should sanitize their hands after glove changes because hands can become contaminated even with gloves on. In an interview on 07/13/2023 at 1:52 PM the DON stated staff should sanitize their hands after glove changes, because it could lead to infections. She stated she was in-servicing the staff regarding this failure. Review of the facility's policy Fundamentals of Infection Control Precautions dated 04/25/2022 reflected A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene .After removing gloves Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves .

Based on observation, interview and record review the facility failed to provide ongoing activity programs to support residents in their choice of activities, both facility sponsored group and individual activities to meet the interests of and support the physical, mental and psychosocial well-being for nine of 31 residents reviewed for activities. (Residents #38, #2, #36, #1, #34, #49, #155, #27 and #11). The facility failed to consistently provide activities for Resident #'s 38, 2, 1, 34,49, 155, 27 and 11. This failure could place residents who have impaired cognition and needed assistance to attend activities or required in-room activities at risk for a decline in social, mental, psychosocial well-being and decreased in quality of life. Findings included: Review of Resident #38's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses athetoid cerebral palsy (birth injury with damage to the brain), contractures, quadriplegia (paralysis of all four limbs) and cystic fibrosis with intestinal manifestations (a genetic disorder, in which the lungs and the digestive system get clogged with mucus). Review of Resident #38's Annual MDS dated [DATE] reflected she was assessed to have a BIMS score of 13 indicating she was cognitively intact. Review of section F of the MDS for preferences for customary routine and activities reflected it was very important to the resident to do her favorite activities, and somewhat important to listen to music and participate in religious services or practices. Resident was further assessed to require dependent assist with all ADLs. Review of Resident #38's Comprehensive Care Plan reflected a focus area activities with the start date of 05/20/2015 . Resident benefits from one-to-one daily activities with a goal Resident will attend appropriate activities and benefit from in room activities twice weekly. Interventions included provide resident within room activities and provide resident with appropriate activities related to condition and respect resident right to refuse. Further review of Resident #38's comprehensive care plan reflected Resident #38 had a communication problem, was nonverbal and responded to yes or no questions with clicks with one click for no and two clicks for yes responses. Review of Resident #38's Activity Quarterly assessment dated [DATE] reflected Resident #38 participates in: one-to-one visits and prefers morning activities in her room. Resident #38 was assessed to have socialization pattern and of prefers to be with people. Further review of Resident #38's activity assessment reflected resident is room bound and does not participate in any social or group activities. Resident enjoys getting her nails done and visiting/ listening to staff in her room. She also enjoys watching movies . Review of Resident #38's Individualized One-To-One Programming Record reflected the resident had visits on 03/09/2022, 04/15/2022 and 05/12/2022. Interview and observation on 05/15/2022 at 9:48 AM, revealed Resident #38 in room alert. Her TV was not on. Resident #38 was able to communicate with surveyor using her mouth to make a clicking sound with one clicksce for no and twice two clicks for yes. When asked if she liked her TV to be on, she responded with a yes. Observation on 05/15/2022 at 11:48 AM, revealed Resident #38 was in her room with the TV still off. In an interview on 05/17/2022 at 9:37 AM, the Activity Director stated if the residents care plan indicated she needed daily in room visits this resident needed some type of stimulation from activity staff daily or at least 5-7 days out of the week. She stated if the only stimulation the resident received was from the television, it could affect their mood and mental status. She also stated the resident could become bored, depressed, and have a decline in their cognition. She also stated the activity director and/or her part time assistant was responsible for in room activities. Review of Resident 27's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses unspecified macular degeneration ( a degenerative condition affecting the central part of the retina and resulting in distortion or loss of central vision), bi-polar disorder ( a mental condition marked by alternating periods of elation and depression), schizophrenia, unspecified ( experiences signs of psychosis, such as delusions, hallucinations, drastic changes of behavior, speech or mobility), major depressive disorder (remains depressed for an extended period and has at least four of the following symptoms - sleep problems, loss of appetite or other eating issues, lack of energy, loss of concentration , problems with self-image or confidence) and unsteadiness on feet ( unable to walk or stand easily). Review of Resident #27's Annual MDS assessment dated [DATE] reflected he had a BIMS score of 15 indicating his cognitive status was intact. Resident #27 was interviewed on the assessment related to his activity preferences. The following was his activity preferences: very important to keep up with the news, do favorite activities and go outside to get fresh air when weather permits. The following activities was not very important to resident: listen to music, be around pets, do things with groups of people or participate in religious services or practices. He was further assessed not steady but able to stabilize without staff assistance with walking. Review of Resident #27's Quarterly MDS assessment dated [DATE] reflected he was assessed to have a BIMS score of 15 indicating his cognitive status was intact. Resident was not steady but able to stabilize without staff assistance with walking. Review of Resident #27's Comprehensive Care Plan date initiated 03/04/2017 and revised on 3/9/2022 reflected resident had impaired visual function- macular degeneration. Resident needed in room socialization and sensory stimulation. Resident enjoys tv and smoking. Interventions: discuss news/ current events and the Activity Director will provide the resident with one on oneone-on-one visits with sensory stimulation at least 3 times per week date initiated on 03/10/2017. Review of Resident #27's Activity Initial assessment dated [DATE] reflected resident was interviewed for the assessment. The following activities were very important to resident: participating in religious services or practices, doing favorite activity, going outside for fresh air when the weather was nice. The following activities were assessed to be somewhat important: reading, be around pets, keep up with the news, do things with group of people and listening to music. He is missing left eye and vision is poor. Review of Resident #27's Activity Quarterly assessment dated [DATE] reflected resident participated less than one activity per week. He participated in one-to-one visits/programs and preferred own room to do activities. Resident #27 preferred to be alone and preferred to stay in his room. Resident #27 attended activities independently and was a passive participant. He did not prefer any size group. His psychosocial needs were group interaction. He had difficulty making friends and rarely initiated conversations. He was further assessed to have adequate vision. Review of Resident #27's Individualized One-To-One Programming record reflected resident received visits from the activity staff on 03/05/2022, 03/11/2022 and 04/05/2022. Review of Resident #27's Group Participation Records revealed resident attended shopping for you 2 times in Month of April. There were not any participation records for the months of February, March, and May of 2022. Observation and interview on 05/17/2022 at 11:15 AM, Resident #27 was in bed watching tv. He stated he did not attend group activities except he sometimes went to listen to music but that was all he would do. He stated no one came to his room and did activities with him in room. He stated sometimes he would like to see someone and talk with them. Resident #27 further stated he did not attend group activities very often and he preferred doing activities in his room. He stated he did not know anything about one-to-one in room activity provided by the activity department. In an interview with the Activity Director on 05/17/2022 at 9:37 AM, she said she was not aware of any other one-to-one programming records except the ones she provided on 05/16/2022. She stated resident (#27) did not attend group activities very often. She stated having 2 one on one visits in a month and having one visit in a month was not enough visits for the resident. She further stated he needed more visits and stimulation because he does become depressed at times. She stated shopping for you activity on the group activity calendar was not a group activity it was when she would shop for the residents. She also stated she was responsible, and the part time activity assistant was responsible for one-to-one visits. She stated residents needed visits at least 3 times a week. She also stated another person needed to be hired in the activity department. One Activity Director and a part time activity assistant was not enough staff for 40 residents. Review of Resident #155's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses depression ( serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety disorder ( a type of mental health condition that makes it difficult to get through your day- nervousness, panic and fear as well as sweating and rapid heartbeat) and muscle weakness ( decrease in strength in one or more muscles). Review of Resident #155's Initial MDS dated [DATE] reflected she was assessed to have a BIMS score of 8 indicating her cognition was moderately impaired. Review of section F of the MDS for preferences for customary routine and activities reflected resident was feeling down, depressed, or hopeless, trouble concentrating on things such as reading the newspaper or watching television. Resident #155 was interviewed for her activity preferences. The following were the activities that was very important to her: listen to music, be around pets, do favorite activities, go outside to get fresh air when the weather is good and participate in religious services or practices. Resident #155 was further assessed to require limited assistance with one-person physical assist for locomotion off the unit. Review of Resident #155's Quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 6 indicating her cognition was impaired. Resident mood interview reflected she was feeling down, depressed, or hopeless, she had little energy and she had trouble concentrating on things, such as reading the newspaper or watching tv. Resident #155 required limited assistance with one-person physical assist for locomotion off the unit (areas set aside for dining, activities, or treatments). Review of Resident #155's Comprehensive Care Plan on 5/15/2022 reflected a focus area with the start date of 03/01/2022 resident has impaired cognitive function. Resident #155 was able to (remember one/two/three instructions, find room, read, sit for an hour, and do puzzles. Engage the resident in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodates the resident's abilities. Review of Resident #155's Comprehensive Care Plan on 5/16/2022 reflected a focus area with the start date of 5/16/2022 Resident needs out of room social, spiritual and stimulus activities and mental stimulation. Interventions: Resident enjoys bingo, socials, and visits with family. The activity director will provide reading material for mental stimulation. Review of Resident #155's Activity Initial assessment dated on 01/17/2022 reflected resident was interviewed for the assessment. The following activities were very important to resident: music, animals, doing favorite activities, going outside for fresh air when the weather is nice and participate in religious activities. The following activities were not important to her such as: books, newspapers, and magazines to read and keeping up with the news. Participating with groups of people was somewhat important. Resident was further assessed she required reminders/cues, she enjoyed watching tv, visiting with family and being outdoors. Activity Director will continue to monitor and record. Review of Resident #155's Activity Quarterly assessment dated [DATE] reflected resident participated in activities 1-3 times per week. She participated in independent activities of choice, her preferred activity setting own room and activities room. She required reminding to attend activities and is an active participant. Resident's socialization patterns indicated she preferred to be alone, makes friends easily, prefers to stay in room and enjoys small groups. She was further assessed to be oriented to person, place, and time. Her psychosocial needs were group interaction. Review of Resident #155's Activity Participation Records reflected resident did not have any participation records for months of February 2022 and March 2022. Resident did attend 1-3 activities per week during months of April and May. She was not involved in her activity of choice: going outside. In an interview and observation on 5/15/2022 at 11:19 AM, Resident #155 was in her room, she was alert she was not smiling and had a frown expression. She was in bed and was looking toward the wall in front of her. There was no stimulation in the room. Resident stated she was sad and stated all she wanted to do was go outside and watch birds or see the flowers and maybe grow some flowers. Resident also stated this was all she did when she was at home was be outside doing something. She stated she did not enjoy being inside all the time. She stated if she could go outside it would make her happy. Did not observe any books in her room for reading. Resident stated she did not like to read, and it was hard for her to know what she was reading. Did observe a magazine in the room and she stated she would look at the pictures when she needed something to do but did not read anything in the magazine. She also stated her favorite activity is being outside. She stated she did go to bingo and music sometimes. She stated there were times she did not want to go but they kept asking her and she hated to say no. In an interview and observation on 05/16/2022 at 11:00 AM, Resident #155 was in room and alert. She was not smiling and had a frown expression. Resident #155 stated her favorite activity was going outside and watching the birds and looking at the flowers. She stated when I was at home I never stayed inside. I would get depressed if I stayed in the house. I had to get outside and do something in the yard or just sit on the porch. Resident #155 also stated she did not like to read. She stated, I can't keep up with what I am reading my mind will not let me think about what I am reading sometimes. Did not observe any books in the room. Did observe the same magazine and asked her about the magazine. She stated she liked to look at the pictures sometimes when she did not have anything else to do. She stated she did not like to read the magazine. Resident stated I do go to bingo, church, and music but it was not the same as going outside. She stated there were times she did not want to go to bingo, church or music but they (did not know staff names) kept asking her and telling her she needed to get out of the room and she did not want to disappoint them. She stated I do not know why they will not take me outside. She stated she has told some people she wanted to go outside, and they would tell her maybe later. (she did not know name of staff she related this information to- she stated it was some of the girls came in her room to bring her food and help her). In an interview and observation on 05/17/2022 at 9:00 AM, revealed Resident # 155 was in room alert, she was not frowning. She stated her favorite activity was going outside. She stated she rather be outside than sitting in this dark room. She stated she was tired of looking at the walls in her room. She also stated she did attend bingo and music but rather be outside doing something than playing bingo. She stated when she was living at home she never stayed inside, and she would always sit outside or work in the yard doing something. She also stated being outside was her favorite activity of all time. In an interview on 05/17/2022 at 9:37 AM, the Activity Director stated all resident's activity preferences should be considered when planning activity programs and developing care plans. She stated she did not speak to Resident #155 prior to the care plan being updated on 5/16/2022. She stated the resident needed to have input on what she preferred to do in activities. She stated she knew resident attended bingo and music. She also stated she did not know resident wanted to go outside and that was her favorite activity or that resident did not want to read. Review of Resident #11's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses major depression disorder ( affects how a person feels, thinks, behaves and can lead to a variety of emotional and physical problems), anxiety disorder ( a type of mental health condition that makes it difficult to get through your day- nervousness, panic and fear as well as sweating and rapid heartbeat), persistent mood disorder ( a continuous long-term chronic form of depression. May lack productivity, have low self-esteem ad an overall feeling of inadequacy), Alzheimer's disease with late onset ( progressive decline in episodic memory, with variable involvement of other cognitive domains), insomnia ( unable to sleep) and cognitive communication disorder ( difficulty with communicating because of injury to the brain that controls the ability to think). Review of Resident #11's Annual MDS dated [DATE] reflected she was assessed to have a BIMS score of 5 indicating her cognition is severely impaired. Resident #11 did have behavior of wandering 4-6 days, but less than daily. Review of section F of the MDS for preferences for customary routine and activities reflected the resident answered the questions. The following activities were very important to resident: listen to music, doing things with group of people, do favorite activity, go outside to get fresh air when weather is good and participate in religious activities. It was somewhat important to the resident to have books, newspapers, and magazines to read, be around animals and keep up with the news. Resident #11was further assessed to require supervision and one person assist when walking in corridor and when off unit (areas set aside for dining, activities, or treatments). Review of Resident #11's Quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 3 indicating her cognitive status is severely impaired. Resident #11 needed set up only when walking in corridor. She required supervision with one person assist with locomotion off unit (areas set aside for dining, activities, or treatments). Review of Resident #11's Comprehensive Care Plan date initiated on 12/28/2020 and last care plan reviewed on 05/15/2022 reflected resident had impaired cognitive function/dementia or impaired thought processes. Interventions: engage resident in simple, structured activities that avoids overly demanding tasks. Provide a program of activities that accommodates the resident's abilities and use task segmentation to support short term memory deficits. The care plan further reflected resident was at risk for falls date initiated on 12/28/2020 Intervention: encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Resident is at risk for wandering. Interventions initiated on 12/28/2020 distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book. Date initiated on 12/28/2020 provide structured activities walking inside and outside, reorientation, pictures, and memory boxes. Review of Resident #11's Activity Initial assessment dated [DATE] reflected family was interviewed for the assessment. Resident religion was Church of Christ. It was very important for resident to be involved with the following activities: have books, newspapers and magazines to read, listen to music she likes, do things with group of people, do favorite activities, go outside for fresh air when the weather is nice and participate in religious services or practices. The assessment did not indicate that resident preferred other types of religion other than Church of Christ. Review of Resident #11's Activity Quarterly assessment dated [DATE] reflected resident participated in activities 1-3 times per week. Resident participates in independent activities of choice and one-to-one programs. She preferred to be with people, required reminding to attend activities, ambulates independently. Assessment further reflected resident loved to visit with others, participated in crafts, music, dance, and any social event. Activity Director will continue to monitor and record. There was not any indication that resident was comfortable being in other religious programs except Church of Christ. Review of Resident #11's Activity Participation records reflected there was not any participation records reflecting resident had attended group activities in February or March. She attended 1-4 group activities in April and May. Resident #11 was not on the one -one programming as indicated on her activity quarterly assessment dated [DATE]. Resident #11's religion was Church of Christ. Reviewed the activity calendar and resident's participation record for February and March. There were not any opportunities for resident to practice her religious preferences. Observation and interview of Resident #11 on 5/15/2022 at 10:45 AM, she was walking in halls and around the lobby area, she did not respond to any questions. In an interview on 05/17/2022 at 9:37 AM, the Activity Director stated all resident's activity preferences should be considered when planning activity programs and developing care plans. The activity director stated she did not have any memory boxes for anyone. She stated memory boxes was not on anyone's care plans. She stated if it was on the care plan, she did not know anything about it. She also stated she did review residents (Resident #11) care plan on 5/15/2022. She also stated if a resident had a religious preference the resident should not be attending other type religions. She stated resident was not capable of relating if it was ok for her to attend other religions. She stated she had not asked the family if the resident only preferred Church of Christ religion. The activity director also stated if it is documented on the activity assessment that resident received one-one visits there should be an in-room participation record. She also stated she could not prove if the resident attended any activities in February or March of 2022. She did not have any participation records for those months. The Activity Director stated the resident was not involved in any activities due to being risk for falls. She stated there was not any activities related to task segmentation. Review of Resident #2's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses unspecified dementia without behavioral disturbance ( a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems), unspecified mental disorder due to known physiological condition ( a range of mental disorders grouped together on the basis of their having in common a demonstrable etiology in cerebral disease, brain injury, or other insult leading to cerebral dysfunction) aphasia following unspecified cerebrovascular disease ( a brain disorder where a person has trouble speaking or understanding other people speaking) and personal history of transient ischemic attack cerebral infarction without residual deficits (disrupted blood flow to the brain due to problems with blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). Review of Resident #2's Initial MDS assessment dated [DATE], reflected he was assessed to rarely/never makes self-understood and rarely/never understands others. His vision is highly impaired. He does have glasses. Resident unable to complete the BIMS. The staff assessment was completed for cognitive patterns. Resident has poor short- and long-term memory recall. His decision-making ability is severely impaired. He had difficulty focusing and had difficulty keeping track of what was being said to him. Review of section F of the MDS for preferences for customary routine and activities reflected the resident unable to answer questions. Staff completed daily and activity preferences. His activity preferences were the following: listen to music, being around animals/pets, doing things with groups of people, participating in favorite activities, spending time away from the nursing home and spending time outdoors. Resident walked independently and was not steady, but able to stabilize without staff assistance. Review of Resident #2's Quarterly MDS assessment dated on 04/20/2022, reflected resident had unclear speech, he was usually understood and rarely/never understands others. No issues with his vision. Section C Cognitive Patterns indicated resident is rarely/never understood and a staff assessment will be required to complete section c cognitive patterns. Resident has poor short- and long-term memory recall, decision making skills was severely impaired, he had difficulty focusing and had disorganized thinking. Resident was independent walking in room and in corridor. Review of Resident #2's Comprehensive Care Plan reflected care plan was reviewed on 04/26/2022 but not revised. The last revision of care plan was on 07/26/2021 and/or 08/23/2021. Resident is dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. Intervention: invite resident to scheduled activities. Resident had impaired cognitive function/dementia or impaired thought processes. Interventions: Engage resident in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodates the resident's abilities and use task segmentation to support short term memory deficits. Resident was at risk for falls. Intervention: resident needed activities that minimize the potential for falls while providing diversion and distraction. Resident had a communication problem related to dementia. Interventions: Provide a program of activities that accommodates the resident's communication abilities. The resident had potential fluid deficit. Intervention: Offer drinks during one to one visit and invite resident to activities that promotes additional fluid intake. The comprehensive care plan further reflected resident was at risk for wandering. Interventions: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book. Provide structured activities walking inside and outside, reorientation strategies, pictures, and memory boxes. Resident is at risk for signs and symptoms of COVID-19. Intervention: Provide in room activities of choice, as able. Review of Resident #2's Activity Initial assessment dated [DATE], reflected family was interviewed for the assessment. Resident had no speech. The following are activity pursuit patterns which is very important to resident: listening to music, do favorite activities and go outside for fresh air when the weather is nice. Activities not very important are the following: have books, newspapers, and magazines, doing things in groups of people and participating in religious services or practices. Activities somewhat important was the following: being around pets and keeping up with the news. He does not understand or respond to questions. Review of Resident #2's Activity Quarterly assessment dated [DATE] reflected resident participated in activities 1-3 times per week. He participated in independent activities of choice. He required reminding to attend activities. He was a passive participant. Resident preferred to be alone, makes friends easily, rarely initiates conversations, enjoys small groups, prefers to stay in room and communicates verbally/ able to make needs known. Resident was further assessed to be oriented to person, place, and time. Resident spends most of his time in his room listening to music, he enjoys sitting outside and some social events. Review of Resident #2's Activity Participation Records reflected there was no indication resident participated in any activities independently, one-one activities or group activities for the month of February, March or May of 2022. Upon review of all the one-one participation records received from the activity director indicated resident had not received any one-one visits. Resident attended 1-2 activities during the month of April 2022 (outside group activity and food related activity). Observation on 05/15/2022 at 11:18 AM, resident # 2 was outside sitting on the side of porch. He stared and would nod his head in yes motion at times. Observation on 05/16/2022 at 8:02 AM, Resident #2 was in his room. Lights were off and the door was closed. There was no stimulation. He had a frown expression. In an interview on 05/17/2022 at 9:37 AM, the Activity Director stated she did not know it was on the care plan for resident (Resident #11) to have one-one visits. She also stated she did not have memory box for resident. She stated she wasn't using any task segmentation for resident activities. She stated she was involved in care plans when they were reviewed. She stated she did not have any proof of resident attending any activities for the months of February and March of 2022 and if there was not anything highlighted on the May 2022 calendar with is name at the top, he did not attend group activities. She also stated she was not aware of any activities for resident when he was at risk for falls and she did not have an activity program to help his communication needs. Review of Resident #34's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses legal blindness (central visual acuity 20/200 or less in the better eye with best correction or widest diameter or visual field subtending an angle of no greater than 20 degrees, other Alzheimer's disease ( your memory can be harmed by many other health issues such as a stroke, Parkinson's Disease, or a buildup of fluid on your brain), mood disorder due to known physiological condition with depressive features ( a prominent and persistent period of depressive mood markedly diminished interest/pleasure thought to be related to physiological effects or another medical condition), major depressive disorder ( remains depressed for an extended period and has at least four of the following symptoms - sleep problems, loss of appetite or other eating issues, lack of energy, loss of concentration , problems with self-image or confidence) and difficulty with walking ( unsteady when walking). Review of Resident # 34's Annual MDS assessment dated [DATE], reflected she was assessed to have a BIMS score of 11 indicating her cognitive status moderately impaired. Resident was assessed on her activity preferences the following: very important to go outside to get fresh air when weather was good, do [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that one (1) of four (4) residents on [MEDICATION NAME] therapy (Resident #1) received treatment and care in accordance with professional standards of practice. The facility failed to: A. Obtain a repeat blood test PT/ INR ([MEDICATION NAME] time (PT) / international normalized ratio) weekly as ordered by the physician from 06/29/2018 to 08/12/2018. B. Recognize that Resident #1's lab work had not been completed on 06/29/2018; 07/06/2018; 07/13/2018; 07/20/2018; 07/27/2018; 08/03/2018; or 08/10/2018. Resident #1 was transferred to the hospital on [DATE] with the [DIAGNOSES REDACTED]. This was determined to be past non-compliance immediate jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure affected one (1) resident (Resident #1) and had the potential to affect three (3) residents receiving [MEDICATION NAME] therapy placing them at risk for undetected health issues, overdosing, bleeding, delayed treatment and death. The Findings included: Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's 60 day MDS dated [DATE] reflected Resident #1 did not have a BIMS score conducted and was coded to have short term memory problems with intact long-term Memory. Resident #1 was coded to be able to recall the current season, the location of his room, staff names and faces and that he was in a nursing home. Resident #1 was coded to usually understand others and rarely/ never make self-understood. Resident #1 was coded to require supervision for transfers and ambulation in room. Resident #1 was coded to be on anticoagulant medication seven days a week. Review of Resident #1's Comprehensive Care Plan dated 06/04/2018 and revised on 06/05/2018 reflected a focus area of anticoagulant therapy with a goal that the resident will be free from discomfort or adverse reactions related to anticoagulant use. Interventions/Tasks included; if any of the following are observed report immediately to the charge nurse: bruising, nosebleeds, bleeding gums, prolonged bleeding from wound .blood I urine/feces/vomit .Labs as ordered. Report abnormal lab results to the MD. Monitor/document/ report to MD signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea , vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, Shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Further review of Resident #1's comprehensive care plan reflected a focus of right side [MEDICAL CONDITION]/ [MEDICAL CONDITION] related to stroke with the intervention; obtain and monitor lab/ diagnostic work as ordered. Observation and Interview on 08/20/2018 at 11:14 AM revealed Resident #1 in room lying in bed. Resident #1 alert with [MEDICAL CONDITION] and communicated using yes and minimal words; Resident #1 stated he was ok. Faded bruising noted to right wrist. No bruising noted to left wrist or ankles. Review of Resident #1's Consolidated Physician order [REDACTED].#1's Consolidated Physician order [REDACTED]. The international normalized ratio (INR) is a calculation based on results of a PT that is used to monitor treatment with the blood-thinning medication [MEDICATION NAME] ([MEDICATION NAME]). Review of Resident #1's Medical Record reflected one (1) PT/ INR lab result in Resident #1's medical record dated 06/22/2018 with the results of PT 21.0 (H) high (normal range 9.9 to 11.8) and INR of 2.1 (H) (normal range 0.9 to 2.0). Written on the lab report was; reported to MD, no new orders. No PT/ INR lab results were noted for 06/29/2018; 07/06/2018; 07/13/2018; 07/20/2018; 07/27/2018; 08/03/2018; or 08/10/2018. Review of Resident #1's physician progress notes [REDACTED]. No notation of Resident #1's lab result was noted. Review of Resident #1's Nursing Progress Notes dated 08/12/2018 at 9:40 AM reflected Received report from RN B. That resident's sister-in-law called stating that resident had called her and told her that he was having a stroke. This nurse and RN A assessed resident. Found no significant findings of stroke. Symmetry noted with facial features, hand grips equal. Denies pain or discomfort. Blood pressure 121/76, heart rate 84. Resident without any distress noted at this time. Notified residents sister-in-law of findings states I'm coming up there to check him out. Will continue to monitor. Note signed by LVN D. Further review of Resident #1's Nursing Progress Notes reflected an entry on 08/12/2018 at 10:16 AM Residents family in facility at this time. Requests for resident to be sent to ER. EMS notified of need for transfer. Will continue to monitor. Note signed by LVN D. Review of Resident #1's Hospital Record reflected Resident #1 was admitted on [DATE] at 1:17 PM with reason for visit listed as acute [MEDICAL CONDITION] with GI (gastrointestinal) bleed and hypercoagulable state. Further review of Resident #1's hospital record reflected Resident #1 presented to ED (emergency department) for evaluation of weakness, nausea and vomiting of maroon coloring. Resident #1 was assessed to have abdominal tenderness on exam and a blood pressure of 88/59, and heart rate of 107 bpm (beats per minute). Resident #1's Hemoglobin was 5.2 g/dl (normal range 14.0-18.0) and Hematocrit level was 15.3 % (normal range 42.0-52.0). Resident #1's PT level was 77.1 (normal range 9.9 to 11.8) and INR level was 9.7 (normal range 0.9 to 2.0). Resident #1's hospital record reflected he received two (2) units of PRBC's (packed red blood cells); was started on [MEDICATION NAME] ([MEDICATION NAME]) reversal agents: vitamin K and factors 10,9,7 and 2; GI was consulted, and Resident #1 was placed in ICU (intensive care unit). Further review of Resident #1's hospital record reflected Resident #1 had an eophagogastroduodenoscopy with APC (argon plasma coagulation) treatment (Argon plasma coagulation or APC is a medical endoscopic procedure used primarily to control bleeding from certain [MEDICAL CONDITION] in the gastrointestinal tract) listed as the indications for the procedure was hematemesis and acute blood loss [MEDICAL CONDITION] in the context of a supratherapeutic INR. Review of Resident #1's Hospital Discharge orders reflected Resident #1 was discharged back to the nursing facility on 08/15/2018 with an order for [REDACTED]. In an interview on 08/20/2018 at 1:20 PM Resident #1's Physician stated he saw Resident #1 at the facility in (MONTH) and Aug on the 3rd the nurses did not tell him that Resident #1's labs were not being done. Resident #1's Physician stated he saw Resident #1 at the hospital and his blood pressure was very low and his INR was high. Resident#1's Physician stated he realized the facility had not been monitoring Resident #1's PT/ INR. Resident #1's Physician stated the PT/ INR has to be monitored closely. Resident #1's Physician stated he expected the nursing home to follow orders and make sure the labs are done. When Resident #1's Physician was asked if he had, had problems with the facility before of this nature he stated no. Resident #1's Physician stated at the hospital Resident #1was noted to have a low blood count and received 2 units of blood and was placed in ICU. Resident #1's Physician stated the next day Resident #1 had a procedure to cauterize the bleeders. Resident #1's Physician stated if the PT/INR gets to high the residents will start to bleed. Resident #1's Physician stated Resident #1 was given vitamin K in ER to counteract the [MEDICATION NAME]. Review of Resident #1's Medical Record reflected the Pharmacy Consultant reviewed Resident #1's record on 07/11/2018. The Pharmacy Consultant report reflected a note PT/ INR monitoring: most recent INR: on 06/22/2018, INR=2.1 (H) Resident's current orders are for [MEDICATION NAME] 5mg by mouth every day. Staff: monitor resident for signs and symptoms of a bleed. Signs and Symptoms include but are not limited to: bruising, coughing up blood, gum bleeds, nose bleeds, cola/tea colored urine, black tarry stools, etc. Notify doctor ASAP if any of the above develop to see what should be done for resident. In an interview on 08/20/2018 at 1:10 PM the Pharmacy Consultant stated she did a chart audit on 07/11/2018. The Pharmacy Consultant stated she gave the facility a notice to send to MD regarding Resident #1's PT being high on 06/22/18. When asked if the Pharmacy Consultant caught that Resident #1 was missing a PT/INR for the 06/29/2018, and 07/06/2018 she stated she missed that. The Pharmacy Consultant stated it is important to check labs when someone starts [MEDICATION NAME] to ensure the [MEDICATION NAME] dosage is correct. In an interview on 08/20/2018 at 1:56 PM the Administrator stated when she became aware of the missing lab reports for Resident #1 the facility preformed a complete lab audit. The Administrator stated the lab process was definitely broken. The Administrator stated the ADON was in charge of tracking the lab results and she quit on (MONTH) 1st. The Administrator stated the new ADON started on (MONTH) 1st and has been trained in lab tracking. In an interview on 08/20/2018 at 2:00 PM the DON stated when she became aware of the missing lab reports she called the lab to the facility to do an audit. The DON stated she felt the audit was not thorough and requested that the lab re-due the audit. The DON stated the facility also did a complete audit of all the residents' charts to check for missing lab. In an interview on 08/20/2018 at 2:20 PM the Administrator stated the DON was ultimately responsible for making sure residents' labs are done and reported to the physician. When the Administrator was asked if the DON should have caught Resident #1's missing PT/INR's the Administrator stated, let me just say the system was definitely broken. Review of the facility's Provider Investigation Report dated 08/17/2018 reflected the facility reported to HHSC on 08/15/2018 at 1:33 PM the following information regarding Resident #1Resident medical record from hospital visit received and reviewed by facility. Lab records reveal an elevated PT/ INR. Upon investigation facility reviewed residents' chart and labs and determined that PT/ INR labs were not obtained . In an interview on 08/21/2018 at PM the Administrator stated the facility did not have a policy for labs. The Administrator stated the facility followed physician orders. It was determined the above failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 06/29/2018 through 08/15/2018. AN IJ was identified at Past non compliance and the Administrator was notified on 08/21/2018. Review of the facility provided list of actions to correct the non-compliance dated 08/15/2018 reflected: 1.) A complete chart audit of current resident's lab orders was conducted, and any found to be missing were drawn and sent to the physician. 2.) The DON or ADON will monitor all lab on a daily basis by reviewing the lab book, labs that are due for that day. 3.) The DON or ADON will keep a log of all daily labs and log when labs have arrived. If labs do no arrive the DON/ ADON will call the lab and notify the MD. 4.) The DON/ ADON will review labs in the morning meeting and review pending labs for that day. 5.) The ADON will check the Lab log for [MEDICATION NAME] to ensure that labs have been obtained. If lab is missing the ADON will call the lab and notify the MD. 6.) All labs will be reviewed weekly in the S[NAME] Meeting. 7.) All nurses will start administering [MEDICATION NAME] and logging the labs. 8.) All labs will be reviewed at the monthly QA meeting. 9.) All nursing staff in-serviced regarding the new process. 10.) The DON and ADON were in serviced by the Corporate compliance nurse regarding lab monitoring. In interviews on 08/20/2018 two LVN's (LVN E and LVN F) stated they were aware of the new PT/ INR monitoring system and stated they now have to check the lab results prior to administering [MEDICATION NAME] to ensure lab results are done and the physician is aware of the results. Review of the Medical Records for all residents on [MEDICATION NAME] reflected the residents had PT/ INR lab test were drawn as ordered, the lab results were in the charts and the results were reported to the physician. Review of the medication administration records for all residents on [MEDICATION NAME] reflected the new tracking system was in place and all residents on [MEDICATION NAME] were being monitored by the nurses and current PT/INR levels were documented on the flow sheets. The facility provided a list of four (4) residents on [MEDICATION NAME].

Based on observation, interview and record review, the facility failed to obtain physician ordered lab test for one (1) of four (4) residents reviewed for laboratory services. (Resident #1) The facility failed to: A. Obtain a repeat blood test PT/ INR ([MEDICATION NAME] time (PT) / international normalized ratio) weekly as ordered by the physician from 06/29/2018 to 08/12/2018. B. Recognize that Resident #1's lab work had not been completed on 06/29/2018; 07/06/2018; 07/13/2018; 07/20/2018; 07/27/2018; 08/03/2018; or 08/10/2018. Resident #1 was transferred to the hospital on [DATE] with the [DIAGNOSES REDACTED]. This was determined to be past non-compliance immediate jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure affected one (1) resident (Resident #1) and had the potential to affect three (3) residents receiving [MEDICATION NAME] therapy placing them at risk for undetected health issues, overdosing, bleeding, delayed treatment and death. The finding included: Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's 60 day MDS dated [DATE] reflected Resident #1 did not have a BIMS score conducted and was coded to have short term memory problems with intact long-term Memory. Resident #1 was coded to be able to recall the current season, the location of his room, staff names and faces and that he was in a nursing home. Resident #1 was coded to usually understand others and rarely/ never make self-understood. Resident #1 was coded to require supervision for transfers and ambulation in room. Resident #1 was coded to be on anticoagulant medication seven days a week. Review of Resident #1's Comprehensive Care Plan dated 06/04/2018 and revised on 06/05/2018 reflected a focus area of anticoagulant therapy with a goal that the resident will be free from discomfort or adverse reactions related to anticoagulant use. Interventions/Tasks included; if any of the following are observed report immediately to the charge nurse: bruising, nosebleeds, bleeding gums, prolonged bleeding from wound .blood I urine/feces/vomit .Labs as ordered. Report abnormal lab results to the MD. Monitor/document/ report to MD signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea , vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, Shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Further review of Resident #1's comprehensive care plan reflected a focus of right side [MEDICAL CONDITION]/ [MEDICAL CONDITION] related to stroke with the intervention; obtain and monitor lab/ diagnostic work as ordered. Observation and Interview on 08/20/2018 at 11:14 AM revealed Resident #1 in room lying in bed. Resident #1 alert with [MEDICAL CONDITION] and communicated using yes and minimal words; Resident #1 stated he was ok. Faded bruising noted to right wrist. No bruising noted to left wrist or ankles. Review of Resident #1's Consolidated Physician order [REDACTED].#1's Consolidated Physician order [REDACTED]. The international normalized ratio (INR) is a calculation based on results of a PT that is used to monitor treatment with the blood-thinning medication [MEDICATION NAME] ([MEDICATION NAME]). Review of Resident #1's Medical Record reflected one (1) PT/ INR lab result in Resident #1's medical record dated 06/22/2018 with the results of PT 21.0 (H) high (normal range 9.9 to 11.8) and INR of 2.1 (H) (normal range 0.9 to 2.0). Written on the lab report was; reported to MD, no new orders. No PT/ INR lab results were noted for 06/29/2018; 07/06/2018; 07/13/2018; 07/20/2018; 07/27/2018; 08/03/2018; or 08/10/2018. Review of Resident #1's physician progress notes [REDACTED]. No notation of Resident #1's lab result was noted. Review of Resident #1's Nursing Progress Notes dated 08/12/2018 at 9:40 AM reflected Received report from RN B. That resident's sister-in-law called stating that resident had called her and told her that he was having a stroke. This nurse and RN A assessed resident. Found no significant findings of stroke. Symmetry noted with facial features, hand grips equal. Denies pain or discomfort. Blood pressure 121/76, heart rate 84. Resident without any distress noted at this time. Notified residents sister-in-law of findings states I'm coming up there to check him out. Will continue to monitor. Note signed by LVN D. Further review of Resident #1's Nursing Progress Notes reflected an entry on 08/12/2018 at 10:16 AM Residents family in facility at this time. Requests for resident to be sent to ER. EMS notified of need for transfer. Will continue to monitor. Note signed by LVN D. Review of Resident #1's Hospital Record reflected Resident #1 was admitted on [DATE] at 1:17 PM with reason for visit listed as acute [MEDICAL CONDITION] with GI (gastrointestinal) bleed and hypercoagulable state. Further review of Resident #1's hospital record reflected Resident #1 presented to ED (emergency department) for evaluation of weakness, nausea and vomiting of maroon coloring. Resident #1 was assessed to have abdominal tenderness on exam and a blood pressure of 88/59, and heart rate of 107 bpm (beats per minute). Resident #1's Hemoglobin was 5.2 g/dl (normal range 14.0-18.0) and Hematocrit level was 15.3 % (normal range 42.0-52.0). Resident #1's PT level was 77.1 (normal range 9.9 to 11.8) and INR level was 9.7 (normal range 0.9 to 2.0). Resident #1's hospital record reflected he received two (2) units of PRBC's (packed red blood cells); was started on [MEDICATION NAME] ([MEDICATION NAME]) reversal agents: vitamin K and factors 10,9,7 and 2; GI was consulted, and Resident #1 was placed in ICU (intensive care unit). Further review of Resident #1's hospital record reflected Resident #1 had an eophagogastroduodenoscopy with APC (argon plasma coagulation) treatment (Argon plasma coagulation or APC is a medical endoscopic procedure used primarily to control bleeding from certain [MEDICAL CONDITION] in the gastrointestinal tract) listed as the indications for the procedure was hematemesis and acute blood loss [MEDICAL CONDITION] in the context of a supratherapeutic INR. Review of Resident #1's Hospital Discharge orders reflected Resident #1 was discharged back to the nursing facility on 08/15/2018 with an order for [REDACTED]. In an interview on 08/20/2018 at 1:20 PM Resident #1's Physician stated he saw Resident #1 at the facility in (MONTH) and Aug on the 3rd the nurses did not tell him that Resident #1's labs were not being done. Resident #1's Physician stated he saw Resident #1 at the hospital and his blood pressure was very low and his INR was high. Resident#1's Physician stated he realized the facility had not been monitoring Resident #1's PT/ INR. Resident #1's Physician stated the PT/ INR has to be monitored closely. Resident #1's Physician stated he expected the nursing home to follow orders and make sure the labs are done. When Resident #1's Physician was asked if he had, had problems with the facility before of this nature he stated no. Resident #1's Physician stated at the hospital Resident #1 was noted to have a low blood count and received 2 units of blood and was placed in ICU. Resident #1's Physician stated the next day Resident #1 had a procedure to cauterize the bleeders. Resident #1's Physician stated if the PT/INR gets to high the residents will start to bleed. Resident #1's Physician stated Resident #1 was given vitamin K in ER to counteract the [MEDICATION NAME]. Review of Resident #1's Medical Record reflected the Pharmacy Consultant reviewed Resident #1's record on 07/11/2018. The Pharmacy Consultant report reflected a note PT/ INR monitoring: most recent INR: on 06/22/2018, INR=2.1 (H) Resident's current orders are for [MEDICATION NAME] 5mg by mouth every day. Staff: monitor resident for signs and symptoms of a bleed. Signs and Symptoms include but are not limited to: bruising, coughing up blood, gum bleeds, nose bleeds, cola/tea colored urine, black tarry stools, etc. Notify doctor ASAP if any of the above develop to see what should be done for resident. In an interview on 08/20/2018 at 1:10 PM the Pharmacy Consultant stated she did a chart audit on 07/11/2018. The Pharmacy Consultant stated she gave the facility a notice to send to MD regarding Resident #1's PT being high on 06/22/18. When asked if the Pharmacy Consultant caught that Resident #1 was missing a PT/INR for the 06/29/2018, and 07/06/2018 she stated she missed that. The Pharmacy Consultant stated it is important to check labs when someone starts [MEDICATION NAME] to ensure the [MEDICATION NAME] dosage is correct. In an interview on 08/20/2018 at 1:56 PM the Administrator stated when she became aware of the missing lab reports for Resident #1 the facility preformed a complete lab audit. The Administrator stated the lab process was definitely broken. The Administrator stated the ADON was in charge of tracking the lab results and she quit on (MONTH) 1st. The Administrator stated the new ADON started on (MONTH) 1st and has been trained in lab tracking. In an interview on 08/20/2018 at 2:00 PM the DON stated when she became aware of the missing lab reports she called the lab to the facility to do an audit. The DON stated she felt the audit was not thorough and requested that the lab re-due the audit. The DON stated the facility also did a complete audit of all the residents' charts to check for missing lab. In an interview on 08/20/2018 at 2:20 PM the Administrator stated the DON was ultimately responsible for making sure residents' labs are done and reported to the physician. When the Administrator was asked if the DON should have caught Resident #1's missing PT/INR's the Administrator stated, let me just say the system was definitely broken. Review of the facility's Provider Investigation Report dated 08/17/2018 reflected the facility reported to HHSC on 08/15/2018 at 1:33 PM the following information regarding Resident #1Resident medical record from hospital visit received and reviewed by facility. Lab records reveal an elevated PT/ INR. Upon investigation facility reviewed residents' chart and labs and determined that PT/ INR labs were not obtained . In an interview on 08/21/2018 at PM the Administrator stated the facility did not have a policy for labs. The Administrator stated the facility followed physician orders. It was determined the above failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 06/29/2018 through 08/15/2018. AN IJ was identified at Past non compliance and the Administrator was notified on 08/21/2018. Review of the facility provided list of actions to correct the non-compliance dated 08/15/2018 reflected: 1.) A complete chart audit of current resident's lab orders was conducted, and any found to be missing were drawn and sent to the physician. 2.) The DON or ADON will monitor all lab on a daily basis by reviewing the lab book, labs that are due for that day. 3.) The DON or ADON will keep a log of all daily labs and log when labs have arrived. If labs do no arrive the DON/ ADON will call the lab and notify the MD. 4.) The DON/ ADON will review labs in the morning meeting and review pending labs for that day. 5.) The ADON will check the Lab log for [MEDICATION NAME] to ensure that labs have been obtained. If lab is missing the ADON will call the lab and notify the MD. 6.) All labs will be reviewed weekly in the S[NAME] Meeting. 7.) All nurses will start administering [MEDICATION NAME] and logging the labs. 8.) All labs will be reviewed at the monthly QA meeting. 9.) All nursing staff in-serviced regarding the new process. 10.) The DON and ADON were in serviced by the Corporate compliance nurse regarding lab monitoring. In interviews on 08/20/2018 two LVN's (LVN E and LVN F) stated they were aware of the new PT/ INR monitoring system and stated they now have to check the lab results prior to administering [MEDICATION NAME] to ensure lab results are done and the physician is aware of the results. Review of the Medical Records for all residents on [MEDICATION NAME] reflected the residents had PT/ INR lab test were drawn as ordered, the lab results were in the charts and the results were reported to the physician. Review of the medication administration records for all residents on [MEDICATION NAME] reflected the new tracking system was in place and all residents on [MEDICATION NAME] were being monitored by the nurses and current PT/INR levels were documented on the flow sheets. The facility provided a list of four (4) residents on [MEDICATION NAME].

Based on observation, interview and record review, the faciltiy failed to ensure that residents were free from neglect for one (1) of ten (10) residents reviewed for neglect. The facility failed to: A. Provide a repeat blood test PT/ INR ([MEDICATION NAME] time (PT) / international normalized ratio) weekly as ordered by the physician from 06/29/2018 to 08/12/2018. B. Track or Monitor that Resident #1's lab work had not been completed on 06/29/2018; 07/06/2018; 07/13/2018; 07/20/2018; 07/27/2018; 08/03/2018; or 08/10/2018. Resident #1 was transferred to the hospital on [DATE] with the [DIAGNOSES REDACTED]. Due to these failutres it was determined to be past non-compliance immediate jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure affected one (1) resident (Resident #1) and had the potential to affect three (3) residents receiving [MEDICATION NAME] therapy placing them at risk for undetected health issues, overdosing, bleeding, delayed treatment and death. The findings included: Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's 60 day MDS dated [DATE] reflected Resident #1 did not have a BIMS score conducted and was coded to have short term memory problems with intact long-term Memory. Resident #1 was coded to be able to recall the current season, the location of his room, staff names and faces and that he was in a nursing home. Resident #1 was coded to usually understand others and rarely/ never make self-understood. Resident #1 was coded to require supervision for transfers and ambulation in room. Resident #1 was coded to be on anticoagulant medication seven days a week. Review of Resident #1's Comprehensive Care Plan dated 06/04/2018 and revised on 06/05/2018 reflected a focus area of anticoagulant therapy with a goal that the resident will be free from discomfort or adverse reactions related to anticoagulant use. Interventions/Tasks included; if any of the following are observed report immediately to the charge nurse: bruising, nosebleeds, bleeding gums, prolonged bleeding from wound .blood I urine/feces/vomit .Labs as ordered. Report abnormal lab results to the MD. Monitor/document/ report to MD signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea , vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, Shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Further review of Resident #1's comprehensive care plan reflected a focus of right side [MEDICAL CONDITION]/ [MEDICAL CONDITION] related to stroke with the intervention; obtain and monitor lab/ diagnostic work as ordered. Observation and Interview on 08/20/2018 at 11:14 AM revealed Resident #1 in room lying in bed. Resident #1 alert with [MEDICAL CONDITION] and communicated using yes and minimal words; Resident #1 stated he was ok. Faded bruising noted to right wrist. No bruising noted to left wrist or ankles. Review of Resident #1's Consolidated Physician order [REDACTED].#1's Consolidated Physician order [REDACTED]. The international normalized ratio (INR) is a calculation based on results of a PT that is used to monitor treatment with the blood-thinning medication [MEDICATION NAME] ([MEDICATION NAME]). Review of Resident #1's Medical Record reflected one (1) PT/ INR lab result in Resident #1's medical record dated 06/22/2018 with the results of PT 21.0 (H) high (normal range 9.9 to 11.8) and INR of 2.1 (H) (normal range 0.9 to 2.0). Written on the lab report was; reported to MD, no new orders. No PT/ INR lab results were noted for 06/29/2018; 07/06/2018; 07/13/2018; 07/20/2018; 07/27/2018; 08/03/2018; or 08/10/2018. Review of Resident #1's physician progress notes [REDACTED]. No notation of Resident #1's lab result was noted. Review of Resident #1's Nursing Progress Notes dated 08/12/2018 at 9:40 AM reflected Received report from RN B. That resident's sister-in-law called stating that resident had called her and told her that he was having a stroke. This nurse and RN A assessed resident. Found no significant findings of stroke. Symmetry noted with facial features, hand grips equal. Denies pain or discomfort. Blood pressure 121/76, heart rate 84. Resident without any distress noted at this time. Notified residents sister-in-law of findings states I'm coming up there to check him out. Will continue to monitor. Note signed by LVN D. Further review of Resident #1's Nursing Progress Notes reflected an entry on 08/12/2018 at 10:16 AM Residents family in facility at this time. Requests for resident to be sent to ER. EMS notified of need for transfer. Will continue to monitor. Note signed by LVN D. Review of Resident #1's Hospital Record reflected Resident #1 was admitted on [DATE] at 1:17 PM with reason for visit listed as acute [MEDICAL CONDITION] with GI (gastrointestinal) bleed and hypercoagulable state. Further review of Resident #1's hospital record reflected Resident #1 presented to ED (emergency department) for evaluation of weakness, nausea and vomiting of maroon coloring. Resident #1 was assessed to have abdominal tenderness on exam and a blood pressure of 88/59, and heart rate of 107 bpm (beats per minute). Resident #1's Hemoglobin was 5.2 g/dl (normal range 14.0-18.0) and Hematocrit level was 15.3 % (normal range 42.0-52.0). Resident #1's PT level was 77.1 (normal range 9.9 to 11.8) and INR level was 9.7 (normal range 0.9 to 2.0). Resident #1's hospital record reflected he received two (2) units of PRBC's (packed red blood cells); was started on [MEDICATION NAME] ([MEDICATION NAME]) reversal agents: vitamin K and factors 10,9,7 and 2; GI was consulted, and Resident #1 was placed in ICU (intensive care unit). Further review of Resident #1's hospital record reflected Resident #1 had an eophagogastroduodenoscopy with APC (argon plasma coagulation) treatment (Argon plasma coagulation or APC is a medical endoscopic procedure used primarily to control bleeding from certain [MEDICAL CONDITION] in the gastrointestinal tract) listed as the indications for the procedure was hematemesis and acute blood loss [MEDICAL CONDITION] in the context of a supratherapeutic INR. Review of Resident #1's Hospital Discharge orders reflected Resident #1 was discharged back to the nursing facility on 08/15/2018 with an order for [REDACTED]. In an interview on 08/20/2018 at 1:20 PM Resident #1's Physician stated he saw Resident #1 at the facility in (MONTH) and Aug on the 3rd the nurses did not tell him that Resident #1's labs were not being done. Resident #1's Physician stated he saw Resident #1 at the hospital and his blood pressure was very low and his INR was high. Resident#1's Physician stated he realized the facility had not been monitoring Resident #1's PT/ INR. Resident #1's Physician stated the PT/ INR has to be monitored closely. Resident #1's Physician stated he expected the nursing home to follow orders and make sure the labs are done. When Resident #1's Physician was asked if he had, had problems with the facility before of this nature he stated no. Resident #1's Physician stated at the hospital Resident #1was noted to have a low blood count and received 2 units of blood and was placed in ICU. Resident #1's Physician stated the next day Resident #1 had a procedure to cauterize the bleeders. Resident #1's Physician stated if the PT/INR gets to high the residents will start to bleed. Resident #1's Physician stated Resident #1 was given vitamin K in ER to counteract the [MEDICATION NAME]. Review of Resident #1's Medical Record reflected the Pharmacy Consultant reviewed Resident #1's record on 07/11/2018. The Pharmacy Consultant report reflected a note PT/ INR monitoring: most recent INR: on 06/22/2018, INR=2.1 (H) Resident's current orders are for [MEDICATION NAME] 5mg by mouth every day. Staff: monitor resident for signs and symptoms of a bleed. Signs and Symptoms include but are not limited to: bruising, coughing up blood, gum bleeds, nose bleeds, cola/tea colored urine, black tarry stools, etc. Notify doctor ASAP if any of the above develop to see what should be done for resident. In an interview on 08/20/2018 at 1:10 PM the Pharmacy Consultant stated she did a chart audit on 07/11/2018. The Pharmacy Consultant stated she gave the facility a notice to send to MD regarding Resident #1's PT being high on 06/22/18. When asked if the Pharmacy Consultant caught that Resident #1 was missing a PT/INR for the 06/29/2018, and 07/06/2018 she stated she missed that. The Pharmacy Consultant stated it is important to check labs when someone starts [MEDICATION NAME] to ensure the [MEDICATION NAME] dosage is correct. In an interview on 08/20/2018 at 1:56 PM the Administrator stated when she became aware of the missing lab reports for Resident #1 the facility preformed a complete lab audit. The Administrator stated the lab process was definitely broken. The Administrator stated the ADON was in charge of tracking the lab results and she quit on (MONTH) 1st. The Administrator stated the new ADON started on (MONTH) 1st and has been trained in lab tracking. In an interview on 08/20/2018 at 2:00 PM the DON stated when she became aware of the missing lab reports she called the lab to the facility to do an audit. The DON stated she felt the audit was not thorough and requested that the lab re-due the audit. The DON stated the facility also did a complete audit of all the residents' charts to check for missing lab. In an interview on 08/20/2018 at 2:20 PM the Administrator stated the DON was ultimately responsible for making sure residents' labs are done and reported to the physician. When the Administrator was asked if the DON should have caught Resident #1's missing PT/INR's the Administrator stated, let me just say the system was definitely broken. Review of the facility's Provider Investigation Report dated 08/17/2018 reflected the facility reported to HHSC on 08/15/2018 at 1:33 PM the following information regarding Resident #1Resident medical record from hospital visit received and reviewed by facility. Lab records reveal an elevated PT/ INR. Upon investigation facility reviewed residents' chart and labs and determined that PT/ INR labs were not obtained . Review of the facility's Policy on abuse/ Neglect dated 03/29/2018 reflected Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. It was determined the above failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 06/29/2018 through 08/15/2018. AN IJ was identified at Past non compliance and the Administrator was notified on 08/21/2018. Review of the facility provided list of actions to correct the non-compliance dated 08/15/2018 reflected: 1.) A complete chart audit of current resident's lab orders was conducted, and any found to be missing were drawn and sent to the physician. 2.) The DON or ADON will monitor all lab on a daily basis by reviewing the lab book, labs that are due for that day. 3.) The DON or ADON will keep a log of all daily labs and log when labs have arrived. If labs do no arrive the DON/ ADON will call the lab and notify the MD. 4.) The DON/ ADON will review labs in the morning meeting and review pending labs for that day. 5.) The ADON will check the Lab log for [MEDICATION NAME] to ensure that labs have been obtained. If lab is missing the ADON will call the lab and notify the MD. 6.) All labs will be reviewed weekly in the S[NAME] Meeting. 7.) All nurses will start administering [MEDICATION NAME] and logging the labs. 8.) All labs will be reviewed at the monthly QA meeting. 9.) All nursing staff in-serviced regarding the new process. 10.) The DON and ADON were in serviced by the Corporate compliance nurse regarding lab monitoring. In interviews on 08/20/2018 two LVN's (LVN E and LVN F) stated they were aware of the new PT/ INR monitoring system and stated they now have to check the lab results prior to administering [MEDICATION NAME] to ensure lab results are done and the physician is aware of the results. Review of the Medical Records for all residents on [MEDICATION NAME] reflected the residents had PT/ INR lab test were drawn as ordered, the lab results were in the charts and the results were reported to the physician. Review of the medication administration records for all residents on [MEDICATION NAME] reflected the new tracking system was in place and all residents on [MEDICATION NAME] were being monitored by the nurses and current PT/INR levels were documented on the flow sheets. The facility provided a list of four (4) residents on [MEDICATION NAME].

Based on observation, interview and record review the facility failed to ensure resident's that have the right to receive services in the facility with reasonable accommodations of individual needs and preferences for one (1) of four (4) reviewed for rehabilitation services (Resident #1). The facility failed to provide Resident #1 a customized wheelchair, as recommended by Occupational Therapy on 11/14/13, for positioning in order to decrease her pain and increase her mobility. Resident #1 became bedbound, lonely and depressed due to not receiving the customized wheelchair. This deficient practice could cause 25 residents a decline in quality of life, loneliness, depression and physical pain. Findings include: Review of the Facesheet for Resident #1 reflected she was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had unclear speech but was usually understood. She was intact cognitively. She had symptoms of feeling down, depressed or hopeless. She was totally dependent on staff for Activity of Daily Living (ADLs). She had decreased range of motion of both upper and lower extremities. She required a wheelchair for mobility. Resident #1 was frequently incontinent of bladder and occasionally incontinent of bowel. Her active [DIAGNOSES REDACTED]. Review of the current Care Plan dated 2/18/14 reflected Resident #1 had [MEDICAL CONDITION]. Interventions included to evaluate the need for safety measures and modify her environment as needed to promote safety. Occupational Therapy (OT) to monitor/document and treat as indicated. Use assistive devices recommended by OT to facilitate independence. Resident #1 had anxiety. Staff were to intervene by encouraging socialization with staff and other residents out of her room. Review of consolidated Physician orders [REDACTED].#1 had an additional [DIAGNOSES REDACTED]. She was ordered to receive the following medications: [REDACTED] [MEDICATION NAME] (antidepressant) 60 milligrams (mg) every day for major [MEDICAL CONDITION]. Klonopin 1 mg two times a day for Axiety. Review of Physician telephone orders for Resident #1 reflected the following: 12/17/13-May have Psychiatric consult. 1/9/14-Occupational Therapy (OT) evaluate and treat for positioning. Observation on 3/6/14 at 8:40 AM revealed Resident #1 lying in bed watching television. She had numerous contractures. Her head was tilted to the left, her back was curved, her pelvis was twisted, her legs were straight and stiff and she had bilateral foot drop. When asked if she was doing alright, she clicked her tongue two times. The Surveyor asked her if two clicks meant " yes? " She mouthed the word " yes. " The Surveyor asked if one click meant " no? " Resident #1 clicked twice for " yes. " In an interview on 3/6/14 at 10:10 AM Licensed Vocational Nurses (LVN) A stated Resident #1 did not get out of bed very much. She stated Resident #1 had outgrown her wheelchair. LVN A stated she thinks Resident #1 was nervous and scared around people at the facility because they are all older than her. There are no other residents her age. She stated therapy had gotten involved and a new wheelchair was going to be ordered for Resident #1 but that was a long time ago and she didn ' t know what happened with that. LVN A stated that Resident #1 uses her Tablet, likes to get on Facebook and just watch television. In an interview on 3/6/14 at 12:15 PM the Physical Therapy Assistant (PTA) stated that Resident #1 was fully alert and oriented, she just could not talk because of her [MEDICAL CONDITION]. She communicated by mouthing words and clicking her tongue one time for "no" and two times for "yes." We were able to understand her that way. She stated that Resident #1 was admitted to the facility with a wheelchair that had been donated to her approximately [AGE] years ago. She used to get out of bed and use that chair when she first came here; however, she had far outgrown that chair. She was approximately 40 pounds heavier now than when she was admitted in poor nutritional health. The PTA stated now, her legs just hang off the end of the chair with no support and she complains that it hurt her. The only place she says she can be comfortable is in her bed right now. She stated that Resident #1 had no quality of life, was fully cognitive and only [AGE] years old. There was so much more she could do if she had a customized wheelchair. She stated that the facility's OT recommended a custom fitted wheelchair for her a long time ago, so she could get up out of bed and not lay there all day. She stated it was so sad to see her not get out of bed when she had so much more potential. She stated that the customized wheelchair was not approved by administration. The PTA stated it was her understanding that it was due to the cost of the chair, but Resident #1 had Medicaid which would pay for the chair. The facility wanted to get her out of bed into a Geri-chair but that would not give her the support where her body needed it and she would not be able to sit in a Geri-chair for very long without special support. Resident #1 really wants to get up and out of her room. She wants to go outside and go to the park across the street with activities and go shopping like any person her age. She is very sad and depressed that her bed is the only place she can be comfortable. In an interview on 3/6/14 at 12:10 PM the Occupational Therapy Assistant (OTA) stated Resident #1 " really has no quality of life because she has to stay in bed. " When we were working on getting her the custom wheelchair, she was so excited and then it never happened. She is very sad and depressed, even tearful at times. She wants so badly to get out of her bed and her room and she really needs that. In an interview on 3/6/14 at 1:10 PM the Administrator stated that when she became the Administrator of the facility she was approached by one of the nurses and asked to follow up on getting Resident #1 a new wheelchair. She stated that with equipment like that, their process was to go through corporate. We ' ve been working on getting her a chair. The company should be coming to fit and measure her next week. They will assess her and custom build her chair and it should arrive in a couple of weeks. She stated it would be a custom fitted Broda chair (a tilt reclining and positioning chair on wheels). At 1:25 PM the Administrator provided manufacturer information on the Broda chair and stated that the chair was already being built for Resident #1. She stated the Director of Nurses (DON) had given the representative measurements of Resident #1's height and weight over the telephone. Review of the Broda chair Model 785 manufacturer information of the make and model being constructed for Resident #1 reflected the following: The Broda HSP package provides comfortable, stable, protective padding and positioning for residents with severe agitation and involuntary movement. Ideal for [MEDICAL CONDITION] ' s, Alzheimer ' s and Dementia. Its ideal for use in Long-term care and acute-care facilities for residents requiring medium to heavy levels of nursing care; residents with [MEDICAL CONDITION] ' s Chorea or severe agitation and involuntary movement. In an interview on 3/6/14 at 1:54 PM the OT stated that Resident #1 had Scoliosis, Kyphosis and twisted hips. She needed a special, tilted, chair fitted to her for proper trunk support and pelvis stability. The OT stated that she reviewed the information regarding the Broda HSP Model 785 and it would not be appropriate for Resident #1. It would not be much more than placing her in a Geri-chair. She would need to be positioned with pillows to prevent pressure areas from developing whereas the custom built wheelchair would be molded to her special body contours to relieve pressure points. Additionally, Resident #1 would be fully capable of maneuvering an electric wheelchair using a device to move the chair with her chin or the slight movement she has in her left hand. She would not have that independence with the Broda chair. She would remain dependent on staff for her mobility. She stated that Resident #1 was only [AGE] years old and had her whole life ahead of her. She would have more mobility and could even go out of the facility with friends if she had a custom wheelchair that she could maneuver on her own. It would improve her quality of life tremendously. She stated right now, Resident #1 had no quality of life. The OT stated that lying in her bed in her room all the time and being depressed was not good for her. She stated that she made this recommendation and the representative from the Seating and Mobility company had come out and took special measurements on Resident #1 in order to customize a chair to fit her needs, but then the chair was never ordered by administration. In a telephone interview on 3/6/14 at 1:30 PM the Broda chair representative stated he could not make it to the facility to get measurements on Resident #1 but her chair was currently being constructed based on height and weight provided to them by the facility. On 3/12/14 at 1:00 PM the representative of Seating and Mobility services, an Assistive Technology Professional, contacted the surveyor for interview regarding Resident #1. He stated that he had gone to the facility and took various measurements of Resident #1 to provide her with a custom fitted wheelchair that molded to her body. He stated Resident #1 was "orthopedically complicated" due to Scoliosis that had progressed to rib cage collapse; she had a rib hump, hip rotation and leg length discrepancy. He stated that a Broda chair is a flat back, flat seated, very generic chair that would not be appropriate for Resident #1 under any circumstances. He stated without the custom molding, she would be at very high risk for developing Pressure Ulcers. He stated Resident #1 was a young lady that was very cognitively intact, had good head movement and movement of the tips of her fingers on her left hand. With good trunk and head support and fiberoptic devices, there were many, many alternatives for her independent mobility that would get her out of bed and greatly improve her quality of life. He stated he even offered to donate the chair if the facility would pay for the custom molding. Review of the Occupational Therapy Certification dated 11/14/13 reflected Resident #1 was a [AGE] year old female who had been a Long Term Care resident at the facility since 2011. She was referred to OT services for wheelchair and positioning assessment. Her past medical history included [MEDICAL CONDITION], [DIAGNOSES REDACTED], Stroke with right sided [MEDICAL CONDITIONS], Gastrostomy, [MEDICAL CONDITION] and Depression. Reason for Referral: Recent decline in upper extremity function, Weakness, positioning needs, contracture management, joint pain and stiffness, and equipment needs. Prior Level of Function with Ambulation: Does not occur. Patient/Caregiver Goal: Resident #1 indicated that she would like to be able to sit up in a wheelchair without pain. Positive Prognostic Indicators: Resident #1 had the ability to follow directions; potential for new learning; she was motivated and able to participate. Her rehabilitation potential was good. Short Term Goals: Resident #1 to obtain appropriate seating system to allow joints of her body to be in alignment with the least amount of discomfort permitting her to be out of bed for four hours or more to participate in facility activities to improve her quality of life. Coordination: Her left upper extremity is the only extremity that has movement. Static Sitting Balance: Absent; full support was needed. Dynamic Sitting Balance: Absent; full support was needed. Resident #1 reported pain to bilateral legs, left thumb, right upper extremity and right knee. Resident #1 was sitting upright in a customized wheelchair that was poorly fitted since she had it for over [AGE] years. It provided no leg support at all. She was leaning to the left with her head no longer supported by the head rest. The lateral trunk support was pressing into her axillary area limiting her functional movement of her left upper extremity. She had no upper extremity support. Resident #1 was fully oriented and recognized her limitations. She was highly motivated to obtain an appropriate seating system to meet her needs. She needed midline trunk alignment; midline head and neck alignment and she had internal rotation of her hips. She would benefit from a customized power wheelchair that was to her size, since her wheelchair was over [AGE] years old. Appropriate head support, trunk support arm and leg support are needed as well as the ability to tilt to relieve pressure from the coccyx and sacrum. Additional Comments: Resident #1 would have improved functional use of her left upper extremity to better control a power wheelchair if her pelvis, trunk, shoulders and head were better realigned in an ergonomically correct position and supported appropriately. She would have decreased pain throughout her body if her joints had decreased strain on them by using proper support. Review of Psychological Services Progress Notes for Resident #1 reflected the following: 12/20/13-Resident #1 often cries and states she wants to die. She was depressed and anxious. She had average insight and normal judgment. 1/24/14-Working on Resident #1 ' s self-esteem. 2/7/14-Resident #1 was being seen for [MEDICAL CONDITION], Recurrent and Severe. She talked about not wanting to go out of her room. 2/21/14-Resident #1 ' s mood and affect were depressed. We were able to communicate better today. We discussed her feelings of loneliness and her reluctance to go outside of her room. She said she likes to play UNO. Review of the Activity Progress Note dated 5/22/13 reflected Resident #1 was oriented to person, place and time. She had good long term and short term memory. She was able to follow instructions and use good judgment. Her decision making ability was not impaired. Review of Resident #1 ' s Social History dated 5/22/13 reflected she had an 11th grade education. She liked to watch television and play games. Review of Resident #1 ' s Social Service assessment dated [DATE] reflected she gets moved around in a Geri-chair. She agreed that she would like to go to the park, would like to go shopping and start going to bingo. She appears to be oriented to self, place and time. She denied problems remembering things. She was able to communicate non-verbally. One would need to read her lips or go by the clicks of her tongue (one click for " no " and two clicks for " yes. " ) Review of Activities Progress Notes dated 11/12/13 reflected Resident #1 was mobile to bed or Geri-chair at this time (sic). She had outgrown her electric wheelchair. She was alert and oriented to person, place and time, but didn't speak verbally. She communicated yes or no by clicking her tongue and she would also talk so one could read her lips. She seemed to have some depression and didn't seem to be involved in activities much lately. Review of the Recreational Services assessment dated [DATE] reflected Resident #1 currently enjoyed activities such as crafts, animal visits, and children, church services, wheeling outdoors, music, bingo, books, parties, television bible study and movies. She enjoyed in the past, outdoor trips and social hour. She had outgrown her wheelchair and now had to use a Geri-chair or stay in bed. Review of Individualized One-To-One Programming (Activities) dated 9/6/13 reflected Resident #1 wanted to go on a shopping trip to look for goofy socks and get her nails done. She wanted to go to the pumpkin patch in October, a play (sic). Review of the Activity Progress Note dated 2/20/13 reflected Resident #1 was emotional, sad/crying, and depressed. Review of Nurse ' s Notes dated 1/10/14 reflected Resident #1 indicated to the Psychologist that she wanted to die. She indicated that she felt this way due to being " alone all the time. " Review of the Weekly Nursing Summaries for Resident #1 reflected the following: 1/6/14-Uses a wheelchair when out of bed but not often. 1/13/14-Rarely gets up. 2/3/14-Gets up out of bed less than one time a week. Review of the Therapy Screen Form dated 7/25/13 reflected Resident #1's current wheelchair was too small. Her legs just hang off the seat. Review of the Occupational Therapy Discharge Summary dated 1/9/14 reflected Resident #1 was seen for positioning assessment. Short Term Goal: Resident to obtain appropriate seating system to allow joints of body to be in alignment with the least amount of discomfort and supporting the trunk, head, bilateral upper and lower extremities allowing for improved bilateral upper extremity use. Suggestions from the facility OT, facility staff, area manager and Therapists all contributed knowledge/suggestions for equipment and presented to the facility Administrator and clinical staff. Resident #1 was awaiting the facility's decision for a wheelchair. Review of the Quarterly therapy evaluation dated 1/10/14 reflected Resident #1 had difficulty bending and straitening her upper and lower extremities and had fluctuating tone. She had poor positioning in her wheelchair, leaning and complained of pain when in her wheelchair. Her chair is too small non-supportive and non-functional. She had a sore on the back of her head from lying in bed. Recommend a customized wheelchair to allow Resident #1 improved functional use of her left upper extremity for increased quality of life. In an interview on 3/6/14 at 2:29 PM Resident #1 was asked if the facility had spoken to her about getting a new chair. She clicked twice for "yes." When the Surveyor showed Resident #1 a photo of the Broda chair that had been ordered for her and asked if they ever showed her what they ordered, she did not reply and looked away. When asked if a wheelchair especially fitted for her that she could maneuver on her own by using her chin or her left hand would motivate her to get out of bed and out of her room more, she smiled very big and clicked twice for "yes." Review of the facility's CMS 672 reflected 25 residents receiving rehabilitative services.

Based on observation, interview and record review, the facility failed to train all employees in emergency procedures to meet all potential emergencies and disasters for one (1) of one (1) Resident (Resident #9) reviewed for evacuation. The facility failed to develop a policy regarding Resident # 9's special need to safely in order to evacuate to areas of refuge from the building when necessary due to the Resident residing in a bariatric bed. This resulted in an Immediate Jeopardy (IJ) on 07/24/2013. While the IJ was removed prior to exit on 07/26/13, the facility remained out of compliance at a Severity Level of Potential for More Than Minimal Harm with a Scope of isolated that is not IJ. This deficient practice had the potential to delay or prevent the safe, rapid, and efficient evacuation from the facility, for one (1) Resident identified as utilizing the Bariatric bed, in the event of an emergency. Findings include: Review of Resident # 9's Face Sheet reflected a [AGE] year old male who entered the facility on 08/16/210 and readmitted on [DATE]. Resident # 9's [DIAGNOSES REDACTED]. Review of Resident # 9's Plan of Care dated 08/16/2010 reflected the Resident had an ADL deficit due to [MEDICAL CONDITION]. Interventions included Resident to be bathed three (3) times per week, provide incontinent care every two (2) hours and as needed, assist with grooming, hygiene, oral care and dressing. Turn and reposition every two (2) hours and as needed. Monitor throughout the day for other ADL needs. Keep call light within reach. Encourage fluids every two (2) hours during ADL rounds and staff will totally assist Resident # 9 with transfers using the Hoyer lift. Observations during initial tour on 07/23/2013 at 10:45 AM revealed one Resident # 9 was lying supine in a bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals). In an interview on 07/24/2013 at 9:20 AM the Director of Nurses (DON) stated Resident # 9 cannot transfer himself. The DON stated Resident # 9 required the assistance of two (2) staff to transfer using a Hoyer lift. The DON stated Resident # 9 does not get out of bed unless he is going to [MEDICAL TREATMENT]. The DON stated Resident # 9 is placed on a stretcher and transported to [MEDICAL TREATMENT] by the Emergency Medical Technicians. The DON stated the facility did not have a stretcher to ensure safe evacuation of Resident # 9. The DON stated Resident # 9 would not sit in a wheelchair. Observation on 07/24/2013 at 9:30 AM revealed the Maintenance Supervisor (MS) measured Resident # 9's bariatric bed. The bed was 42" (inches) wide. The MS measured the door that exited Resident # 9's room and it measured 41" wide. In an interview on 07/24/2013 at 9:35 AM the MS stated he the bariatric bed would only fit through the door if someone pulled pins out of the sides in six separate places, the sides and the headboard would come off and the bed would go through the door. The MS stated he had trained the housekeeping staff regarding directions to break down bed. The MS stated he did not know if any other staff knew how to do it or not. In an interview on 07/24/2013 at 9:20 AM, Medication Aide (MA) T stated she did not know how to get Resident # 9 out of the building in case of an emergency. MA T stated she had not been trained to evacuate residents in bariatric beds. In an interview on 07/24/2013 at 9:30 AM, Certified Nurse Aide (CNA) V stated she had not been trained by the facility regarding Resident # 9's special need in case of an emergency but she had just finished CNA training and stated she would put the Resident on the floor and drag him out with a sheet. In an interview on 07/24/2013 at 9:40 AM, Licensed Vocational Nurse (LVN) U stated she had not been trained regarding Resident # 9's special need but she guessed facility staff would lower Resident # 9's bed to the lowest position, then lower Resident # 9 to a blanket on the floor by using a sheet. LVN U stated facility staff would drag the Resident out on the blanket. In an interview on 07/24/2013 at 9:45 AM LVN D stated she had not been trained regarding Resident # 9's special need in case of emergency but staff would lift the Resident manually and carry him out the door. In an interview on 07/24/2013 at 9:50 AM LVN E stated she hoped Resident # 9's bed would go out the door then asked the surveyor "do we have any that don't?" In an interview on 07/24/2013 at 10:30 AM the Director of Nurses (DON) stated Resident # 9 had been on Hospice and when he was discharged from Hospice the facility placed him in the bariatric bed. The DON stated this occurred approximately 07/01/2013. The DON stated she knew the bariatric bed would break down but did not know how to do it, nor did she know it would break down with the Resident in it. The DON stated she had not received in-service regarding breaking down Resident # 9's bariatric bed but she had notification from the Corporate Office approximately two weeks ago to measure all bariatric beds in the facility to ensure a safe evacuation. The DON stated she mis-measured the bed, she thought it would fit through the door but it would not. In an interview on 07/24/2013 at 11:30 AM the Administrator stated she did not know the bed would not fit through the door until the survey team pointed it out. The Administrator stated approximately two (2) weeks ago the facility had received notification from the Corporation to measure bariatric beds to ensure safe evacuation. The Administrator stated she had been told the bed would go through the door without any adjustments. The Administrator stated there is no written plan to remove Residents in bariatric beds to safety in case of an emergency. Review of the facility Disaster Plan dated 2003 reflected no plan to remove residents in bariatric beds to a place of safety in case of emergency. On 07/24/2013 at 11:55 AM the Administrator and DON were an IJ had been identified regarding safe evacuations of residents in bariatric beds. The facility provided a Plan of Removal on 07/24/2013 at 12:40 PM. A revised Plan of Removal was accepted on 07/24/2013 at 4:30 PM and reflected the following: Immediate Jeopardy Plan of Removal - 7/24/2013 Specific Problem: Bariatric Bed not going through the door in a disaster evacuation. 1. Resident #9 bariatric Bed will be decreased in size by removing the extended sides, lowering the bed electronically in order to engage wheels in order to evacuate. Extension cord was placed in room so that the bed can be plugged into the red socket outside in hall way in case electricity goes out. Measurable Goal: Resident #9 will be able to be removed from his room without any restrictions in case of emergency evacuation. Achievable Actions: All staff will be in serviced on the proper procedure of removing the extended sides of the bariatric bed, extension cord in room in case of an electricity outage so it can be plugged into the re outlet in the hall, and that the bed has to be in the lowest position before it can be moved on wheels. All beds checked and Resident #9 is the only bed not going through the door. Medical Director was notified of the immediate jeopardy event on 7/23/13, at 1605 hours. In services will be completed on 7/25/13. Disaster plan updated as follows: Residents will be evacuated in the following sequence: 1) Ambulatory Residents 2) Residents in wheelchairs 3) Residents who are bed-bound/bariatric bed Evacuation of bariatric bed: remove the side bars by pulling 2 pins (one at each end) from each bar. There are 3 bars on each side of the bed for a total of 6 bars and 12 pins. Lower the bed so that it can be wheeled out of the room. In case of an electrical power outage, use the extension cord and plug it into the RED socket outside the hall way. The extension cord will be kept in the room with a bariatric bed. Electric cord may be found at the top of the closet. Trackable actions: DON/ADON will ask 3 staff members per day 5 days a week x 4 weeks how the bed is decreased in size, shat the extension cord is for, and what position the bed has to be in before it can be moved. Finding will be discussed in the monthly QA meeting for 3 months and if needed changes will be made to the plan. The survey team monitored the Plan of Removal as follows: Observation on 07/24/2013 at 12:45 PM revealed the MS training staff to ensure safe breakdown of Resident # 9's bariatric bed in order for safe evacuation. Staff made return demonstrations. Six (6) staff members were interviewed who all had been trained and knew steps to evacuate a bariatric bed from the facility. Review of In-Service regarding breakdown of the bariatric bed dated 07/24/2013 reflected approximately 70% of staff had been trained. Review of the facility Disaster Plan addendum dated 07/24/2013 to the Fire Evacuation reflected "Evacuation of bariatric bed: remove the side bars by pulling two (2) pins (one at each end) from each bar. There are three (3) bars on each side of the bed for a total of 6 bars and 12 pins. Lower the bed so that it can be wheeled out of the room. In case of an electrical power outage, use the extension cord and plug it into the RED socket outside the hall way. The extension cord will be kept in the room with a bariatric bed. It may be found at the top of the closet. On 07/24/2013 at 6:20 PM the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm with a scope as isolated due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list of one (1) resident who required use of a bariatric bed.