Every finding on record at Hacienda Oaks at Beeville

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #2 and Resident #41) of 8 residents reviewed for care plans. 1. The facility failed to ensure Resident #2's comprehensive care plan reflected the use of a soft touch call light. 2. The facility failed to ensure Resident #41's comprehensive care plan reflected what his PTSD triggers were. This failure could place residents at risk of not receiving individualized care and services to attain or maintain the residents' highest practicable physical, mental, and psychosocial wellbeing. 1. Record review of Resident #2's face sheet, dated 06/29/26, reflected an [AGE] year-old female, admitted on [DATE], diagnoses included: hemiplegia/hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke) affecting right dominant side, unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs), congestive heart failure (long-term condition that affects the heart's ability to pump blood), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), and anxiety disorder (uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident #2's quarterly MDS assessment, dated 04/16/26, reflected a BIMS score of 15, which indicated intact cognition. The MDS reflected Resident #2 had impairment on both upper extremities and one lower extremity. Record review of Resident #2's care plan, dated 07/01/26, reflected [Resident #2] had impaired physical functioning related to hemiplegia/hemiparesis. Date initiated: 09/16/25. Interventions included: needs two staff for transfers, incontinent care, and repositioning. Resident #2's care plan did not reflect the soft touch call light. 2. Record review of Resident #41's admission record on 06/29/26 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus with hyperglycemia (chronic condition that happens when blood sugar levels are persistently high), hyperlipidemia (high cholesterol), essential (primary) hypertension (high blood pressure), alcoholic cirrhosis of liver (liver damage caused by drinking alcohol), vascular dementia, mild, with mood disturbance (problems with thought processes and memory caused by brain damage from impaired blood flow), non-compliance with medical treatment and regimen due to unspecified reason (when someone intentionally does not take their medication or follow their doctor's recommendations), and Post Traumatic Stress Disorder, unspecified (a psychiatric condition that occurs in people who have experienced or witnessed a traumatic event or series of traumatic events). Record review of Resident #41's quarterly MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated moderate cognitive impairment. This MDS assessment also reflected an active diagnosis of PTSD. Record review of Resident #41's care plan dated 08/18/25 reflected the focus at risk for behaviors associated with PTSD initiated 04/22/26. The goal was Resident #41 would feel more peaceful and at ease with improved quality of life through the next review date, initiated on 04/22/26 with review date 08/17/26. The interventions were, create a calm and safe environment, reduce stimuli that may increase anxiety, encourage to express feelings and concerns, and identify specific triggers or situations that exacerbate anxiety, initiated on 04/22/26. Record review of Resident #41's psychosocial assessment dated [DATE] reflected in the social isolation section, question 8: Summary of sections above (assessment of mood, affect, and psychosocial well-being): Resident does not like to be bothered and does not like to talk about his past. He prefers to be left alone. Question 9 asked if the care plan was updated to reflect psychosocial well-being and mood components and was answered, yes. Record review of Resident #41's social service history and initial assessment dated [DATE] reflected Resident #41 was a truck driver and a veteran. The significant life experiences section reflected Resident #41 was married for many years, experienced a lot in life in the army as a truck driver. [FM] says he feels like [Resident #41] had a good life. Record review of Resident #41's trauma informed care assessment dated [DATE] reflected in section A- PTSD screen, the interviewer read the following statement to Resident #41, Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide, then asked if he had ever experienced this kind of event. Resident #41 answered, yes. Resident #41 denied he had nightmares about the event(s) or thought about the event(s) when he did not want to, tried hard not to think about the event(s) or went out of his way to avoid situations that reminded him of the event(s), had been constantly on guard, watchful, or easily startled, felt numb or detached from people, activities, or his surroundings, or felt guilty or unable to stop blaming himself or others for the event(s) or any problems the event(s) may have cause. In an interview on 07/01/26 at 10:00 am, Resident #41 asked what PTSD was then stated there was not anything anyone did that made him mad or anxious. In an interview on 07/01/26 at 11:30 am, the SSA stated on the trauma informed assessment on 05/11/26, Resident #41 answered yes he had been through something traumatic, but it did not bother him and he did not want to go into specifics. She stated as per nursing staff, Resident #41 had no symptoms, he was sleeping well and not requesting his melatonin, and he was not complaining of any issues. The SSA stated he never divulged if he had any triggers, but she felt trying to push him for information may trigger him because FM said Resident #41 liked to keep personal things private. She stated some of the interventions on Resident #41's care plan included create a calm and safe environment and encourage him to express triggers and concerns. The SSA stated she needed to update his care plan because asking him to express triggers and concerns could trigger him. She stated it was important to have updated care plans so facility staff continued to provide the best care for residents. She stated as things changed, they updated the care plan so staff were aware of the changes. She stated if something was not care planned appropriately or updated new staff or night staff who did not know the resident and what triggered them may unintentionally trigger the resident and cause a behavior that could have been avoided. The SSA stated the negative effect of triggering a behavior that could have been avoided could alter the resident's state of mind or feelings of depression and/or the resident could feel like they did something wrong when it was actually triggered by the facility. In an interview on 07/01/26 at 12:13 pm, the DON stated the way they knew what were triggers for residents with PTSD was through the resident assessment. The DON stated Resident #41 was uncooperative with the assessments and usually just answered no to all the questions or did not answer at all. She stated information about triggers were supposed to be on the care plan but his were not because he did not tell anyone what his triggers were. In an interview on 07/01/26 at 1:23 pm, RN A stated Resident #41 had divulged to her that he was involved in Vietnam and exposed to agent orange and that was why his fingers were discolored. RN A stated Resident #41 did not divulge any other information. She stated she was not aware of any triggers he had. RN A stated she had never seen him strike out at anyone and he was very quiet. She said she was not really familiar with the Resident #41's care plan and had never been informed of any triggers for him. She stated a negative effect of not knowing a resident's triggers for PTSD was there could be behavior issues with the resident. She said if something appeared to trigger a resident, she would just ensure the resident was calm and safe and would talk to him. In an interview on 07/01/26 at 2:05 pm, CNA B stated she was aware Resident #41 had PTSD. She stated he did get agitated at times. In regard to his triggers, she stated it just depended on his mood on any given day. CNA B stated one day something would get him upset and the next day the same thing would not upset him. She stated when she talked to Resident #41 and he did not answer her, she would just leave him alone and return later. She stated as far as she knew she had not figured out his triggers and he had not divulged any. CNA B stated no one had informed her he had any triggers. CNA B stated a negative effect of not care planning or informing staff of triggers for a resident could cause the resident to lash out at staff and place them in a predicament and for the resident it could bring him down or make him not motivated or not his normal self. In an interview on 07/01/26 at 2:15 pm, CNA C stated she had heard that Resident #41 had PTSD, but she had never seen or heard that he had shown any signs or symptoms. She stated no one had told her he had triggers and it was not in his care plan. CNA C stated she had never seen him have any issues while working down his hall. She stated a negative effect of not care planning or informing staff of triggers a resident may have could cause the resident to get angry or mad and take it out on staff or it could even cause him to have a fall. In an interview and observation, on 07/01/26 at 2:25 pm, Resident #2 stated she was fine. Resident #2 was asked basic questions but she did not respond. Resident #2 was observed with no visible injury. Resident #2 had a soft touch call light within reach. In an interview, on 07/01/26 at 2:50 pm, the ADON stated Resident #2 had a soft touch call light but she was not sure since when. The ADON stated she did not know how much Resident #2 used the call light because she did not move around much but the staff checked on her frequently. The ADON stated the MDS Nurse developed and updated the care plans. In an interview, on 07/01/26 at 3:00 pm, the MDS Nurse stated she developed and updated care plans but it was also a team effort. The MDS Nurse stated Resident #2 had a soft touch call light and that should have been added to her care plan as an intervention. The MDS Nurse stated there was no negative outcome for Resident #2 as staff checked on her frequently. The MDS Nurse stated it was important for the care plan to be developed with accurate information to ensure all staff were aware of how to care for the resident. In an interview on 07/01/26 at 3:11 pm, the MDS nurse stated until today (07/01/26) there were no triggers listed anywhere in Resident #41's chart. She stated she checked his trauma assessments, previous social services notes, progress notes, previous MDS assessments, and other assessments and was not able to find any triggers noted. The MDS nurse stated as of today, his triggers were documented as, asking too many questions aggravated him which was documented by the SSA. She stated care plan updates were a team effort upon new information being known. She stated she also updated care plans when she did her MDS assessments. The MDS nurse stated it was important to update care plans so everyone was aware of the resident's wishes and how to take care of them. She stated if care plans were not updated, the staff would not be aware of the resident's preferences. The MDS nurse stated she had monthly MDS calls with their corporate MDS personnel. She stated she completed the MDS assessments and the regional RN looked over and signed them. The MDS stated Resident #41 had not had any negative outcomes from his triggers not being care planned. In an interview, on 06/27/26 at 3:30 pm, the DON stated care plans were developed and updated by the team, including the MDS Nurse, the ADON, herself. The DON stated Resident #2 had a soft touch call light which should have been included in her care plan. The DON stated there was no negative outcome or risk of injury for Resident #2 as staff checked on her frequently and Resident #2 was vocal to make her needs known. The DON stated it was important for the care plan to be accurate to ensure everyone was aware of the resident's needs and how to care for her. Record review of the facility's Comprehensive Care Plans policy, dated 06/01/25 and revised 06/02/25, reflected in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Definitions: Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. Professional standards of quality'' means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. ''Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated. 3. The comprehensive care plan will describe, at a minimum, the following: g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific.: interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

Based on observations, interview, and record reviews, the facility failed to provide the required 80 square feet per resident in 48 of 48 resident rooms (1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-27-28-29-30-31-33-34-35-36-37-38-39-41-42-43-44-45-46-48-49-50-51 and 52) in that: The facility failed to provide the required 80 square feet per resident for all 48 rooms. This failure could restrict the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms and limit the residents' ability to move about the room. The findings included: Record review of Health and Human Services Form 3740 Bed Classifications, dated 06/29/26, revealed 44 rooms with 2 beds, and 4 rooms (23, 24, 51, 52) with 3 beds. During an investigation beginning at 11:30 am on 06/29/26 during the facility's survey, an agency laser measuring device was used to obtain measurements for all existing rooms. Rooms with 2 beds measured between 151 and 160 square feet. Rooms with 3 beds measured between 219 and 234 square feet. None of the rooms measured provided the required square feet per resident. During interview and record review on 06/29/26 at 3:00 pm, the ADM provided a letter requesting a room size waiver for rooms 1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-26-27-28-29-30-31-32-33-34-35-36-37-38-39-40-41-42-43-44-45-46-47-48-49-50-51 and 52. The ADM stated there had been no changes to the rooms.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident #1) reviewed for medication errors. The facility failed to hold Resident #1's valsartan (blood pressure medication) when Resident #1's blood pressure was outside of physician's parameters on May 8th, 2026. This failure could place residents at risk for complications such as low blood pressure, exacerbation of symptoms, and potential hospitalization.The findings include:Record review of Resident #1's face sheet dated 05/19/26 revealed a [AGE] year-old male with an admission date of 05/04/26. Resident #1's pertinent diagnosis included essential primary hypertension (chronically elevated blood pressure that lacks a single, identifiable medical cause). Record review of Resident #1's comprehensive MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #1's comprehensive care plan dated 05/19/26 revealed the focus Potential for altered tissue perfusion r/t HTN initiated on 05/14/26. An intervention listed for the focus included Administer medications as ordered by physician initiated on 05/14/26. Record review of Resident #1's order summary on 05/19/26 revealed an active order for valsartan 40 MG Give 1 tablet by mouth in the morning for htn hold for sbp (top number) less than 110 initiated on 05/05/26. Record review of Resident #1's MAR for May 2026 revealed valsartan was administered by LVN A in the morning of 05/08/26 when Resident #1's blood pressure was measured at 105/59. In an interview with LVN A at 8:40 AM on 05/19/26, LVN A stated she always checked a resident's blood pressure before administering any blood pressure altering medication. LVN A stated she always measured it because blood pressure medications had physician parameters on them, and administering a medication outside of those parameters may harm the resident. LVN A stated she did not remember the specific instance of administering valsartan to Resident #1 on 05/08/26. LVN A stated it appeared on the MAR that she administered valsartan to Resident #1 on 05/08/26 outside of the physician's parameters. LVN A stated administering blood pressure medications to residents when their blood pressure was already low may lead to dizziness and cause the resident to fall. In an interview with the DON at 8:50 AM on 05/19/26, the DON stated based on the MAR, it appeared LVN A administered valsartan to Resident #1 on 05/08/26 outside of the physician's parameters. The DON stated the valsartan should not have been administered to Resident #1 at that time. The DON stated it was important to follow physician's parameters because dropping a resident's blood pressure too far could lead to dizziness and ultimately a fall. Record review of the facility's policy Medication Administration dated 05/09/25 revealed the following policy: .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on interview and record review, the facility failed to ensure a baseline care plan, which included the instructions for resident care needed to provide effective and person-centered care, was completed for 1 of 5 residents (Resident #1) reviewed for baseline care plans. The facility did not complete the baseline care plan within 48 hours of admission to include the minimum healthcare information necessary to properly care for Resident #1. This failure could place residents at risk of not receiving person-centered care and/or services to meet their physical and/or psychosocial needs.Findings included: Record review of Resident #1's face sheet, dated [DATE], revealed she was a [AGE] year-old female admitted on [DATE] and discharged on [DATE]. Pertinent diagnoses included Hemiplegia (paralysis affecting only one side of the body) and Hemiparesis (one sided muscle weakness) following Cerebral Infarction (the most common form of stroke) Affecting Left Non-Dominant Side, Chronic Viral Hepatitis C (liver disease caused by a viral infection), Type 2 Diabetes (a chronic condition which affects the way your body processes blood sugar), and Dysphagia (difficulty swallowing). Resident #1's face sheet also revealed Hospice Respite as the primary payer source. Record review of Resident #1's physician orders, dated [DATE], revealed an order for Do Not Resuscitate. Record review of Resident #1's baseline care plan, initiated [DATE], revealed there was no care plan for hospice or DNR code status. Record review of Resident #1's MDS discharge assessment dated [DATE] revealed no BIMS score, as Resident #1 was rarely or never understood. The MDS also revealed Resident #1 was admitted from home hospice, as well as discharged to home hospice, and Resident #1 received hospice care while in the facility. In an interview on [DATE] at 11:35 AM, the ADON stated both hospice and DNR status should have been listed in Resident #1's care plan, and usually the SS nurse or MDS coordinator added this information to the care plan. The ADON also stated Resident #1 was only there for 5 days, so she would not have had a comprehensive care plan, but the information still should have been entered into the baseline care plan since Resident #1 was here for hospice respite care (short term care which gives caregivers a break from caring for a terminally ill loved one). She stated the code status was important to have on the care plan, so staff knew whether or not to perform CPR on a resident. In an interview on [DATE] at 1:24 PM, the DON stated she thought the hospice and DNR status on the care plan for Resident #1 may have been overlooked since she was only here for a 5-day respite stay. She stated Resident #1 continued to get hospice care while in the facility. The DON also stated it looked like someone just forgot to add hospice to Resident #1's orders, which may have contributed to hospice getting missed on the care plan, but DNR should not have been missed, and should have been added to Resident #1's care plan. The DON stated when there was a hospice respite admission, a coordination of care meeting was done at this time with the hospice case worker and the family, and the baseline care plan was completed based on this, and the MDS coordinator and SS nurse were ultimately responsible for this, but the previous MDS nurse was no longer here. The DON stated if the care plans were not updated with accurate or appropriate information, residents may not get the care they need. In an interview on [DATE] at 2:36 PM, the SS nurse stated she visited new admission residents and performed their BIMS and psychosocial assessments, and she typically inputted the code status and hospice status into the care plan, but then it was typically checked by either the MDS nurse, the DON, or the ADON. She stated she was not sure how or why both hospice and DNR status were overlooked on Resident #1's care plan. The SS nurse stated the care plan was used to tell a story about the resident and guide the resident's care. The care plan helped staff familiarize themselves with the resident and what type of care to the resident needed. She also stated without the code and/or hospice status the resident could have been revived when they were not supposed to be, or not received CPR when they were supposed to. Either way, it could have brought harm to the resident. In an interview on [DATE] at 8:41 AM, the MDS coordinator stated she was initially responsible for inputting hospice and code status, and once the care plan information was entered into the care plan, it was typically checked by the DON or the ADON. She stated both hospice and code status should have been care planned into Resident #1's care plan, and these were important things to have in the care plan so staff were aware of the type of care a resident would have needed and whether a resident should or should not have CPR. Record review of the facility's Baseline Care Plan policy, implemented [DATE] and revised [DATE], revealed The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.

Based on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for care plans. The facility failed to add the diagnosis, or anything related to the diagnosis, of Dementia to Resident #3's care plan. This failure could place residents at risk for receiving inadequate care and services.Findings included: Record review of Resident #3's face sheet dated 09/17/2025 revealed an [AGE] year-old female with an admission date of 10/11/2017 and a re-admission date of 08/27/2025. Pertinent diagnoses included Hemiplegia (paralysis affecting only one side of the body) and Hemiparesis (one sided muscle weakness) following Cerebral Infarction (the most common form of stroke) Affecting Right Dominant Side and Unspecified Dementia (a group of thinking and social symptoms which interfere with daily functioning). Record review of Resident #3's diagnoses dated 08/27/2025 revealed Unspecified Dementia was listed as a secondary admission diagnosis. Record review of Resident #3's admission MDS assessment dated [DATE] revealed a BIMS score of 00, severely impaired cognition. The MDS also revealed Resident #3 had an active diagnosis of Non-Alzheimer's Dementia. The Care Area Assessment portion of the MDS revealed Resident #3 triggered for Cognitive Loss/Dementia, and for each triggered care area, either a new care plan, a revised care plan, or a continuation of a current care plan was necessary to address the problems identified. Record review of Resident #3's care plan initiated 08/28/2025 revealed no care plan focus for Dementia. In an interview on 09/16/2025 at 11:35 AM, the ADON stated usually the MDS coordinator added residents' clinical information to the care plan. The ADON also stated Resident #3 had a diagnosis of Dementia, so it should have been added to Resident #3's care plan, and if the care plans were not up to date, residents may not receive adequate care. In an interview on 09/17/2025 at 8:41 AM, the MDS coordinator stated she was responsible performing the MDS and Care Area assessments and adding those triggers to residents' care plans. She also stated the ADON, and the DON were responsible for reviewing and revising the clinical portions of the residents' care plans. She stated Resident #3 had a diagnosis of Dementia, and it triggered on the Care Area Assessment, so it should have been added to Resident #3's care plan so as to provide the resident with the appropriate needed care. In an interview on 09/17/2025 at 10:44 AM, the DON stated the MDS coordinator was initially responsible for the clinical aspect of the care plans, but either herself or the ADON would be the one to look back and review the care plan was completed accurately. Then, the IDT reviewed and revised them quarterly and with changes in condition. The DON stated the clinical staff, to include herself, the ADON, and the MDS nurse, were ultimately responsible for reviewing and revising the clinical care plans. The DON also stated Resident #3's diagnosis of Dementia should have been care planned, and if the care plans were not updated with accurate or appropriate information, residents may not get the care they need. Record review of the facility's Comprehensive Care Plans policy, implemented 06/01/2025 and revised 06/02/2025, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas triggered by the MDS will be considered in developing the plan of care.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 5 residents (Resident #2) whose care plans were reviewed for timing and revision. The facility failed to ensure Resident #2's care plan was revised to accurately reflect current blood pressure medication status. This deficient practice could place residents at risk of receiving inadequate, individualized care and services. Findings included: Record review of Resident #2's face sheet dated 09/17/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Pertinent diagnoses included Unspecified Dementia (a group of thinking and social symptoms which interfere with daily functioning) and Hypertensive Chronic Kidney Disease (a progressive condition in which high blood pressure causes damage to the kidneys). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 02, severely impaired cognition. The MDS assessment also revealed Resident #2 had Hypertension, as well as Renal Insufficiency, Renal Failure, or End-Stage Renal Disease. Record review of Resident #2's comprehensive care plan, initiated 01/17/2024 and revised 07/18/2024, revealed a care plan for potential for complications related to blood pressure medication use. Record review of Resident #2's current active physician orders revealed no order for blood pressure medications. Record review of Resident #2's inactive physician orders which were discontinued 10/03/2024 revealed an order for Lisinopril (a medication used to treat high blood pressure) 10 MG daily for elevated blood pressure. In an interview on 09/16/2025 at 11:35 AM, the ADON stated the IDT reviewed and discussed the care plans at the quarterly care plan meetings and with changes in condition, but usually the MDS coordinator, herself or the DON added or revised the clinical aspect of information in the care plan. The ADON stated she was not sure why this was never removed from the care plan because Resident #2 was no longer on blood pressure medications. In an interview on 09/17/2025 at 8:41 AM, the MDS nurse stated in conjunction with the ADON and the DON, she was responsible for reviewing and revising the clinical portions of the residents' care plans. She stated she had not worked here long and had been trying to review and revise the care plans, but maybe this one got missed. She was not sure why blood pressure medication was still care planned for Resident #2 when Resident #2 was no longer on blood pressure medication. She stated the care plans needed to have up to date and accurate information in them so as to provide staff with a resource on how to care for the residents. In an interview on 09/17/2025 at 10:44 AM, the DON stated the MDS coordinator was initially responsible for the clinical aspect portion of the care plans, but either herself or the ADON would be the one to look back and review the care plan was completed accurately. Then, the IDT reviewed and revised them quarterly and with changes in condition. The DON stated the clinical staff, to include herself, the ADON, and the MDS nurse, were ultimately responsible for reviewing and revising the clinical care plans. The DON also stated Resident #2's blood pressure medication should have been removed a long time ago, and she was not sure why it was never removed because Resident #2 had not been on blood pressure medication for a long time, and if the care plans were not updated with accurate or appropriate information, residents may not get the care they need. Record review of the facility's Comprehensive Care Plans policy, implemented 06/01/2025 and revised 06/02/2025, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive quarterly MDS assessment.

Based on observation, interview and record review, the facility failed to ensure the resident's right to privacy for 1 (Resident #22) of 8 residents reviewed for privacy and dignity. The facility failed to ensure LVN-A provided privacy to Resident #22 while administering his medications in the middle of the dining room without permission. This failure could cause residents to feel uncomfortable, disrespected, and possibly a loss of dignity due to a lack of privacy. Findings included: Record review of Resident #22's face sheet dated 05/19/2025 revealed an [AGE] year-old male with an admission date of 08/06/2024. Pertinent diagnoses included Parkinsonism (a progressive neurological condition which affects movement and characterized by both motor and non-motor symptoms), Dysphagia (difficulty swallowing), Cognitive Communication Deficit (difficulties in communication which arise from impairment in cognitive processes such as attention, memory, perception, and executive function), Bipolar (mental health condition characterized by extreme mood swings which include emotional highs and lows) and Dementia (group of symptoms affecting memory, thinking, and social abilities). Record review of Resident #22's Quarterly MDS assessment 02/12/2025 revealed a BIMS score of 08, moderately impaired cognition. Record review of Resident #22's physician orders started 01/24/2025 revealed Depakote Sprinkles (Divalproex Sodium used to treat seizures, bipolar and migraines); Carbidopa - Levodopa (primarily used to manage the symptoms of Parkinson's Disease) started 08/06/2024; Tylenol Extra Strength started 11/14/2024. During an observation on 05/19/2025 at 8:00 AM revealed LVN-A crushed Resident #22's medication, mixed it with pudding, then walked from Hall A to the middle of the dining room and spoon fed Resident #22's medication to him in a dining room filled with other residents. In an interview with LVN-A on 05/19/2025 at 8:15 AM, he stated he was nervous and could not remember if it was okay or not to give Resident #22's medication in the dining room. He stated he should have asked Resident #22 if he would like to have gone back to his room to take his medication or if he would like to have taken it in the dining room. LVN-A stated he could have caused Resident #22 to experience embarrassment or loss of dignity due to administering his medication in front of other residents without his permission. In an interview with LVN-C on 05/19/2025 at 9:22 AM she stated nurses sometimes got complacent to administering medication wherever the resident was during that given moment, but nurses should not be administering medications in public places such as hallways or dining rooms unless the residents gave permission to do so because it could cause the resident to become embarrassed. In an interview with the DON on 05/19/2025 at 5:27 PM she stated LVN-A should not have administered Resident #22's medication without asking for permission first. She stated this could have caused the resident to experience embarrassment, loss of dignity, or feel uncomfortable. Record review of in-service dated 05/19/2025 revealed staff were in-serviced when doing finger sticks, insulin, and any medication pass, residents must be taken to their room and provided privacy at all times. Record review of in-service dated 05/19/2025 revealed staff were in-serviced to never interrupt meal services to administer medications. Record review the facility's Medication Administration Policy (no implementation or revision date), revealed Policy Explanation and Compliance Guidelines: 7. Provide Privacy.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, transportation of linens designed, to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 linen carts and one (Resident #12) of 8 residents reviewed for infection control practices, in that: 1. The facility failed to ensure LA D covered the linen cart on Hall A. 2. The facility failed to ensure LVN C washed/sanitized hands between glove changes while performing wound care on Resident #12. 3. The facility failed to ensure Resident #12's wound did not come in contact with a contaminated, soiled surface. These failures could place residents that require wound care at risk for cross-contamination and infections. The findings include: 1. During an observation on 05/19/25 at 05:55 PM LA D was observed passing out clean laundry in Hall A with laundry cart uncovered. In an interview on 05/19/25 05:57 PM, LA D stated when he walked into the facility with the laundry cart, the cart was covered but he uncovered it when he was passing out clothes to the residents. LA D was unaware the laundry cart was to be covered at all times. In an interview on 05/20/25 at 08:33 AM, the DON stated the laundry cart was supposed to be covered. The DON stated it must be covered to prevent cross contamination and other residents having access to the clothing. The DON stated she was going to start an in-service on infection control and laundry transportation services. In an interview on 05/20/25 at 09:26 AM, the Laundry Supervisor stated she was not aware the linen cart was supposed to be covered at all times while being transported. The Laundry Supervisor stated the linen cart was covered while transporting into the building then uncovered when clothes are being passed out. The Laundry Supervisor stated the linen cart should be covered at all times to prevent cross-contamination. 2. Record review of Resident #12's face sheet dated 05/20/25 reflected a [AGE] year-old-female with an original admission date of 07/25/23. Diagnoses included pressure ulcer (open wound on the skin caused by long periods of constant pressure) of the sacral region (base of the spine supporting the pelvis), stage 4 (severe pressure ulcer that extends below the subcutaneous fat into deep tissue), severe chronic kidney disease, and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Record review of Resident #12's physician orders dated 5/10/25 reflected: Wound care to stage 4 pressure ulcer at the sacrum 3 times a week and as needed until resolved. Cleanse/irrigate wound with normal saline and Vashe (wound cleanser). Pat dry with gauze. Apply collagen alginate (stimulates new tissue growth) to undermining (erosion that occurs beneath the edges of a wound, leading to a larger wound are with a smaller visible opening) and (cut to fit) Hydrofera blue (antibacterial wound dressing) to wound bed and cover with bordered dressing. Wound care every Tuesday, Thursday, and Saturday. During an observation of wound care 05/20/25 at 10:04 AM LVN C did not wash or sanitize hands after removing gloves and before placing new gloves on. The ADON and LVN C stopped wound care to get supplies, after providing wound care on Resident #12 and rolled Resident #12 on her back, leaving the wound uncovered on her visibly soiled brief. The ADON and LVN C redid Resident #12's wound care. In an interview on 05/20/25 at 11:17 AM LVN C stated she was nervous, and she should have washed or sanitized hands prior to placing new gloves on to prevent the spread of infection. LVN C stated Resident #12's wound should not have come in contact with her soiled brief. LVN C stated Resident #12's wound could get worse or become infected. LVN C stated the last infection control in-service was about a week ago but could not remember the date. LVN C stated her last hands-on skills check off was about a few weeks ago. In an interview on 05/20/25 11:18 AM, the ADON stated LVN C and all staff should wash or sanitize hands after removing gloves to prevent the spread of bacteria and infection. The ADON stated Resident #12's wound should have been covered and not have come in contact with her soiled brief due to contamination to wound and Resident #12's wound could get infected or become septic. The ADON stated a wound care specialist has come to the facility and provided hands on wound care training to nurses. In an interview on 05/20/25 11:32 AM, the DON stated LVN C should have washed or sanitized hands after removing gloves to prevent cross contamination. The DON stated Residents #12's wound should not have come in contact with her soiled brief because the wound could be introduced to bacteria and could get infected or septic. The DON stated she was going to conduct an in-service on infection control and wound care immediately. Record review of the facility's Infection Prevention and Control Program not dated reflected: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. Record review of facility's Hand Hygiene policy not dated reflected: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the facility's Wound Treatment Management not dated reflected: Policy: To promote wound healing of various wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.

Based on observations, interview, and record reviews, the facility failed to provide the required 80 square feet per resident in 48 of 48 resident rooms (1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-27-28-29-30-31-33-34-35-36-37-38-39-41-42-43-44-45-46-48-49-50-51 and 52) in that: All 48 rooms did not account for 80 square feet per resident. This failure could restrict the amount of resident care equipment and resident ' s personal effects that could be accommodated in these resident rooms and limit the residents ' ability to move about the room. Findings were: Review of Health and Human Services Form 3740 Bed Classifications, dated 05/18/25, revealed 44 rooms with 2 beds, and 4 rooms (23, 24, 51, 52) with 3 beds. Beginning at 9:30 am on 05/18/25 during the facility ' s survey, this surveyor, using an agency laser measuring device, obtained measurements for all existing rooms. Rooms with 2 beds measured between 149 and 156.5 square feet. Rooms with 3 beds measured between 220.1 and 220.9 square feet. None of the rooms measured provided the required square feet per resident. On 05/18/25 at 10:50 am, the ADM provided a letter requesting a room size waiver for rooms 1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-26-27-28-29-30-31-32-33-34-35-36-37-38-39-40-41-42-43-44-45-46-47-48-49-50-51 and 52. The ADM stated there had been no changes to the rooms.

Based on observation, interview, and record review the facility failed to care for each resident in a manner that promotes maintenance and enhancement of their quality of life for two (Resident #1 and Resident #2) of 4 residents reviewed for privacy and dignity. The facility failed to ensure Resident #1 and Resident #2's urinary catheter bags were covered. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings were: Record review of Resident #1's face sheet dated November 15, 2024, revealed Resident #1 admitted on [DATE] for Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), pressure ulcer of sacral region (lower back/upper buttocks area), major depressive disorder, and neuromuscular dysfunction of bladder (bladder muscles and nerves are not functioning properly due to damage to the nervous system). Care plan, undated, indicated Resident #1 has altered urinary elimination secondary to catheter with an intervention of a privacy cover in place. Care plan also indicated foley catheter care every shift. Record review of Resident #1's MDS assessment dated [DATE] revealed resident has a BIMS score of 08 (moderate cognitive impairment). Section H of MDS indicated Resident #1 has an indwelling catheter and is always incontinent of bladder. During an observation on November 14, 2024, at 1:00 p.m., Resident #1 was sitting in the dining room in his wheelchair with his catheter bag uncovered at the resident's side. During an interview with Resident #1 on November 14, 2024, at 1:00 p.m., Resident #1 stated he was unaware that the catheter bag needed a cover and does not know when it had a cover. Resident #1 does not need the catheter bag to have a cover and it does not bother him. Record review of Resident #2's face sheet dated November 14, 2024, revealed Resident #2 admitted on [DATE] for pressure ulcer of sacral region, severe protein-calorie malnutrition, chronic kidney disease, vascular dementia (a type of dementia that occurs when the brain doesn't receive enough blood flow, which can damage brain tissue and impair cognitive function), and neuromuscular dysfunction of bladder. Resident #2's care plan indicated to change catheter every 60 days and as needed, catheter care every shift, and utilize catheter bag cover. Record review of Resident #2's MDS assessment dated [DATE], revealed resident has a BIMS score of 12 indicating resident has moderate cognitive impairment. Section H of MDS indicated Resident #2 has indwelling catheter and is always incontinent of bladder. During an observation on November 14, 2024, at 1:15 p.m., Resident #2 had an uncovered catheter bag while lying in her bed in her room eating her lunch. During an interview with Resident #2 on November 14, 2024, at 1:15p.m., the resident stated her bag normally has a cover and does not know why her bag is uncovered at this time. During an interview on November 14, 2024, at 1:20 p.m. the ADON stated the catheter bag on Residents #1 and #2 are usually covered because the only supply of bags in the facility have covers, however if Hospice changed the catheters and/or catheter bags then they may have used their own bags. During an interview on November 18, 2024, at 3:54 p.m., the DON stated Resident #1 and #2's catheter bags were not covered due to hospice changing the bags. The DON stated she will ensure the urinary bags will be covered in the future and Hospice will be using the facility supply of catheter bags with covers. The DON also stated she will be in-servicing Hospice and all in-house nurses about Hospice using the facility supplies of catheter bags with covers. DON stated it is expected that all catheter bags are covered as this is the facility's policy and it is to ensure residents dignity and rights are protected. During an interview on November 18, 2024, at 4 p.m., the Administrator stated it is expected for all residents with catheters to have urinary covers for the catheter bags. The Administrator stated it is also policy for catheters to have covers on the bags. Record review of Catheter care, urinary policy revision dated August 2024 indicated the care and application of a catheter but does not include information about a covering. Record review of Resident rights policy revised December 2016 revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: A. A dignified existence, B. Be treated with respect, kindness, and dignity, and .T. privacy and confidentiality.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 2 of 2 resident refrigerators reviewed for sanitation. 1.The facility failed to implement an approved cleaning schedule. 2.The facility failed to ensure equipment was clean and sanitized. 3.The facility failed to ensure food thermometers were calibrated prior to use. 4.The facility failed to ensure holding food was at the correct temperature for service. 5.The facility failed to ensure thermometers were wiped clean between foods. 6.The facility failed to ensure items in the unit refrigerators were not expired. 7.The facility failed to ensure items in the unit refrigerators were labeled and dated. 8.The facility failed to ensure personal items were not in the unit refrigerators. 9. The facility failed to ensure the unit refrigerators were clean. 10. The facility failed to ensure the kitchen was following their policies. These failures could place residents at risk of foodborne illnesses. Findings included: Initial tour of the kitchen beginning on [DATE] at 11:25 PM revealed a generic cleaning schedule that had no specific assignments or any spaces for initials. There were 3 large spatulas that had small pieces and larger chunks of them missing. The spatulas were in use. The cook did not calibrate the thermometer prior to temping food for lunch service. The cook did not wipe the thermometer clean in between pureed green beans and mashed potatoes. The COOK wiped the prep table multiple times with a rag that left heavy food residue on the prep table. Observation of temperature monitoring of prepped food for lunch service on [DATE] beginning at 11:45 AM revealed pureed green beans at 120 F, mashed potatoes at 120 F. The COOK did not state the foods needed to be be re-heated, nor attempt to re-warm the pureed green beans or the mashed potatoes. In an nterview with the COOK on [DATE] at 11:45 AM he stated, Pieces of the spatulas could break off into the food and kill someone or hurt them. The COOK stated he was using the spatulas because they were the only ones the facility had. The COOK stated he did not mention the spatulas to anyone. The COOK stated he did not calibrate the thermometer because he just didn't. The COOK stated he was not sure who was responsible for keeping equipment sanitary and safe. The COOK stated he had only been at this facility for a week. The COOK stated he should have rinsed his rag more often. The COOK said nothing when asked if using a soiled rag on the prep table was sanitary. The COOK stated the pureed green beans and mashed potatoes were not at temp. The COOK stated food residue from his rag and not sanitizing the thermometer between foods could cause cross contamination and make residents sick. The COOK stated food on the holding table needed to be at least 135 F to prevent bacteria from forming because if the residents ate the food, it could make them sick. In an interview with the DA on [DATE] at 12:00 PM he stated there was no sign-off cleaning log, they just cleaned one thing one day and so on. The DA stated he did not know who was responsible for making sure the kitchen was in sanitary condition. The DA stated he had not been trained regarding proper sanitization, and he guessed if something was left dirty, it could make the residents sick. Interview with the DDM on [DATE] at 9:00 am stated the COOK had only been employeed here for a few days and did not know the kitchen procedures that well. The DDM stated the COOK should have replaced the spatulas. The DDM stated she would obtain a proper cleaning schedule for the kitchen staff to follow. The DDM stated she would begin in-services immediately. The DDM stated the DM was out at this time and she did not know when he was scheduled to return. Observation of a snack cart and interview with LPN C on [DATE] at 10:26 AM revealed the snack cart had labeled sandwiches in baggies, packaged crackers and chips, pudding (on ice), liquid thickener, and a pitcher of iced juice. LPN C stated the small unit refrigerator behind the East nurse's station was for residents and their (staff) personal items. LPN C stated the kitchen brought snack carts at 10:00 AM and 3:00 PM daily and the staff delivers them to the residents. Observation of the small refrigerator behind the East nurse's station on [DATE] at 10:36 AM revealed 1 opened and unlabeled 20 oz. almost full bottle of soda, 4, 12 oz. unopened and unlabeled cans of soda, 1, 20 oz. unopened bottle of electrolyte drink and 1, 16.9 oz. bottle of water, both labeled with a staff member's name in the same handwriting and dated water-[DATE] and the electrolyte drink of [DATE]. 1, 16.9 oz. unopened and unlabeled of water, 1, 12 oz. unopened and unlabeled of another electrolyte drink, 1, 113 gram unopened and unlabeled container of yogurt from a local grocery store with an expiration date of [DATE], 1 unopened and unlabeled packaged sandwich with use by date of [DATE], 1 opened and undated bakery item with the name of LPN D on it. 1 undated and unlabeled lidded plastic container partially full of grapes, 1 unlabeled plastic baggie of what appeared to be sliced sausage, 4 unopened, undated, and unlabeled pieces of commercial cheese, 1 opened to air, undated, and unlabeled sandwich of unidentified substance, 1, 4 oz. unopened, undated, and unlabeled container of pudding, 1, 4 oz. unopened, undated, and unlabeled container of prune juice with a use by date of [DATE], 2, 4 oz. unopened, undated, and unlabeled containers of lemon flavored thickened water, 5, 8 oz. undated, and unlabeled bottles of thickened water, 1 was opened, and 1, 11 oz. unopened, undated, and unlabeled bottle of meal replacement shake. Observation of the small refrigerator behind the East nurse's station and Interview with CNA B on [DATE] at 10:38 AM stated the packaged sandwich belonged to her and the identified bottle of water belonged to LPN C. CNA B stated the kitchen brought thickened water for the residents and pudding. CNA B stated she was not sure what the other items were for in the refrigerator. CNA B stated she did not know who the cheese and other items belonged to. CNA B stated, I guess there should be labels on the items in the refrigerator. CNA B offered to throw her name on (her packaged sandwich) now if this state surveyor wanted her to. CNA B stated she was not sure why staff and resident food could not be together in the same refrigerator. CNA B stated there was a refrigerator in the break room. Observation of the small refrigerator behind the East nurse's station and interview with the ADM on [DATE] at 11:19 AM stated he was not sure if the east unit refrigerator was for the residents until he saw the thickened items inside. The ADM identified the names on the water, electrolyte drink, and bakery items as 2 of his nurses. The ADM would not say if the other items, besides the thickened items, should be in this refrigerator. The ADM did not state there was a designated refrigerator for staff in the bereakroom. The ADM stated he did not routinely check the kitchen and did not know the kitchen staff were not following a proper cleaning schedule or preparing food unsanitarily. The ADM stated it was his expectation that all staff knew about cross contamination and cleanliness. Interview with LPN C on [DATE] at 11:24 AM stated the drinks with her name on them belonged to her and did not know who the other items belonged to. LPN C stated the unit refrigerators were for the resident's things. LPN C stated the other items should not be in there. The staff had a designated refrigerator in the breakroom. LPN C stated she should have used the designated staff refrigerator for her things. LPN C stated the danger in having resident belongings and staff belonging in the same refrigerator would be cross contamination due to bacteria or viruses, possibly contaminating the resident's items and they could become ill. LPN C stated everything should be dated and timed. LPN C stated the items were in there when she put her things in there. LPN C stated all staff were responsible for checking items and cleaning/discarding items. LPN C stated the night shift was mostly responsible for that. LPN C stated the general rule was everyone was responsible, but no one had accountability, including herself. LPN C stated the opened container of the thickened water should never be in there. Interview with LPN E on [DATE] at 11:26 AM stated the small refrigerators behind the East and [NAME] nurses stations were for residents and their (staff) personal items. Observation of the small unit refrigerator behind the [NAME] nurse's station on [DATE] at 11:42 AM revealed no personal items and the resident items were all labeled and dated. However, the inside of the refrigerator was not clean. There was a 2-inch round pink substance on a shelf, a sticky brown liquid substance in the door, varying food crumbs of varying colors also in the door, and larger varying food crumbs of varying colors on the bottom shelf. Observation of the small unit refrigerator behind the [NAME] nurse's station and interview with the ADON on [DATE] at 11:50 AM stated the glob of pink stuff probably did not come from the items that were in the [NAME] unit refrigerator now. The ADON stated, There was a probability staff items were in this refrigerator before this state surveyor inspected it. The ADON stated the nurses were responsible for keeping the west refrigerator clean, and it was not clean. The ADON stated all staff were responsible for checking items and cleaning/discarding items. The ADON stated although there was not any staff belongings in the [NAME] nurse's station refrigerator, the danger in having resident belongings and staff belonging in the same refrigerator would be cross contamination possibly contaminating the resident's items and the residents could become ill Requested kitchen in-services for the last 3 months but none were provided. Record review of the COOK's Food Protection Manager Certification indicated Certification was up to date. Record review of the facility policy titled Food: Preparation revised ,d+[DATE] revealed Policy Statement: All foods are prepared in accordance with the FDA (Food and Drug Administration) Food Code. Procedures: 4. The dining services director/cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 F and/or less than 135 F or per state regulation. 11. When hot pureed, ground, or diced food drop into the danger zone (below 135 F), the mechanically altered food must be reheated to 165 F for 15 seconds if holding for hot service. 13.All foods will be held at appropriate temperatures, greater than 135 F for hot holding, and less than 41 F for cold food holding. 14. Temperature for TCS foods will be recorded at time of service and monitored periodically during meal service periods. Record review of the undated facility policy titled Thermometer use revealed .Thermometer must be sanitized following each use or measurement using food sanitizer or thermometer wipes. Record review of the facility policy titled Environment revised ,d+[DATE] revealed Policy Statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Procedures: 4. The dining services director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. References: FDA Food Code: https://www.fda.gov/food/fda-food-code/food-code-2022

Based on record review and interviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission and after admission for 5 of 8 residents reviewed for PASRR screenings (Residents #6, #16, #33, #42, and #60. 1. The facility failed to ensure Resident #6 received a Level 1 Screening. 2. The facility failed to ensure Residents #16, #33, #42, and #60's PASRR Level 1 screening indicated the residents were positive for mental illness. This failure placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Record review of Resident #6's initial admission record dated 04/10/21 with a re-admission on 07/31/23 revealed a [AGE] year-old female. Diagnoses included a Primary Diagnosis of ataxia (difficulty walking) after a stroke on 07/31/23, major depressive disorder; recurrent moderate on 02/15/23, and secondary diagnosis of neurocognitive disorder with Lewy bodies (a type of Alzheimer's) on 11/01/22. Record review of Resident #6's PASRR Level 1 Screening revealed there were none. There was only a PASRR Evaluation dated 06/01/23. Record review of Resident #16's admission records revealed a [AGE] year-old male admitted to the facility on [DATE] with a re-admission on 02/15/22. Diagnoses included a Primary diagnosis of COPD (chronic obstructive pulmonary disease), major depressive disorder, recurrent on 07/16/10 and 03/25/21, schizophrenia, unspecified on 06/22/22, and schizoaffective disorder, bipolar type on 02/15/22. Record review of Resident #16's PASRR Level 1 screening dated 11/01/16 revealed question C0100. Mental Illness is there evidence or an indicator this is an individual that has a mental illness was marked no. Record review of Resident #16's PASRR Level 1 screening dated 01/06/23 revealed question C0100. Mental Illness is there evidence or an indicator this is an individual that has a mental illness was marked yes. Record review of Resident #16's MDS dated [DATE] revealed a BIMS of 15, indicating no cognitive impairment. Section I of the same MDS revealed a psychiatric/Mood disorder of 15700 Anxiety Disorder, 15800 Depression, and 16000 Schizophrenia. Record review of Resident #33's admission records revealed an [AGE] year-old male admitted to the facility on [DATE] with a re-admission on 08/15/23. Diagnoses included a primary diagnosis of paralysis and weakness after a stroke, major depressive disorder/bipolar on 01/11/24, major depressive disorder/single episode on 10/04/22, and major depressive disorder/recurrent, severe with psychotic symptoms on 10/04/22. Record review of Resident #33's PASRR Level 1 screening dated 09/30/22 revealed question C0100. Mental Illness is there evidence or an indicator this is an individual that has a mental illness was marked no. Record review of Resident #33's PASRR Level 1 screening dated 02/08/23 revealed question C0100. Mental Illness is there evidence or an indicator this is an individual that has a mental illness was marked no. Record review of Resident #33's MDS dated [DATE] revealed a BIMS of 0, indicating severe cognitive impairment. Section I of the same MDS revealed a psychiatric/Mood disorder of 15800 Depression, and 16000 Schizophrenia. Record review of Resident #42's admission records revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included a primary diagnosis of paralysis and weakness after a stroke, dementia in other diseases classified elsewhere, severe with anxiety was ranked as #3, and psychotic disorder with delusions due to known physiological condition. Record review of Resident #42's PASRR Level 1 screening dated 01/22/24 revealed question C0090. Primary Diagnosis of Dementia Is there evidence that dementia is the primary diagnosis for this individual? (This must be listed in the medical record as the primary diagnosis by the physician.) was marked Yes. C0100. Mental Illness is there evidence or an indicator this is an individual that has a mental illness was marked no. Record review of Resident #42's PASRR Level 1 screening dated 01/26/24 revealed question C0090. Primary Diagnosis of Dementia Is there evidence that dementia is the primary diagnosis for this individual? (This must be listed in the medical record as the primary diagnosis by the physician.) was marked Yes. C0100. Mental Illness is there evidence or an indicator this is an individual that has a mental illness was marked no. Record review of Resident #42's MDS dated [DATE] revealed a BIMS of 0, indicating severe cognitive impairment. Section I of the same MDS revealed a psychiatric/Mood disorder of 15950 Psychotic Disorder. Record review of Resident #60's admission records revealed a [AGE] year-old female admitted to the facility on [DATE] with a re-admission on 10/08/23. Diagnoses included a primary diagnosis of pressure ulcer of sacral region stage 4, paralysis and weakness after a stroke, schizoaffective disorder, bipolar type dated 07/06/23, unspecified dementia dated 07/06/23, anxiety disorder dated 10/08/23, and depression, unspecified dated 10/08/23. Record review of Resident #60's PASRR Level 1 screening dated 07/05/23 revealed question C0090. Primary Diagnosis of Dementia Is there evidence that dementia is the primary diagnosis for this individual? (This must be listed in the medical record as the primary diagnosis by the physician.) was marked No. C0100. Mental Illness is there evidence or an indicator this is an individual that has a mental illness was marked no. Record review of Resident #60's PASRR Level 1 screening dated 10/06/23 revealed question C0090. Primary Diagnosis of Dementia Is there evidence that dementia is the primary diagnosis for this individual? (This must be listed in the medical record as the primary diagnosis by the physician.) was marked Yes. C0100. Mental Illness is there evidence or an indicator this is an individual that has a mental illness was marked no. Record review of Resident #60's MDS dated [DATE] revealed a BIMS of 0-5, indicating severe cognitive impairment. Section I of the same MDS revealed a psychiatric/Mood disorder of 15700 Anxiety Disorder, 15800 Depression, and 16000 Schizophrenia. An interview with the DON on 03/19/24 at 3:44 pm regarding the residents that have discrepancies for their PASRR, the DON stated that she did not do PASRR and the person that did, was their MDS-she was the person that oversaw that. The State Investigator asked who oversees checking MDS work, and the DON replied that it was the RMDS. An interview with the RMDS on 03/19/2024 at 3:51pm stated that she was the one that oversaw the work that the MDS did. The State Investigator stated that there were residents that had discrepancies with their PASRR. The RMDS stated that it could be that there was a CHOW that had been done recently and maybe they had not been updated or that maybe the MDS just had not put them into the system. The State Investigator asked if it was common for MDS to not put the PASRR updates into the system immediately. RMDS stated that she did not know if the MDS would do that. An interview with the RMDS and MDS on 03/20/24 beginning at 2:07 pm The MDS stated regarding Resident #33, maybe he went to the hospital in August, so he shouldn't have needed a new PASRR for coming back in August, he should have just still had the initial PASRR. The RMDS stated, Regarding the negative PASRR dated 02/08/23, that was from the CHOW-we had to resubmit everybody in the beginning of 2023 because of the new provider numbers. Regarding Resident #33's diagnosis of schizoaffective disorder bipolar with the date 1/11/24, it was audited last night and he was one of the people I recognized, and I've got a 1012 waiting to go for the doctor to sign off so he can submit a new one with that diagnosis so they can evaluate them. The RMDS stated she did not know the exact date of the CHOW but knew they couldn't submit the PASRR's or like new forms until January February last year. The RMDS stated she thought that the diagnosis was just added recently, and she felt she needed to dig into it just to make sure that was added in January, but nothing was updated, and this is March. Anytime a new diagnosis is done or not, a 1012 should be submitted. An interview with the RMDS and MDS on 03/20/24 continuing from 2:07 pm the RMDS stated she looked into Resident #42's chart last night as well, and saw his primary diagnosis was not dementia, as indicated on his PASRR's. The RMDS stated we have to have him reevaluated. I want to say on the double! He also had a new 1012. I decided just better safe than sorry. It is what it is; the PASRR that was done was negative and it should have been sent. I don't check every single line because he's got this psychotic disorder with delusions. I don't check every single one on a regular basis. An interview with the RMDS and MDS on 03/20/24 continuing from 2:07 pm regarding Resident #60, the RMDS stated, Dementia can't be a primary diagnosis-it is not an acceptable primary diagnosis and she was diagnosed with schizophrenia and bipolar and dementia on 7/6/2. On 10/8/23, it was anxiety and the primary was still pressure ulcer on 2/16/23. She's another one. None of these people have level 2, the authorities haven't been notified till last night from what I can tell. An interview with the RMDS and MDS on 03/20/24 continuing from 2:07 pm regarding Resident #16, the RMDS stated, Resident #60 didn't have a Level 1 when I looked yesterday. He didn't have one in here at all, which makes sense because it says it wasn't updated or loaded till yesterday. An interview with the RMDS and MDS on 03/20/24 continuing from 2:07 pm regarding Resident #16, the MDS stated, Resident #16 had been here for years and years. He came in with this schizophrenia diagnosis and they had evaluated him and whatever determination there was, I don't know. What's happened in the past when we had the CHOW the appropriate diagnosis and they evaluated him during the CHOW so is this like going through a CHOW. The RMDS stated, It's not the first time I had to go through a CHOW I don't know about the MDS, and I've never heard of doing that, but once there's a CHOW, you have to go check back. I had checked on the facility simply in the past to make sure that nobody else was PASRR positive in the building. The MDS stated, Last December they came in and did like four or five of them in two or three days in one week and to evaluate everybody. The RMDS stated, I assume they did their documentation. An interview with the RMDS and MDS on 03/20/24 continuing from 2:07 pm regarding Resident #6, the MDS stated, I'm gonna guess that based off of the dementia and whatever I wasn't here for the meeting or the evaluation but a lot of times when it's mental illness, to qualify, they have to have a history of mental illness services in the community or suicidal ideations, or homelessness, or depressive disorder. But to get the services, from my knowledge, they usually have to have histories of psych hospital stays or getting emergency services for the psych. They don't always qualify just because they got the diagnosis, but the PASRR should be positive to get an evaluation. Her PL-1 showed a positive diagnosis. The RMDS stated, But she didn't have a PASRR Level 1 in her chart. Facility Policy on PASRR was requested but not received.

Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided, consistent with professional standards of practice, for four residents (R #6, R #53, R #63, and R #46) of eight residents reviewed for respiratory care and services. 1.) R #46's suction machine canister had mucus secretions left in the canister for an unknown amount of time. 2.) R #46's suction tubing (connects to aspirators and other medical instruments used for extracting or evacuating body fluids and debris) for the suction machine was not dated or disposed after being used. 3) R # 6, R #53, and R #63 did not have a complete set of supplies that were needed to be able to perform suctioning treatment if needed. This failure could place residents who received respiratory care and services at risk for respiratory complications. Findings included: Record review of Resident #46's face sheet, dated 3/18/24, revealed resident #46 was admitted to the facility on [DATE] with diagnoses of: Type 2 diabetes mellitus (the response to insulin is diminished, and this is defined as insulin resistance), senile degeneration of brain (severe cortical atrophy and cell loss as well as a high index of dementia as measured by numbers of neurofibrillary tangles (NFT) and neuritic plaques (NP ) in neocortex and hippocampus.), not elsewhere classified, and unspecified severe protein-calorie malnutrition (A disorder caused by a lack of. proper nutrition or an inability. to absorb nutrients from food). Record review of Resident #46's comprehensive MDS, dated [DATE], revealed Resident #46 had a BIMS score of 03, signifying severe cognitive impairment. Record review of Resident #46's Physician order Sheet, obtained on 3/18/23, revealed the following order dated 1/11/24: Suction as needed for comfort/aspiration with no directions specified. Record Review of Resident 46's progress notes indicated that the last suction machine treatment was performed by the hospice agency on 01/20/2024. Record Review of Resident # 6 (R # 6)'s face sheet, dated 3/20/24, revealed R #6 was admitted on [DATE] with diagnosis of: neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), epilepsy (a disorder of the brain characterized by repeated seizures), and chronic kidney disease (kidneys are damaged and can't filter blood the way they should ). Record review of Resident #6's comprehensive MDS, dated [DATE], revealed Resident #6 had a BIMS score of 99, signifying severe cognitive impairment. Record review of Resident #6's Physician order Sheet, obtained on 3/20/23, revealed the following order dated 3/19/24: Suction as needed for comfort/aspiration with no directions specified. Record Review of Resident # 53's face sheet, dated 3/20/24, revealed R #53 was admitted [DATE] with diagnosies of: epilepsy (a disorder of the brain characterized by repeated seizures) and, pneumonia (an infection that affects one or both lungs ). Record review of Resident #53's comprehensive MDS, dated [DATE], revealed Resident #53 had a BIMS score of 15, signifying no cognitive impairment. Record review of Resident #53's Physician order Sheet, obtained on 3/20/24, revealed the following order dated 3/19/24: Suction as needed for comfort/aspiration with directions of as needed for excess secretions. Record Review of Resident # 63's face sheet, dated 3/20/24, revealed R #63 was admitted [DATE] with diagnoseis of: epilepsy (a disorder of the brain characterized by repeated seizures) and, malignant neoplasm of frontal lobe (a fast-growing cancer that spreads to other areas of the brain and spine ). Record review of Resident #63's comprehensive MDS, dated [DATE], revealed Resident #63 had a BIMS score of 3, signifying severe cognitive impairment. Record review of Resident #63's Physician order Sheet, obtained on 3/20/23, revealed the following order dated 3/19/24: Suction as needed for comfort/aspiration with directions of as needed for excess secretions. During an observation on 3/18/24 at 11:46 a.m., Resident #46's suction machine tubing did not have a date. The suction machine tubing was not disposed, and it had residue of the secretions from the previous treatment. During an interview on 3/18/24 at 12:04 p.m., C.N.A.B checked Resident #46's suction machine tubing and canister. C.N.A. B stated there was no date on the suction machine tubing and the canister showed secretions. During an observation and interview on 3/18/24 at 12:08 p.m., the ADON stated the tubing was supposed to be dated and it was supposed to be disposed after every use with a suction machine. The ADON stated that the cannister needed to be cleaned properly after every use. The ADON did not know how long the suction machine has been in that condition. The ADON stated that R # 46 hardly ever needed to be suctioned. The ADON could not remember the date of when R #46 was last suctioned. The State Investigator asked the ADON what could happen if the suction machine was needed during an emergency and the ADON stated they would use it immediately even if it was not cleaned to help the resident. The ADON stated that the suction machine was something the hospice company brought in, and they were also responsible for maintaining the machine. Investigator asked the ADON what role the nursing staff have in maintaining the suction machine and the ADON replied that it was a team effort amongst the nursing team and the hospice team since the resident resides at this facility. During an observation on 03/19/2024 at 9:37 a.m., R # 53 had a suction machine at his bedside, but did not have a complete set of suction machine supplies available at the bedside. R # 53 did not have tubing or a canister available in order for the suction machine to function. During an observation on 03/19/2024 at 9:39 a.m., R # 6 had a suction machine at his bedside, but did not have a complete set of suction machine supplies available at the bedside. R #6 did not have tubing for the suction machine. During an observation on 03/19/2024 at 9:46 a.m., R # 63 had short tubing attached to yankauer (device used to touch and suction body fluids) and it was hanging off the bedside table touching the privacy curtain. During an Interview with CNA A on 03/19/2024 at 10:23 a.m. she stated that she knew what a suction machine was. CNA A stated someone could choke and possibly die if they needed to be suctioned. She had never been trained on suctioning during her time employed at the facility. She knew how to use a suction machine. She had never seen nurses use it during wound care. She had witnessed it being done. The last time she witnessed it had not been any time recently. She did not know how to set it up. She would get the supplies on Hall D if they were needed. During an Interview with LPN B on 03/19/2024 at 10:27 a.m. LPN B stated he was trained on suction machines back in nursing school and before his time at this facility. LPN B stated the procedure was a little foggy to him but if he needed to do it, he thought he could remember. He would have to see the set up because there are different ones, but he thought he knew how. LPN B stated if there was an emergency, he would get the crash cart and if the resident was with hospice then it (the suction machine) would be on the bedside table. LPN B stated if a resident was on hospice, they (staff) were still expected to have knowledge in the equipment. LPN B stated someone could choke or aspirate (breathe secretions or vomit or other body fluid into their lungs), or possibly die if they needed to be suctioned. LPN B stated the suction tubing, canister, and yankeur were single patient use, and he was not sure what the facility policy was on changing tubing, but he thought every few days so stuff (bacteria) doesn't grow in it. During an interview with LPN A on 03/19/24 at 10:34 a.m. she stated that she knew quite a bit about suctioning. She learned it in nursing school. She stated she had training on it during her time at the facility, but it had been before 2024. She knew how to use the machine. She could put the machine together, but she needed a refresher training and practice on the tubing. The supplies were located in the supply room if she needed the supplies for it. LPN A stated someone could choke or aspirate (breathe secretions or vomit or other body fluid into their lungs), or possibly die if they needed to be suctioned. LPN A stated the suction tubing, canister, and yankeur were single patient use, and she was pretty sure the facility policy was on changing tubing was every 3 days, but she was not completely sure. During an interview with LPN C on 03/19/2024 at 11:02 a.m. She stated that she knew how to use suction machines. The only training she had for suction machines is the training from when she was first hired, but nothing recent. It had been at least one year since she had received any training on it. If she had to set one up, she knew how to set it up. If the facility received a resident that had a suction machine, the facility wiould receive an in-service on it. The supplies are in the supply room at D Hall. If a resident was on hospice, the nurses would still be responsible for being knowledgeable in the machines. If LPN C saw a canister or tubing that was not clean, she would change everything out in the red bag and dispose properly. During an interview with LPN D on 03/19/2024 at 11:16 a.m. She stated she had been working at the facility since 2007. During the time she has been working at the facility, she had never received training on suction machines. If she had to use one on a resident, she knew how to do it from working at a hospital before her time at this facility. The nursing staff received a training on Respiratory, but it was not thorough. It just touched on it, but that was it. If the facility had all the parts, she thought she could put it together but it has been a while. The LVN believed it would benefit to get a training and practice on it. The supplies would be located on the D Hall if they were needed. During an interview on 3/19/24 at 12:30 p.m., the DON stated when the nursing staff were assigned to resident rooms, the nursing staff would then check the suction machine tubing and the date to make sure the suction machine tubing and canister were disposed and cleaned after each use. The DON stated that each resident had their own set of supplies. The DON stated, to be quite honest, I can't really say how the failure could affect the rsidents. The State Investigator asked the DON when does the nursing staff receive training for suction machines and she stated that she does not know for sure, but it could be yearly. Record Review of the last twelve months did not indicate that there had been a training or an in-service training on suction machines or suctioning. Record review of a policy titled, Suctioning, last updated August 2014, revealed the following: empty the suction collection canister as needed for repeated use on the resident (usually at the end of each shift), and at least daily. Rinse and clean suction collection canister as necessary. If secretions adhere to the canister and cannot be rinsed off, change the canister and discard or disinfect the canister as appropriate. Reusable suction collection canister may be disinfected using the following methods: put on gloves, rinse canister with running water, soak with soapy water until secretions will rinse off. There was no mention of dating the suction machine tubing.

Based on observations and interviews, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 expired/discontinued medication storage room (storage closet of the DON/ADON office) reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure discontinued controlled medications for disposal were stored and separately locked in a permanently affixed compartment. This failure could place the facility at risk of drug diversion and access to medications. Findings included: Observation on [DATE] at 09:50 AM of the discontinued controlled medications in the DON/ADON's office with the ADON present revealed the controlled medications that were to be destroyed were stored in a locked safe that was on a shelf in a locked closet in the DON/ADON's office. The safe was not permanently affixed and was easily moved. The DON/ADON's office was keypad locked. In an interview on [DATE] at 10:33 AM with the DON, she stated that she thought the safe was bolted down in the closet. The DON stated the ADON was the only person that had access to the closet that the safe was in. The DON stated if the safe was removed with the controlled medications inside, it could lead to drug diversion. In an interview on [DATE] at 10:56 AM, the ADON stated, narcotics are to be stored behind double locked doors and in a locked container. When asked about the ability to move the safe, the ADON stated she was not aware that it had to be secured to the floor or wall. The ADON stated the narcotics had already been moved to the locked container that was bolted to the floor in the closet. The ADON stated, If someone managed to get the safe out of the closet and the office, we could have a drug diversion. If that were to happen, we would self-report to state and do an investigation. Observation on [DATE] at 10:35 AM revealed the narcotics had been moved to the locked container that was bolted to the floor in the closet.

Based on observations, interviews, and record review, the facility failed to 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 four residents (Resident #60, Resident #36, Resident #48, and Resident #10) of five residents observed for infection control practices during wound care and medication pass. 1.) CNA A and LPN A did not perform hand hygiene for at least 20 seconds during and after wound care for Resident #60. 2.) LPN A did not sanitize hands between a glove change while performing wound care on Resident #60. 3.) LPN A contaminated the Calcium Alginate Rope (a sterile dressing, advanced fiber-structured alginate with a highly absorbent capacity) with Resident #60's brief while performing wound care. 4.) LPN B did not sanitize the blood pressure cuff between resident use for Resident #36, Resident #48, and Resident #10. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings included: 1.)Record review of Resident #60's face sheet dated 03/17/24 reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included pressure ulcer of the sacrum (lower back between the two hip bones) stage 4 (damage to deeper tissue tendons, nerves, and joints usually with copious amounts of pus and drainage), heart failure, dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), and type two diabetes (the body's inability to regulate insulin). Record review of Resident #60's MDS dated [DATE] reflected a BIMS (Brief Intervew for Mental Status) score was 4 (Severe Impairment). Record review of Resident #60's Care Plan dated 01/02/24 reflected Resident #60 had a stage 4 pressure ulcer to the sacrum with impaired skin integrity related to impaired mobility and diabetes with daily sliding scale insulin. Record review of Resident #60's physician orders stated: Skilled Nurse to perform wound care to Stage 4 Pressure Ulcer at sacrum. Cleanse/irrigate wound with Hibiclens (antiseptic that fights bacteria) and flush with normal saline and pat dry. Apply Collagen particles (protein that gives the skin its tensile strength and plays a key role in wound healing) to wound bed and pack (put inside) wound with Calcium Alginate Rope. Cover with foam dressing daily and as needed until resolved, everyday for wound care. Observation on 03/17/24 at 2:52 PM of Resident #60's wound care revealed LPN A washed hands for approximately 15 seconds, dried hands, applied gloves, and began to perform Resident #60's wound care. During wound care, LPN A began to pack the Calcium Alginate Rope into Resident #60's wound. The Calcium Alginate Rope was held in one hand and applied with a tip applicator with the other hand, feeding the Calcium Alginate Rope into the wound. During this process, the Calcium Alginate Rope was dragging across the inside of Resident #60's opened brief resulting in cross contamination. LPN A then removed gloves, did not perform hand sanitation/hand hygiene, and put on a new glove to apply foam dressing. In an interview on 03/17/24 at 3:13 PM LPN A stated washing hands should take about two happy birthday songs, or maybe 30 seconds. LPN A stated by not performing hand sanitation or washing hands for the appropriate amount of time could lead to introducing various bacteria and germs into Resident #60's wound. LPN A stated she was nervous and thought she had washed her hands long enough and did not realize she forgot to hand sanitize in between glove change but proceeded with the wound care and lost track of her steps. LPN A stated last in-service on hand hygiene was last week. LPN A stated cross contamination of wound care supplies could cause Resident #60's wound to get worse or not heal properly and potentially introduce different bacteria or feces into the wound. In an interview on 03/17/24 at 3:31 PM CNA A stated hand washing should be for at least 20 seconds and insufficient hand washing could lead to the spread of germs or infections for residents, staff, and visitors. CNA A stated she just returned from work after being off for a few months and did not remember when the last hands-on in-service was but did complete an online training in February. In an interview on 03/17/24 at 3:38 PM the DON stated washing hands should be for 20 seconds or greater and the last in-service on hand washing was within the month. The DON stated it was important to wash hands for 20 seconds or greater to stop the spread of infections to resident, staff and all who enter the facility. The DON stated any cross contamination of supplies, especially wound care supplies could make the residents wound worse and introduce bacteria and lead to possible infections. 2.) Record review of Resident #36's Admission record dated 03/20/24 revealed an [AGE] year-old female admitted on [DATE]. Diagnoses included End Stage Renal Disease, Chronic Obstructive Pulmonary Disease (difficulty breathing), Dementia, Atherosclerotic Heart Disease (decreased blood flow to the heart to due narrowed arteries in the heart), Peripheral Vascular Disease (reduced blood flow to the limbs due to narrowed blood vessels), and Hypertension (high blood pressure). Record review of Resident #36's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 05, which indicated severe cognitive impairment. Record review of Resident #36's Order Summary dated 03/18/24 revealed the resident was prescribed Amlodipine Besy- Benazepril HCL 10/20mg, 1 capsule by mouth in the morning for high blood pressure. (Hold if systolic blood pressure is less than 100 or diastolic blood pressure is less than 60). Record review of Resident #48's Admission record dated 03/19/24 revealed an [AGE] year-old female admitted on [DATE]. Diagnoses included Congestive heart failure (heart cannot pump enough blood), unspecified Shiga toxin-producing Escherichia coli (E. Coli)as the cause of diseases classified elsewhere, Chronic obstructive pulmonary disease, Unspecified dementia, Peripheral vascular disease, Age related physical debility, Essential (primary) hypertension (high blood pressure). Record review of Resident #48's quarterly MDS dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment. Record review of Resident #48's Order Summary dated 03/18/24 revealed the resident was prescribed Lisinopril-hydrochlorothiazide 20-12.5mg. 1 tablet by mouth in the morning for HTN. (Hold if systolic blood pressure is less than 110, diastolic blood pressure is less than 60, or heart rate is less than 60). Metoprolol Tartrate 25mg. Give 0.5 tablet by mouth in the morning for hypertension. (Hold if systolic blood pressure is less than 100, diastolic blood pressure is less than 60, or heart rate is less than 60). Record review of Resident #10's Admission record dated 03/20/24 revealed a [AGE] year-old female admitted on [DATE]. Diagnoses included Type II diabetes (adult-onset diabetes) with diabetic chronic kidney disease, Nonrheumatic aortic valve stenosis (stiffening of the aortic valve in the heart), Unspecified dementia, Essential (primary) hypertension, Chronic kidney disease, and Age-related physical debility. Record review of Resident #10's Comprehensive MDS dated [DATE], revealed a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #10's Order summary dated 03/18/24 revealed the resident was prescribed Cardizem LA extended release 240mg, give 1 tablet by mouth in the morning for hypertension (hold if systolic blood pressure is less than 100, diastolic blood pressure is less than 60, or heart rate is less than 60), Hydralazine 25mg, give 0.5 tab=12.5mg by mouth in the morning for hypertension (hold if systolic blood pressure is less than 100, diastolic blood pressure is less than 60 or heart rate is less than 60), and Losartan Potassium 100mg. Give 1 tablet by mouth in the morning for hypertension (hold if systolic blood pressure is less than 100, diastolic blood pressure is less than 60, or heart rate is less than 60). An observation of medication pass on 03/18/24 between 08:49 AM and 09:45 AM revealed LPN B failed to sanitize the blood pressure cuff between resident use for Resident $36, Resident #48, and Resident #10. An interview on 03/18/24 at 09:51 AM with LPN B revealed that there were disinfecting wipes (Super Sani-Cloth Germicidal Disposable Wipe) in the bottom drawer of the medication cart. LPN B stated that equipment should be wiped down after every use and if it's not done, it could cause contamination. LPN B stated that they get in serviced a lot about contamination and cross contamination and they also do online CEs (continuing education) that cover disinfection. On 03/18/24 at 01:13 PM during an interview with the ADON, she stated the procedure for checking blood pressure with medication pass was to make sure the blood pressure cuff was clean by wiping with the purple wipes (Super Sani-Cloth Germicidal Disposable Wipes) and let it sit for 2 minutes to dry. The blood pressure cuff was to be cleaned in between each resident. The ADON stated In-services for infection control were done once a month. ADON stated if the equipment was not cleaned between residents it could lead to infection or cross contamination. Record review of Handwashing/Hand Hygiene dated August 2019 stated: This facility considers hand hygiene the primary means to prevent the spread of infections. 2.Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. The CDC recommends the following steps for handwashing (www.cdc.gov): Wet the hands with clean, running water, either warm or cold, and apply soap. Lather the hands by rubbing them together with the soap. Lather the backs of the hands, between the fingers, and under the nails. Scrub the hands at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice. Rinse the hands under clean running water. Dry the hands with a clean towel or air-dry them. Record review of Wound Care Policy dated October 2010 stated: Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on clean field. Record review on 3/18/24 at 11:15 AM of the facility's Policies and Practices- Infection control (not dated) revealed that it stated in part: 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility. b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. e. Maintain records of incidents and corrective actions related to infections. f. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. 49157

Based on observations, interviews, and record review, the facility failed to ensure that residents were treated with respect and dignity and failed to care for each resident in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #270) of eight residents reviewed for dignity. The facility failed to provide Resident #270 with choices concerning her toileting. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings included: Record review of Resident #270's admission record dated [DATE] revealed an [AGE] year-old female admitted on [DATE] with a diagnosis of primary generalized osteoarthritis (swelling of joints causing pain, stiffness, and loss of mobility), severe obesity, muscle wasting, abnormalities of gait and mobility, and age-related physical debility (weakness). Record review of Resident #270's Comprehensive MDS dated [DATE] revealed a BIMS score of 15 which indicated that resident was cognitively intact. Record review of Resident #270's Comprehensive MDS dated [DATE] also indicated resident required substantial/ maximal assistance (helper did over half of the effort) for toileting hygiene and toileting was not attempted due to medical condition or safety concerns. This MDS also indicated that the resident was always incontinent of bowel and bladder. Record review of Resident #270's Comprehensive MDS dated [DATE] indicated resident had no redness, rash, or skin breakdown. Record review of Resident #270's care plan dated [DATE] indicated: 1. Focus of self-care deficit- impaired mobility related to morbid obesity, arthritis in multiple joints, weakness, inability to stand/ bear her own weight, and admission for therapy services to regain strength and self-care abilities with Interventions including encouraged choices with care, provided limited/partial to extensive/ substantial assistance of 1 or 2 with toileting and toileting hygiene as needed, and provided extensive/ substantial to limited assistance of 1 or 2 with transfers and ambulation as tolerated. 2. Focus of potential for complications related to incontinence of bowel and bladder with interventions includied - encouraged her to call as early as possible to go to the bathroom, encouraged her to go to the bathroom regularly and before going to bed, after meals. Observation on [DATE] at 03:47 PM revealed Resident #270 laying in her bed on her back with head of her bed elevated. In an interview on [DATE] at 03:47 PM with resident #270 she stated she's been here since [DATE] because my legs don't hold me. I can't stand or walk and I lost strength in my arms so I couldn't transfer myself from bed to wheelchair to potty and back. Resident stated that she's here for therapy and will be here for ,d+[DATE] days. Resident stated she didn't do activities unless a therapist, or someone helps her, and that she did go to therapy. Resident stated, I use a pamper here. I didn't know a bedpan was an option. Resident stated that staff usually answered the call light quickly but sometimes they were too busy. Resident stated she was unable to reposition herself while in bed and that staff turn her on her side to change her ,d+[DATE] times a day, but then they put her back on her back. Resident stated that she didn't feel that she had any sore spots on her back or bottom and that every time staff changed her, they would put lotion on her. Resident stated she did know when she needed to urinate or have a bowel movement, but the staff just told her to use her brief and they would clean her up. Resident stated that it made her feel like a baby to use a diaper. In an interview on [DATE] at 10:55 AM with ADON she stated that she was the one who admitted the resident and the family told her that they couldn't transfer her at home so she would use her brief. The ADON stated that she was in the room with the resident and her family during the admission process, but that she talked to the family and not to the resident and did not ask the resident what her toileting preference would be. The ADON stated that the option of a bedpan was never offered to the resident. The ADON also stated that she knew that physical therapy worked with the residents on toileting and transferring. Record review of the facility's admission packet on [DATE] revealed in part that the facility would treat residents with respect and dignity.

Based on interviews and record reviews, the facility failed to ensure care plans were updated for 1 of 8 residents (Resident #59) reviewed for care plans. Resident #59's care plan had no references to whether she was continent. This failure could place residents at risk for unmet care needs and a decreased quality of life. Findings included: Record review of Resident #59's admission records with an initial admitted [DATE] and re-admitted [DATE] revealed a [AGE] year-old female with diagnoses including pressure ulcers to both heels, left hip, and sacrum, diabetes, Parkinson's disease, heart failure, respiratory failure, high blood pressure, anxiety, and kidney disease. Record review of Resident #59's MDS dated [DATE] revealed a BIMS of 11, moderate hearing loss, no behaviors, and required partial assistance with functional abilities. Resident #59 was dependent on staff for toileting and showering, required substantial/maximal staff assistance for personal hygiene, footwear, and dressing. Resident #59 required partial/moderate staff assistance with oral hygiene, and supervision with eating. Under section H, Resident #59's MDS revealed she was always incontinent of bladder and bowel. Record review of Resident #59's Care Plan dated 02/06/24 indicated a focus of impaired communication with a BIMS of 0 dated 02/05/24 and revised 03/06/24, goals of Resident #59 will make her Needs known independently and without outbursts. Will Make Decisions About her Care as Able throughout her stay date initiated with revision of 02/2324. Interventions included Invite resident to make decisions, coach through process as needed date initiated 02/05/23 with revision of 02/07/24. Resident #59's care plan did not address toileting. Record review of progress note dated 03/08/24 - Resident alert and oriented x 4. makes all needs known. No complaint of pain or discomfort. Ambulates with wheelchair propels with arms or staff assistance. Continent of bowel and bladder, wears briefs due to heel wounds and non-weight bearing status to bilateral feet. Record review of Progress notes dated 03/14/24 revealed Note Text: Resident alert and oriented x 4. makes all needs known. No c/o pain or discomfort. Ambulates with wheelchair propels with arms or staff assistance. Continent of bowel and bladder wears briefs due to heel wounds and non-weight bearing status to bilateral feet. Record review of Resident #59's B&B (bowel and bladder) 72-hour assessment dated [DATE] revealed 1a. Voids appropriately without incontinence - Always. 1b. Incontinent of Stool- 1-3 times a week 1c. Ability to get to the BR/transfer to toilet commode/urinal, adjust clothing and wipe etc.- 0. Immobile, or 2 person assist. 1d. Mental Status-alert and oriented. 1e. Mentally aware of need to toilet- Usually aware of need to toilet. Record review of Resident #59's Admission assessment dated [DATE] revealed on page 1, that she was alert and oriented with intermittent confusion and had no problem with cognition/communication. Page 2 revealed her fall risk was high, she needed total assistance with mobility and her mental status was alert, oriented x 3. Page 8, number 3, 2. revealed she was incontinent of bladder and bowel. 5. Revealed resident did not have an altered bowel or bladder function. Pages 11 and 12, under extremities, revealed 6. Devices-None. 6b. Specify-wheelchair, air mattress. 7z. Toileting Needs: resident is incontinent of B&B. Page 13 under ADL/Functional Devices revealed she was a 2 person physical assist, had a wheelchair, 3Ba. could bear weight on both legs. Page 15 of 15- 6. Baseline Care Plan Summary 6.1. Plan of care 1. Resident's preference for being notified of updates to Plan of Care 1. As changes occur. Observation and interview with Resident #59 on 03/18/24 at 1:09 PM, Resident # 59 stated she was continent of both bladder and bowel. Resident #59 stated, They want us to use our diapers for a commode. This wheelchair I'm in does not fit in any of the bathrooms. I just wish I could use a toilet somewhere in this building. Resident # 59 was observed beginning 03/17/24-03/20/24 able to self-propel in her wheelchair, was up in the dining room, or activities on all days of the survey. In an interview with the DOR on 03/20/24 at 10:15 AM she stated she was familiar with Resident #59. The DOR stated this was the first time she had heard that Resident #59 felt she was using her diapers as a commode. The DOR stated Resident #59 was non weight bearing to both lower extremities, but she could still use a bedside commode if needed. We do have bedside commodes, but she's (Resident #59) not very strong and it would be a very, very difficult transfer.One that I would deem not safe at this time for her to go to a bedside commode with a person transferring her. The DOR stated, (Resident #59) never verbalized to me regarding being told to go in her diaper. The DOR did not know if Resident #59 was continent or not. Interview with the DON, MDS nurse, and the ADON on 03/20/24 at 10:55 AM The ADON stated Resident #59 was toileted, but she was toileted in a shower chair because she was a mechanical lift. The ADON stated (Resident #59) was put into a shower sling and put in the shower chair with the bucket underneath her in the shower. That's been since she came in the first time on 07/19/23. The ADON stated, This is the second time we've had her she didn't say anything about that to me at all. The ADON stated, After Resident # 59 went home, all her wounds came back, and so she came back to us. As far as the toileting, they put her on the shower chair because they can get her wheelchair through the shower. When asked if that was in her care plan, the DON and ADON both stated, That's done because that's person centered. The ADON stated, I can give you the right answer-it should be care planned but I can almost guarantee it's not. When asked if this situation would be something that should be in the care plan? The DON and ADON stated, Yes, because if I'm a new staff member and it's my first day,that's going to be helpful for me. When asked who would be the person that would add that information to the care plan? They stated, it would be against clinical-that should be the MDS nurse. They stated, The MDS nurse does our care plans but we will. We could have done it. We will update it. The ADON stated, Resident #59 is incontinent. She has Parkinson's, so why Requip (an anti-Parkinson's drug) doesn't work, I don't know. They DON stated, I don't even see toileting in here (the care plan) anyway. The ADON stated Resident #59 basically came in for rehab because she can't stand, and the family couldn't take care of her at home. She's a long term they (the family) wanted her to work with therapy and she's too weak-she can't tolerate it. The MDS nurse said nothing during this interview. An interview with the RMDS and the MDS on 03/20/24 at 2:07 pm The MDS stated, There was a question on who enters the care plans. I do as part of the admission assessment and then I review their admission assessment. The RMDS stated, She (MDS) starts it with the diagnosis and medications and any pertinent orders. Then they (MDS and nurses) should be reviewing it daily. The MDS stated, I just go down each little topic on the admission assessment to get it into the care plan. It's 16 pages or whatever and I identify the problem as I go along. A facility policy on Care plans was requested but not provided.

Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one resident (Resident #63) of nineteen residents reviewed for quality of care. The facility did not reposition or otherwise provide pressure relieving interventions for resident #63 per facility protocol and left her laying on her back in bed with the head of bed elevated and a pillow under her head. This deficient practice could affect residents receiving preventative skin care at risk for pressure ulcer development or a deterioration of a current pressure ulcer. The findings included: Record review of Resident #63's admission record on 03/20/24 revealed an [AGE] year-old female admitted on [DATE]. Diagnoses included malignant neoplasm of the frontal lobe (brain tumor), hemiplegia and hemiparesis following other cerebrovascular disease affecting the right dominant side (right sided weakness/paralysis due to brain tumor), encounter for surgical aftercare following surgery on the nervous system (small hole drilled into the skull to obtain a sample of the brain tumor), age related physical debility, and cognitive communication deficit. Record review of Resident #63's Comprehensive MDS dated [DATE] revealed resident had a BIMS score of 03 which indicated severe cognitive impairment. Resident #63's MDS also revealed resident required substantial/ maximal assistance (helper does more than half the effort) for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene. The same MDS revealed the resident was at risk for developing a pressure ulcer but did not have any unhealed pressure ulcers or pressure injuries at the time of admission. Record review of Resident #63's Initial Wound Sheet dated 03/04/24 revealed resident had a Stage 2 pressure ulcer (painful broken skin with an open wound or pus-filled blister that may ooze clear fluid or pus) to her sacrum that measured: Length: 1.5 cm, Width: 0.7cm, Depth: 0.2cm and indicated that NP A was notified of this wound on 04/04/24 at 12:15 PM. This Initial Wound Sheet was e-signed by the DON. Record review of Resident #63's Weekly Head to Toe Skin Check dated 03/04/24 revealed the same information of the stage 2 sacral ulcer and included Wound documentation and notes: Stage 2 to sacrum, 1.5 x0.7. Clean with NS (Normal saline), pat dry and apply triad cream mixed with collagen particles. Leave OTA (open to air) until resolved. This documentation was e signed by LPN B on 03/04/24 at 01:59 PM. Record Review of Resident #63's Weekly Skin and Weight Review dated 03/07/24 revealed Reason for review (a) Weekly review and (g) New Admit. Weekly skin and weight assessment also stated, Stage 2 Sacrum- 1.5 x 0.7 x 0.2cm. Follow up comments stated, resident started on weekly weights due to acquiring a stage 2 to sacrum. Wound care is in place and tolerates well. Dependent on staff for all ADLs. MD, RP (responsible party) and RD (registered dietician) made aware of situation. This form also indicated that the care plan was current/ updated and the meeting was attended by the DON, the ADON, the dietary manager, and the wound nurse. Record review of Resident #63's Weekly Skin and Weight Review dated 03/14/24 revealed Stage 2 Sacrum 2.0 x 1.5 x 0.2cm and stated, No new orders. Record review of Resident #63's Order Summary Report dated 03/18/24 revealed, SN (skilled nurse) to perform wound care to stage 2 pressure ulcer at sacrum every shift and as needed until resolved. Cleanse wound with NS and gauze, pat dry. Apply Triad cream, apply collagen particles and cover with dry dressing. Record review of Resident #63's Care Plan dated 03/18/24 revealed FOCUS of Alteration in skin integrity R/T (related to) Incontinence Bowel and Bladder and Impaired Mobility. Stage 2 Sacrum. Initiated on 03/07/24, revised 03/12/24 with GOAL: Resident will have no signs/symptoms of pressure areas developing throughout her stay. Initiated 01/27/24, revised 02/07/24. INTERVENTIONS: 1) Document any beginning stages of breakdown and notify wound care consultant/ nurse and MD, 2) Weekly skin checks- Initiated 01/27/24, revised 02/03/24, 3) SN to perform wound care to stage 2 pressure ulcer at sacrum Q (every) shift and as needed until resolved. Cleanse wound with NS and gauze, pat dry. Apply Triad cream, apply collagen particles and cover with dry dressing. Initiated 03/13/24, revised 03/13/24. In an interview with Resident #63's family member on 03/18/24 at 01:40 PM, FM stated resident had a pressure ulcer on her buttocks and a rash to the peri area. FM further stated, they do not reposition her. FM stated the facility got resident an air mattress (hospice RN ordered it for her on Wednesday and it got here on Thursday.) There was no air controller attached to the bed. The mattress had a very soft surface. Observation of Resident #63 on 03/18/24 at 01:47 PM revealed resident lying flat on her back in bed with head of bed elevated and her head on a pillow. There were no other pillows on the bed. Resident was not responding to FM but was occasionally grimacing and appeared to have some pain. Observation of Resident #63 on 03/19/24 at 11:23 AM revealed resident lying flat on her back in bed with head of bed elevated and head on a pillow. There were no other pillows on the bed. In an interview with Resident #63's FM on 03/19/24 at 11:23 AM, FM stated she arrived at the facility at approximately 9:00 AM on 03/18/24 and 03/19/24. FM stated she left the facility at approximately 10:00 PM on 03/18/24. FM stated the resident had not been repositioned at all on 03/18/24 and had not been repositioned on 03/19/24 at the time of this interview. FM stated she was here with the resident almost every day and the resident was never repositioned. Whenever staff went in to change/clean the resident, the resident was placed flat on her back in bed with the head of the bed elevated and a pillow under her head when staff was finished. In an interview on 03/19/24 at 11:27 AM LPN A stated that residents are usually repositioned every two hours but that she liked to do it more frequently if residents had a pressure ulcer. LPN A stated the resident would be repositioned every time they were changed or whenever she went in to check them. In reference to Resident #63, LPN A stated that she gets repositioned every two hours, but not necessarily by her. LPN A stated, I've been here since 6 AM today. I've repositioned her three times and my aides have repositioned her also. LPN A explained that she would use the drawsheet to roll the resident onto her side, then put a pillow underneath her toward her bottom to alleviate the pressure on her wound and then would put a pillow between her knees to keep them from touching. LPN A stated that once she knew the CNAs had repositioned the resident a couple of times, she would let the resident lay on her back for a little while. LPN A stated that if residents are not repositioned it could result in more skin breakdown, redness, or bruising which could cause a lot of pain. LPN A stated it could especially cause those issues for Resident #63 because she already has a pressure ulcer on her buttocks. LPN A stated, with her, I really don't want her to have any pressure. LPN A stated they are inserviced on repositioning every 3 months, but she feels that she hears about it all the time. In an interview on 03/19/24 at 11:42 AM, CNA A stated, residents are repositioned every 2 hours. I make sure I go in there every 2 hours to reposition them. CNA A stated regarding resident #63, she is being repositioned every 2 hours. I put a pillow on the left, then on the right, and usually put a pillow under her heels also. CNA A further stated, if residents are not repositioned, they can get ulcers and skin breakdown. We get in-services quite often; I would say sometimes 2 a month, but at least once a month. In an interview on 03/19/24 at11:47 AM, the ADON stated, Residents are repositioned every 2 hours or as needed. If they're uncomfortable and requesting repositioning, we reposition. If residents are not repositioned, they will have breakdown, redness, pressure ulcers or they could develop respiratory issues. When asked under what circumstances staff would not reposition a resident, ADON answered, when they're independent and can do it themselves. ADON stated, staff is in-serviced on repositioning for sure annually, and now quarterly since I've been asked this question more than once. Record review of facility's Repositioning Policy (not dated) revealed: Purpose The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. General Guidelines 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 2. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. 3. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. Interventions 1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. 2. Frequency of repositioning a bed- or chair-bound resident should be determined by: a. The type of support surface used; b. The condition of the skin; c. The overall condition of the resident; d. The response to the current repositioning schedule; and e. Overall treatment objectives. 3. Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule. 4. For residents with a Stage I or above pressure ulcer, an every two hour (q2 hour) repositioning schedule is inadequate. 5. Residents who are in a chair should be on an every one hour (ql hour) repositioning schedule. 6. If ineffective, the turning and repositioning frequency will be increased.

Based on observations, interviews, and record review, the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and residents having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and further development of skin breakdown or pressure ulcers for 1 (Resident #63) of 3 residents reviewed for pressure ulcers. -The facility failed to prevent the development of Resident #63's facility acquired sacral pressure ulcer. -The facility failed to ensure Resident #63 was repositioned This failure placed residents at risk of developing new pressure injuries/ulcers, worsening of existing pressure injuries/ulcers, infection, experiencing pain, decreased quality of life, and death. The findings included: Record review of Resident #63's admission record on 03/20/24 revealed an [AGE] year-old female admitted on [DATE]. Diagnoses included malignant neoplasm of the frontal lobe (brain tumor), hemiplegia and hemiparesis following other cerebrovascular disease affecting the right dominant side (right sided weakness/paralysis due to brain tumor), encounter for surgical aftercare following surgery on the nervous system (small hole drilled into the skull to obtain a sample of the brain tumor), age related physical debility, and cognitive communication deficit. Record review of Resident #63's Comprehensive MDS dated [DATE] revealed resident had a BIMS score of 03 which indicated severe cognitive impairment. Resident #63's MDS also revealed resident required substantial/ maximal assistance (helper does more than half the effort) for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene. The same MDS revealed resident was at risk for developing a pressure ulcer but did not have any unhealed pressure ulcers or pressure injuries at the time of admission. Record review of Resident #63's Initial Wound Sheet dated 03/04/24 revealed resident had a Stage 2 pressure ulcer (painful broken skin with an open wound or pus-filled blister that may ooze clear fluid or pus) to her sacrum that measured: Length: 1.5 cm, Width: 0.7cm, Depth: 0.2cm and indicated that NP A was notified of this wound on 03/04/24 at 12:15 PM. This Initial Wound Sheet was e-signed by the DON. Record review of Resident #63's Weekly Head to Toe Skin Check dated 03/04/24 revealed the same information of the stage 2 sacral ulcer and included Wound documentation and notes: Stage 2 to sacrum, 1.5 x0.7. Clean with NS (Normal saline), pat dry and apply triad cream mixed with collagen particles. Leave OTA (open to air) until resolved. This documentation was e signed by LPN B on 03/04/24 at 01:59 PM. Record Review of Resident #63's Weekly Skin and Weight Review dated 03/07/24 revealed Reason for review (a) Weekly review and (g) New Admit. Resident was admitted to the facility on [DATE]. Weekly skin and weight assessment also stated, Stage 2 Sacrum- 1.5 x 0.7 x 0.2cm. Follow up comments stated, resident started on weekly weights due to acquiring a stage 2 to sacrum. Wound care is in place and tolerates well. Dependent on staff for all ADLs. MD, RP (responsible party) and RD (registered dietician) made aware of situation. This form also indicated that the care plan was current/ updated, and the meeting was attended by the DON, the ADON, the dietary manager, and the wound nurse. Record review of Resident #63's Weekly Skin and Weight Review dated 03/14/24 revealed Stage 2 Sacrum 2.0 x 1.5 x 0.2cm, and stated, No new orders. The measurements on 03/14/24 indicated worsening of the pressure ulcer. Record review of Resident #63's Order Summary Report dated 03/18/24 revealed, SN (skilled nurse) to perform wound care to stage 2 pressure ulcer at sacrum every shift and as needed until resolved. Cleanse wound with NS and gauze, pat dry. Apply Triad cream, apply collagen particles and cover with dry dressing. Record review of Resident #63's Care Plan dated 03/18/24 revealed FOCUS of Alteration in skin integrity R/T (related to) Incontinence Bowel and Bladder and Impaired Mobility. Stage 2 Sacrum. (Initiated on 03/07/24, revised 03/12/24) with GOAL: Resident will have no signs/symptoms of pressure areas developing throughout her stay. (Initiated 01/27/24, revised 02/07/24). INTERVENTIONS: 1) Document any beginning stages of breakdown and notify wound care consultant/ nurse and MD, 2) Weekly skin checks- (Initiated 01/27/24, revised 02/03/24), and 3) SN to perform wound care to stage 2 pressure ulcer at sacrum Q (every) shift and as needed until resolved. Cleanse wound with NS and gauze, pat dry. Apply Triad cream, apply collagen particles and cover with dry dressing. (Initiated 03/13/24, revised 03/13/24). In an interview with Resident #63's family member on 03/18/24 at 01:40 PM, FM stated the resident has a pressure ulcer on her buttocks and a rash to the peri area. FM further stated, they do not reposition her. FM stated the facility got resident an air mattress (hospice RN ordered it for her on Wednesday and it got here on Thursday.) There was no air controller attached to the bed. The mattress had a very soft surface. Observation of Resident #63 on 03/18/24 at 01:47 PM revealed resident lying flat on her back in bed with the head of bed elevated and her head on a pillow. There were no other pillows on the bed. Resident was not responding to FM but was occasionally grimacing and appeared to have some pain. Observation of Resident #63 on 03/19/24 at 11:23 AM revealed the resident lying flat on her back in bed with the head of the bed elevated and her head on a pillow. There were no other pillows on the bed. In an interview with Resident #63's FM on 03/19/24 at 11:23 AM, FM stated she arrived at the facility at about 09:00 AM on both 03/18/24 and 03/19/24. FM stated she left the facility at approximately 10:00 PM on 03/18/24. FM stated the resident had not been repositioned at all on 03/18/24 and had not been repositioned on 03/19/24 at the time of this interview. FM stated she was here with resident almost every day and resident was never repositioned. Whenever staff went in to change/clean resident, resident was placed flat on her back in bed with head of bed elevated and a pillow under her head when staff was finished. In an interview on 03/19/24 at 11:27 AM LPN A stated that residents are usually repositioned every two hours but that she liked to do it more frequently if residents had a pressure ulcer. LPN A stated the resident would be repositioned every time they were changed or whenever she went in to check them. In reference to Resident #63, LPN A stated that she gets repositioned every two hours, but not necessarily by her. LPN A stated, I've been here since 6 AM today. I've repositioned her three times and my aides have repositioned her also. LPN A explained that she would use the drawsheet to roll the resident onto her side, then put a pillow underneath her toward her bottom to alleviate the pressure on her wound and then would put a pillow between her knees to keep them from touching. LPN A stated that once she knew the CNAs had repositioned the resident a couple of times, she would let the resident lay on her back for a little while. LPN A stated that if residents are not repositioned it could result in more skin breakdown, redness, or bruising which could cause a lot of pain. LPN A stated it could especially cause those issues for Resident #63 because she already has a pressure ulcer on her buttocks. LPN A stated, with her, I really don't want her to have any pressure. LPN A stated they are inserviced on repositioning every 3 months, but she feels that she hears about it all the time. In an interview on 03/19/24 at 11:42 AM, CNA A stated, residents are repositioned every 2 hours. I make sure I go in there every 2 hours to reposition them. CNA A stated, regarding resident #63, she is being repositioned every 2 hours. I put a pillow on the left, then on the right, and usually put a pillow under her heels also. CNA A further stated, if residents are not repositioned, they can get ulcers and skin breakdown. We get in-services quite often; I would say sometimes 2 a month, but at least once a month. In an interview on 03/19/24 at11:47 AM, the ADON stated, Residents are repositioned every 2 hours or as needed. If they're uncomfortable and requesting repositioning, we reposition. If residents are not repositioned, they will have breakdown, redness, pressure ulcers or they could develop respiratory issues. When asked under what circumstances staff would not reposition a resident, ADON answered, when they're independent and can do it themselves. ADON stated, staff is in-serviced on repositioning for sure annually, and now quarterly since I've been asked this question more than once. Record review of facility's Repositioning Policy (not dated) revealed: Purpose The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. General Guidelines 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 2. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. 3. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. Interventions 1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. 2. Frequency of repositioning a bed- or chair-bound resident should be determined by: a. The type of support surface used; b. The condition of the skin; c. The overall condition of the resident; d. The response to the current repositioning schedule; and e. Overall treatment objectives. 3. Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule. 4. For residents with a Stage I or above pressure ulcer, an every two hour (q2 hour) repositioning schedule is inadequate. 5. Residents who are in a chair should be on an every one hour (ql hour) repositioning schedule. 6. If ineffective, the turning and repositioning frequency will be increased. Documentation The following information should be recorded in the resident's medical record: 1. The position in which the resident was placed. This may be on a flow sheet. 2. The name and title of the individual who gave the care. 3. Any change in the resident's condition. 4. Any problems or complaints made by the resident related to the procedure. 5. If the resident refused the care and the reason(s) why. 6. Observations of anything unusual exhibited by the resident. 7. The signature and title of the person recording the data. Record review of the facility's Prevention of Pressure Injuries Policy revealed: Purpose The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Skin Assessment 1 . Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. 2. During the skin assessment, inspect: a. Presence of erythema; b. Temperature of skin and soft tissue; and c. Edema. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema) For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. Mobility/Repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. 3. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Support Surfaces and Pressure Redistribution 1. Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice. Monitoring I. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.

Based on Interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 4 of 109 days reviewed for RN coverage. 1. The facility failed to ensure that an RN was present in the facility on two occasions, and 2. The facility failed to ensure that an RN was present in the facility for at least 8 consecutive hours per day on two separate occasions. This failure could place residents at risk of missed nursing assessments, interventions, and treatments. The findings included: Record review of the facility schedules for December, 2023, and January, February, and March (1-18) 2024 revealed: No RN coverage on Saturday, 12/30/23. No RN coverage on Saturday, 01/06/24. RN coverage for only 6 consecutive hours on Friday, 02/09/24. RN coverage for only 4 1/2 consecutive hours on Friday, 03/08/24. Record review of the schedule for 02/09/24 revealed there was no RN scheduled to work. Review of timesheets for 02/09/24 for the DON and the MDS nurse revealed the DON did not work that day and the MDS nurse only worked 6.4 hours. Record review of the schedule for 03/08/24 revealed there was no RN scheduled to work. Review of timesheets for 03/08/24 for the DON and the MDS nurse revealed the MDS nurse did not work that day and the DON only worked 4.6 hours. During an interview with the DON on 03/19/24 at 03:14 PM, she stated that she was unaware that a 6:00pm to 6:00am shift did not count for the 8 hours of RN coverage because it was a 12-hour shift. The DON also stated that some of the days that there was no RN coverage on the schedule, either she or the MDS nurse would be at the facility to provide RN coverage. The DON stated that without RN coverage, the residents were at risk of not receiving care or assessments that needed to be done.