Every finding on record at Hereford Nursing & Rehabilitation

Based on observation, interview, and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated for 2 (Resident #8 and Resident #30) of 15 residents reviewed for investigating abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to complete a thorough investigation of Resident #8's injury of unknown source (black eye).2. The facility failed to complete a thorough investigation of misappropriation of Resident #30's property (missing diamond ring).These failures could place residents at risk of continued abuse/misappropriation of property in the facility.Findings Included:1. Record review of Resident #8's admission record dated 08/06/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning) and dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere mild with mood disturbance.Record review of Resident #8's quarterly MDS completed on 06/16/25 revealed a BIMS score of 8 which indicated moderate cognitive impairment. Resident #8 was noted to require setup or clean-up assistance or supervision/touching assistance across all ADLs.Record review of Resident #8's care plan completed on 06/17/25 revealed he was not able to measure his pain on a pain scale from 0-10 due to cognitive impairment and he had limited physical mobility. Resident #8 was noted to have Dementia with cognitive impairment as evidence by: Memory problems.Record review of Resident #8's orders revealed the following: Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGETSTIVE) HEART FAILURE. with start date of 11/27/24. Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE. with start date of 11/27/24.Record review of Resident #8's progress notes from 07/07/25 to 08/07/25 revealed the following note written by LVN D on 07/31/25 at 12:41 PM: [Initials of dialysis center] called concerning black eye to resident explained it was from a shower head that fell onto his eye.Further review revealed no other progress notes were found pertaining to the black eye.Record review of incident by incident report for May-July of 2025 revealed Resident #8 had a bruise incident on 07/30/25.Record review of incident report found in EHR under Clinical and Risk Management revealed the following: . Bruise Date 7/30/2025 11:00 (AM)Resident: [Name of Resident #8]Incident Location: ShowerPerson Preparing Report: [Name of LVN A]Incident DescriptionNursing Description: Resident noticed with a bruise to right eye underneath. Resident noted earlier was self showering in shower and then noted with bruise. Resident denies falling. No other injuries noted.Resident Description: I don't knowWas this incident witnessed: N .Description: Resident noted to go in shower and shower self, Showerhead is a removeable sprayer and comes off the wall.Injuries Observed at Time of IncidentInjury Type BruiseInjury Location 4) FaceLevel of Pain:Numerical: 0 .Mental Status Lack of Safety Awareness .Agencies/People NotifiedPhysician . 7/30/2025 11:05 (AM)DON/RN . 7/30/25 15:49 (03:49 PM)Family Member . 7/30/2025 11:10 (AM)During an observation and interview on 08/06/25 at 09:18 AM LVN A stated when a resident has an injury nurses document in the EHR under Clinical and Risk Management. She demonstrated how to find incident reports in the EHR.During an observation and interview on 08/06/25 at 09:45 Resident #8 was standing near the nurses' station. He had fading, yellowish, green bruising approximately the size of a quarter underneath his right eye. He stated no one hit him. When asked about the bruise he stated a garlic was growing above his right eyebrow (gestured to the area) and it slid down his face. He also mentioned that his right ear was falling. When asked directly if a shower head had fallen on his eye, he stated it had not.2. Record review of Resident #30's admission record dated 08/06/25 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and other signs and symptoms involving cognitive functions and awareness.Record review of Resident #30's admission MDS completed on 07/15/25 revealed a BIMS score of 10 which indicated moderately impaired cognition.Record review of Resident #30's care plan completed on 07/15/25 revealed she had impaired communication due to cognitive impairment. Resident #30 was noted to have dementia with cognitive impairment Record review of Resident #30's progress notes from 07/06/25 to 08/06/25 revealed no mention of her missing diamond ring. It did reveal the following progress note written by LVN D on 08/02/25 at 09:06 AM: resident is slapping and hitting staff and other residents. making accusations that staff and other residents are stealing her stuff.Record review of incident by incident report for May-July 2025 revealed no mention of Resident #30's ring or any incident of misappropriation of resident property.Record review of grievance for the last three months revealed a grievance written by ADM on 07/28/25 regarding Resident #30's missing ring.During an observation and interview on 08/05/25 at 11:06 AM Resident #30 wheeled herself in her wheelchair down the hall to speak to this surveyor. She stated she had a diamond ring stolen. She stated it was a diamond solitaire and it was given to her by a family member. She stated she did not know who took it but she did know it was missing.During an interview on 08/05/25 at 02:49 PM Resident #30's family member stated Resident #30's diamond solitaire ring disappeared on 07/28/25. He stated the ring was on her finger and in a ring keeper with her two wedding diamond rings and a gold band. He stated the ring keeper was a plastic ring that went through all of her rings to keep them together and on her finger.During an observation and interview on 08/06/25 at 10:21 AM Resident #30 was seated in her wheelchair at the nurses' station. She had a gold band and a larger silver ring with purple stones in it on her finger but no ring keeper. She stated the ring with the purple stones was fake. She stated she was very sad her diamond ring had been stolen.During an interview on 08/06/25 at 10:33 AM Resident #30's family member stated after her diamond solitaire ring was stolen, he cut the ring protector and took her other two diamond rings home leaving her with the gold band only. He stated the silver ring with the purple stones was his way of giving her something pretty to wear that was not valuable. He stated he visited Resident #30 on 07/26/25 and her diamond solitaire ring was on her finger with her other rings inside the ring keeper. He stated he visited her on 07/28/25 and the ring was not on her finger, but the other three rings (gold band and two wedding diamond rings) were still inside the ring keeper on her finger. He stated someone would have had to cut the band of the diamond solitaire ring to get it out of the ring keeper and off her finger. He stated as soon as he noticed the diamond solitaire ring was missing, he told MDS LVN and she went and got [first name of ADM]. He stated ADM called the owner of the local pawn shop regarding Resident #30's missing ring.During an interview on 08/07/25 at 09:29 AM LVN A stated she did not see the shower head fall on Resident #8's eye. She stated Resident #8 had been in the shower by himself. She stated, When staff are not looking, he will go in there by himself to shower and we knew he was in there because he opened the door to tell us he needed a towel. LVN A stated later in the day she noticed the bruise to Resident #8's right eye. She stated when she first interviewed him and filled out the incident report, he told her he did not know how it happened. She stated later when she spoke to him about it again, he told her the shower head fell on his eye. LVN A stated she forgot to document that conversation anywhere. During an interview on 08/07/25 at 09:46 PM DON stated she expects her staff to report injuries of unknown origin and missing resident property to her. She stated, We investigate it. She stated Resident #8 was in the shower with an aide and the aide believed he hit himself with the shower head. She stated she was not sure which aide was with him in the shower. DON stated it was not okay for staff to assume what happened with an injury of unknown origin. She stated Resident #8 told her the shower head bruised his eye. When asked where she documented that conversation she stated, I haven't completed his note on his event report yet, but it would be in there. She stated staff were to report missing resident property to her and we do an investigation. Seh stat4ed Resident #30's family member told her about the missing diamond ring. She stated ADM was notified and he investigated. DON stated ADM wrote a grievance regarding the ring.During an interview on 08/07/25 at 09:59 AM MDS LVN stated Resident #30's family member reported the missing diamond ring to her and she immediately let DON and ADM know. She stated she and ADM went to Resident #30's room and began to search everywhere for the ring. During an interview on 08/07/25 at 10:33 AM ADM stated Resident #8 was fine when he went into the shower and had a black eye when he came out. He stated Resident #8 was tall and the shower head is right there, and he probably turned and bumped his head on it (the shower head). He stated he looked for Resident #30's ring and wrote a grievance. ADM stated he spoke to staff who worked the days the ring disappeared, but he did not document any of those conversations or his search for the ring. He stated he called the owner of the local pawn shop and described the ring and asked for a call if it came into the pawn shop, but he did not document his call to the pawn shop. He stated he told Resident #30's family member to file a police report. Record review of facility policy titled Abuse/Neglect and dated 11/15/2016 revealed the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Injury of Unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury . All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s).

Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #8 and Resident #30) of 15 residents reviewed for abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to implement their policy titled Abuse/Neglect and report Resident #8's black eye to state authorities.2. The facility failed to implement their policy titled Abuse/Neglect and report Resident #30's missing diamond ring to state authorities.This failure placed residents at increased risk of abuse, neglect, exploitation and misappropriation of their property.Findings Included:1. Record review of Resident #8's admission record dated 08/06/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning) and dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere mild with mood disturbance.Record review of Resident #8's quarterly MDS completed on 06/16/25 revealed a BIMS score of 8 which indicated moderate cognitive impairment. Resident #8 was noted to require setup or clean-up assistance or supervision/touching assistance across all ADLs.Record review of Resident #8's care plan completed on 06/17/25 revealed he was not able to measure his pain on a pain scale from 0-10 due to cognitive impairment and he had limited physical mobility. Resident #8 was noted to have Dementia with cognitive impairment as evidence by: Memory problems.Record review of Resident #8's orders revealed the following: Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGETSTIVE) HEART FAILURE. with start date of 11/27/24. Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE. with start date of 11/27/24.Record review of Resident #8's progress notes from 07/07/25 to 08/07/25 revealed the following note written by LVN D on 07/31/25 at 12:41 PM: [Initials of dialysis center] called concerning black eye to resident explained it was from a shower head that fell onto his eye.Further review revealed no other progress notes were found pertaining to the black eye.Record review of incident by incident report for May-July of 2025 revealed Resident #8 had a bruise incident on 07/30/25.Record review of incident report found in EHR under Clinical and Risk Management revealed the following: . Bruise Date 7/30/2025 11:00 (AM)Resident: [Name of Resident #8]Incident Location: ShowerPerson Preparing Report: [Name of LVN A]Incident DescriptionNursing Description: Resident noticed with a bruise to right eye underneath. Resident noted earlier was self showering in shower and then noted with bruise. Resident denies falling. No other injuries noted.Resident Description: I don't knowWas this incident witnessed: N .Description: Resident noted to go in shower and shower self, Showerhead is a removeable sprayer and comes off the wall.Injuries Observed at Time of IncidentInjury Type BruiseInjury Location 4) FaceLevel of Pain:Numerical: 0 .Mental Status Lack of Safety Awareness .Agencies/People NotifiedPhysician . 7/30/2025 11:05 (AM)DON/RN . 7/30/25 15:49 (03:49 PM)Family Member . 7/30/2025 11:10 (AM)During an observation and interview on 08/06/25 at 09:18 AM LVN A stated when a resident has an injury nurses document in the EHR under Clinical and Risk Management. She demonstrated how to find incident reports in the EHR.During an observation and interview on 08/06/25 at 09:45 Resident #8 was standing near the nurses' station. He had fading, yellowish, green bruising approximately the size of a quarter underneath his right eye. He stated no one hit him. When asked about the bruise he stated a garlic was growing above his right eyebrow (gestured to the area) and it slid down his face. He also mentioned that his right ear was falling. When asked directly if a shower head had fallen on his eye, he stated it had not.2. Record review of Resident #30's admission record dated 08/06/25 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and other signs and symptoms involving cognitive functions and awareness.Record review of Resident #30's admission MDS completed on 07/15/25 revealed a BIMS score of 10 which indicated moderately impaired cognition.Record review of Resident #30's care plan completed on 07/15/25 revealed she had impaired communication due to cognitive impairment. Resident #30 was noted to have dementia with cognitive impairment Record review of Resident #30's progress notes from 07/06/25 to 08/06/25 revealed no mention of her missing diamond ring. It did reveal the following progress note written by LVN D on 08/02/25 at 09:06 AM: resident is slapping and hitting staff and other residents. making accusations that staff and other residents are stealing her stuff.Record review of incident by incident report for May-July 2025 revealed no mention of Resident #30's ring or any incident of misappropriation of resident property.Record review of grievance for the last three months revealed a grievance written by ADM on 07/28/25 regarding Resident #30's missing ring.During an observation and interview on 08/05/25 at 11:06 AM Resident #30 wheeled herself in her wheelchair down the hall to speak to this surveyor. She stated she had a diamond ring stolen. She stated it was a diamond solitaire and it was given to her by a family member. She stated she did not know who took it but she did know it was missing.During an interview on 08/05/25 at 02:49 PM Resident #30's family member stated Resident #30's diamond solitaire ring disappeared on 07/28/25. He stated the ring was on her finger and in a ring keeper with her two wedding diamond rings and a gold band. He stated the ring keeper was a plastic ring that went through all of her rings to keep them together and on her finger.During an observation and interview on 08/06/25 at 10:21 AM Resident #30 was seated in her wheelchair at the nurses' station. She had a gold band and a larger silver ring with purple stones in it on her finger but no ring keeper. She stated the ring with the purple stones was fake. She stated she was very sad her diamond ring had been stolen.During an interview on 08/06/25 at 10:33 AM Resident #30's family member stated after her diamond solitaire ring was stolen, he cut the ring protector and took her other two diamond rings home leaving her with the gold band only. He stated the silver ring with the purple stones was his way of giving her something pretty to wear that was not valuable. He stated he visited Resident #30 on 07/26/25 and her diamond solitaire ring was on her finger with her other rings inside the ring keeper. He stated he visited her on 07/28/25 and the ring was not on her finger, but the other three rings (gold band and two wedding diamond rings) were still inside the ring keeper on her finger. He stated someone would have had to cut the band of the diamond solitaire ring to get it out of the ring keeper and off her finger. He stated as soon as he noticed the diamond solitaire ring was missing, he told MDS LVN and she went and got [first name of ADM]. He stated ADM called the owner of the local pawn shop regarding Resident #30's missing ring.During an interview on 08/07/25 at 09:17 AM CNA B stated when a resident had an injury of unknown origin or a new bruise, she reported the injury to her charge nurse and ADM. She stated she had been trained and was regularly trained on reporting injuries of unknown origin to her charge nurse and ADM. CNA B stated if a resident told her they were missing personal property she would report it to her charge nurse and DON. She stated she had been trained on this procedure. She stated she heard about Resident #30's missing ring when ADM asked staff if they had seen the ring. She stated she was not working the day Resident #8 acquired his black eye and she was told by the CNA going off the night shift that it happened due to a fall. CNA B stated residents could be hurt more than we see if injuries and missing property were not properly reported.During an interview on 08/07/25 at 09:29 AM LVN A stated if a CNA drew her attention to, or she noticed on her own an injury of unknown origin on a resident she would notify the physician, DON, and ADM. She stated she had been trained and was regularly trained on this procedure. LVN A stated, Once a month we go through the reporting process. She stated a possible negative outcome for a resident if injuries of unknown origin were not properly reported was, If they have a bruise we don't know if they fell, or it was caused by an object or something. Sometimes the bruises cause blood clots, and they could have a fracture or something and we don't take care of it. She stated she did not see the shower head fall on Resident #8's eye. She stated Resident #8 had been in the shower by himself. She stated, When staff are not looking, he will go in there by himself to shower and we knew he was in there because he opened the door to tell us he needed a towel. LVN A stated later in the day she noticed the bruise to Resident #8's right eye. She stated when she first interviewed him and filled out the incident report, he told her he did not know how it happened. She stated later when she spoke to him about it again, he told her the shower head fell on his eye. LVN A stated she forgot to document that conversation anywhere. She stated when a resident's property went missing the procedure was to report to DON and ADM. LVN A stated she had been trained on this procedure probably every month. She stated she heard about Resident #30's missing ring when ADM was asking staff if they had seen the ring. LVN A stated a possible negative outcome of not reporting residents missing property was, This is their home and if we don't report it, and it is valuable to the resident, they will feel neglected that we didn't do anything about it.During an interview on 08/07/25 at 09:46 PM DON stated she expects her staff to report injuries of unknown origin and missing resident property to her. She stated, We investigate it. She stated staff had been trained on these reporting procedures at hire and about every 6 months during in-services. She stated she did not think there was a negative outcome to a resident if an injury of unknown origin was not reported to the state. She stated Resident #8 was in the shower with an aide and the aide believed he hit himself with the shower head. She stated she was not sure which aide was with him in the shower. DON stated it was not okay for staff to assume what happened with an injury of unknown origin. She stated Resident #8 told her the shower head bruised his eye. When asked where she documented that conversation she stated, I haven't completed his note on his event report yet, but it would be in there. DON stated she did not know of a possible negative outcome of not reporting resident's missing property to the state. She stated Resident #30's family member told her about the missing diamond ring. She stated ADM was notified and he investigated. DON stated ADM wrote a grievance regarding the ring and that was why it was not reported to the state. DON stated ADM was usually responsible for reporting incidents to the state.During an interview on 08/07/25 at 09:59 AM MDS LVN stated she had been trained 3-4 times a year on reporting injuries of unknown origin and missing resident property. She stated a resident could be negatively impacted if an injury of unknown origin was not reported. MDS LVN stated, It could affect their health, it cold affected their mobility. She stated staff might not give proper care to the resident if they were unaware of the injury. MDS LVN stated if a resident's missing property was reported to her, she would tell DON and ADM. She stated there was a clause in the admission packet that stated the facility was not responsible for lost or stolen property. She stated at admission the residents and families were encouraged not to bring items of value to the facility. She stated if misappropriation of resident property was not reported the resident and the family could be upset. She stated Resident #30's family member reported the missing diamond ring to her and she immediately let DON and ADM know. She stated she and ADM went to Resident #30's room and began to search everywhere for the ring. MDS LVN stated ADM and DON were responsible for reporting misappropriated resident property to the state.During an interview on 08/07/25 at 10:33 AM ADM stated he expected his staff to report injuries of unknown origin and missing resident property to him or the charge nurse. He stated staff were trained on reporting procedure at hire and biannually. He stated he would not speculate on something that had not happened. ADM stated Resident #8 was fine when he went into the shower and had a black eye when he came out. He stated he would speculate on that because Resident #8 was tall and the shower head is right there, and he probably turned and bumped his head on it (the shower head). He stated he looked for Resident #30's ring and wrote a grievance. ADM stated he spoke to staff who worked the days the ring disappeared, but he did not document any of those conversations or his search for the ring. He stated he called the owner of the local pawn shop and described the ring and asked for a call if it came into the pawn shop, but he did not document his call to the pawn shop. He stated he told Resident #30's family member to file a police report. ADM stated he did not know he was supposed to report Resident #8's black eye and Resident #30's missing ring to the state. ADM stated, Do I need to report it when a resident loses their glasses? Because glasses cost a lot more than that diamond ring, I guarantee. He stated he was responsible for reporting incidents to the state.During exit conference on 08/07/25 at 01:35 PM after preliminary findings were read, ADM stated, I guess I'll start reporting lost pajamas and lost glasses, then.Record review of facility policy titled Abuse/Neglect and dated 11/15/2016 revealed the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Injury of Unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury . All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents . Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services . Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s).

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 15 residents (Residents #37, #35, and #40) reviewed for infection control. CNA C failed to utilize clean gloves while performing incontinence care for Resident #37. LVN D failed to disinfect the blood pressure cuff between uses for Resident #35 and Resident #40. These failures could place residents at risk for cross contamination and infection.The findings included:1.Resident #37Record review of Resident #37 undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #37 had a medical history of type two diabetes, muscle weakness, and chronic kidney disease. Record review of Resident #37's annual MDS dated [DATE] revealed the following:*Section C- Cognitive Patterns, revealed a BIMS score of 13, which indicated Resident #37 was cognitively intact. *Section H- Bladder and bowel revealed resident was frequently incontinent of bowel and bladder.During an incontinence care observation on 8/05/2025 at 11:10 AM, CNA C placed a bag of clean wipes and clean gloves on a table in Resident #37's room. CNA C proceeded with incontinence care for Resident #37's and reached into the clean bag with contaminated gloves to grab the wipes. While reaching into the clean bag with contaminated gloves, CNA C picked up the clean gloves with the contaminated gloves and placed them back into the bag. CNA C changed gloves, washed her hands with soap and water, and donned on contaminated gloves from the bag and finished incontinence care for Resident #37. During an interview on 8/6/2025 at 1:54pm with CNA C, she stated the infection preventionist was the DON. She stated she had been trained on infection control and her last training was approximately a month ago. She stated she had been trained to change her gloves during incontinence care. She stated if clean gloves were touched with contaminated gloves, those gloves should be thrown away and new ones should be used. She stated she did not notice she had grabbed the clean gloves with contaminated gloves, she believed she had only grabbed the wipes. She stated the potential negative outcome of using contaminated gloves during incontinence care could be spreading infection. She stated they had been trained to put the clean gloves and wipes in one bag and the clean brief in another bag. 2.During a medication administration observation on 8/6/2025 at 8:05AM LVN D used a blood pressure cuff to take Resident #35's blood pressure. At 8:16 AM, LVN D used the same blood pressure cuff to take Resident #40's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #35 or Resident #40. During an interview on 8/6/2025 at 1:39pm with LVN D she stated she had been trained on infection control and her last training was this past summer. She stated the infection preventionist was the DON. She stated she had been trained to disinfect the blood pressure cuff between residents. She stated the potential negative outcome of not disinfecting the blood pressure cuff before and after use could be spreading skin disease, cold, flu, bacteria or viruses. She stated she did not disinfect the blood pressure because she had a bad habit of not doing so. During an interview on 8/7/2025 at 9:54AM with the ADM, he stated the DON was the infection preventionist. He stated infection control was monitored by doing walkarounds and having staff do return demonstrations. He stated staff are also in-service on infection control and the last in-service was last month. He stated staff are trained to place a set of gloves with one bag with the wipes and then another set of gloves with the clean brief, that way they stay clean in between glove changes. He stated he was not aware of staff mixing clean gloves with contaminated gloves. The ADM stated staff had been trained on disinfecting the blood pressure cuff after each use. He stated that his expectation was for staff to disinfect the blood pressure cuff after use, with the appropriate wipes and allow the blood pressure cuff to dry completely before using on another resident. He stated his expectations of staff are to follow the policy. He stated the potential negative outcome of not following infection control practices could be possible infections. During an interview on 8/07/2025 at 10:08 AM with the DON, she stated she was the infection preventionist. She stated staff are trained on infection control twice a year and yearly through competencies. She stated the last training was on 7/01/2025. She stated she was not aware staff was contaminating clean gloves during incontinence care. She stated staff are trained to have two bags, one with the wipes and one with the gloves that way after they change their gloves and wash their hands, they can don clean gloves. She stated staff have been trained to disinfect the blood pressure cuff after each resident use. She stated she was not aware staff had not been disinfecting the blood pressure cuff after using it on residents. She stated the potential negative outcome of staff not following infection control could be cross contamination and risk for infection. Record review of undated facility policy titled Remember Care begins and Ends with Washing your hands revealed; 2. Gather supplies, keeping the blue gloves and clean brief in the bag by themselves.If contamination occurs while performing the skill, start over from the very beginning. If contamination of your work area occurs, start over from the beginning.Bag 1: Blue gloves, brief. Bag 2: Wipes, gloves (4-5[pair]), towel/blue pad. Record review of facility policy titled Infection Control- Precautions- Categories and Notices effective date 12/2017, revealed; f. Resident- Care Equipment.If use of common items is unavoidable, the adequately clean and disinfect them before use for another resident.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #8 and Resident #30) of 15 residents reviewed for reporting abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to report Resident #8's black eye to state authorities.2. The facility failed to report Resident #30's missing diamond ring to state authorities.These failures could place residents at risk of continued abuse/misappropriation of property in the facility.Findings Included:1. Record review of Resident #8's admission record dated 08/06/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning) and dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere mild with mood disturbance.Record review of Resident #8's quarterly MDS completed on 06/16/25 revealed a BIMS score of 8 which indicated moderate cognitive impairment. Resident #8 was noted to require setup or clean-up assistance or supervision/touching assistance across all ADLs.Record review of Resident #8's care plan completed on 06/17/25 revealed he was not able to measure his pain on a pain scale from 0-10 due to cognitive impairment and he had limited physical mobility. Resident #8 was noted to have Dementia with cognitive impairment as evidence by: Memory problems.Record review of Resident #8's orders revealed the following: Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGETSTIVE) HEART FAILURE. with start date of 11/27/24. Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE. with start date of 11/27/24.Record review of Resident #8's progress notes from 07/07/25 to 08/07/25 revealed the following note written by LVN D on 07/31/25 at 12:41 PM: [Initials of dialysis center] called concerning black eye to resident explained it was from a shower head that fell onto his eye.Further review revealed no other progress notes were found pertaining to the black eye.Record review of incident by incident report for May-July of 2025 revealed Resident #8 had a bruise incident on 07/30/25.Record review of incident report found in EHR under Clinical and Risk Management revealed the following: . Bruise Date 7/30/2025 11:00 (AM)Resident: [Name of Resident #8]Incident Location: ShowerPerson Preparing Report: [Name of LVN A]Incident DescriptionNursing Description: Resident noticed with a bruise to right eye underneath. Resident noted earlier was self showering in shower and then noted with bruise. Resident denies falling. No other injuries noted.Resident Description: I don't knowWas this incident witnessed: N .Description: Resident noted to go in shower and shower self, Showerhead is a removeable sprayer and comes off the wall.Injuries Observed at Time of IncidentInjury Type BruiseInjury Location 4) FaceLevel of Pain:Numerical: 0 .Mental Status Lack of Safety Awareness .Agencies/People NotifiedPhysician . 7/30/2025 11:05 (AM)DON/RN . 7/30/25 15:49 (03:49 PM)Family Member . 7/30/2025 11:10 (AM)During an observation and interview on 08/06/25 at 09:18 AM LVN A stated when a resident has an injury nurses document in the EHR under Clinical and Risk Management. She demonstrated how to find incident reports in the EHR.During an observation and interview on 08/06/25 at 09:45 Resident #8 was standing near the nurses' station. He had fading, yellowish, green bruising approximately the size of a quarter underneath his right eye. He stated no one hit him. When asked about the bruise he stated a garlic was growing above his right eyebrow (gestured to the area) and it slid down his face. He also mentioned that his right ear was falling. When asked directly if a shower head had fallen on his eye, he stated it had not.2. Record review of Resident #30's admission record dated 08/06/25 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and other signs and symptoms involving cognitive functions and awareness.Record review of Resident #30's admission MDS completed on 07/15/25 revealed a BIMS score of 10 which indicated moderately impaired cognition.Record review of Resident #30's care plan completed on 07/15/25 revealed she had impaired communication due to cognitive impairment. Resident #30 was noted to have dementia with cognitive impairment Record review of Resident #30's progress notes from 07/06/25 to 08/06/25 revealed no mention of her missing diamond ring. It did reveal the following progress note written by LVN D on 08/02/25 at 09:06 AM: resident is slapping and hitting staff and other residents. making accusations that staff and other residents are stealing her stuff.Record review of incident by incident report for May-July 2025 revealed no mention of Resident #30's ring or any incident of misappropriation of resident property.Record review of grievance for the last three months revealed a grievance written by ADM on 07/28/25 regarding Resident #30's missing ring.During an observation and interview on 08/05/25 at 11:06 AM Resident #30 wheeled herself in her wheelchair down the hall to speak to this surveyor. She stated she had a diamond ring stolen. She stated it was a diamond solitaire and it was given to her by a family member. She stated she did not know who took it but she did know it was missing.During an interview on 08/05/25 at 02:49 PM Resident #30's family member stated Resident #30's diamond solitaire ring disappeared on 07/28/25. He stated the ring was on her finger and in a ring keeper with her two wedding diamond rings and a gold band. He stated the ring keeper was a plastic ring that went through all of her rings to keep them together and on her finger.During an observation and interview on 08/06/25 at 10:21 AM Resident #30 was seated in her wheelchair at the nurses' station. She had a gold band and a larger silver ring with purple stones in it on her finger but no ring keeper. She stated the ring with the purple stones was fake. She stated she was very sad her diamond ring had been stolen.During an interview on 08/06/25 at 10:33 AM Resident #30's family member stated after her diamond solitaire ring was stolen, he cut the ring protector and took her other two diamond rings home leaving her with the gold band only. He stated the silver ring with the purple stones was his way of giving her something pretty to wear that was not valuable. He stated he visited Resident #30 on 07/26/25 and her diamond solitaire ring was on her finger with her other rings inside the ring keeper. He stated he visited her on 07/28/25 and the ring was not on her finger, but the other three rings (gold band and two wedding diamond rings) were still inside the ring keeper on her finger. He stated someone would have had to cut the band of the diamond solitaire ring to get it out of the ring keeper and off her finger. He stated as soon as he noticed the diamond solitaire ring was missing, he told MDS LVN and she went and got [first name of ADM]. He stated ADM called the owner of the local pawn shop regarding Resident #30's missing ring.During an interview on 08/07/25 at 09:46 PM DON stated she did not think there was a negative outcome to a resident if an injury of unknown origin was not reported to the state. DON stated she did not know of a possible negative outcome of not reporting resident's missing property to the state. DON stated ADM wrote a grievance regarding the ring and that was why it was not reported to the state. DON stated ADM was usually responsible for reporting incidents to the state.During an interview on 08/07/25 at 09:59 AM MDS LVN stated Resident #30's family member reported the missing diamond ring to her and she immediately let DON and ADM know. She stated ADM and DON were responsible for reporting misappropriated resident property to the state.During an interview on 08/07/25 at 10:33 AM ADM stated Resident #8 was fine when he went into the shower and had a black eye when he came out. He stated, I will speculate on that. ADM stated Resident #8 was tall and the shower head is right there, and he probably turned and bumped his head on it (the shower head). He stated he looked for Resident #30's ring and wrote a grievance. He stated he told Resident #30's family member to file a police report. ADM stated he did not know he was supposed to report Resident #8's black eye and Resident #30's missing ring to the state. ADM stated, Do I need to report it when a resident loses their glasses? Because glasses cost a lot more than that diamond ring, I guarantee. He stated he was responsible for reporting incidents to the state.During exit conference on 08/07/25 at 01:35 PM after preliminary findings were read, ADM stated, I guess I'll start reporting lost pajamas and lost glasses, then.Record review of facility policy titled Abuse/Neglect and dated 11/15/2016 revealed the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Injury of Unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury . Appropriate notification to state and home office will be the responsibility of the administrator and per policy. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents . Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services . Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC.

Based on interview and record review the facility failed to complete a significant change assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for 2 (Resident #4 and Resident #39) of 15 residents reviewed for timing of assessments.1. The facility failed to complete Resident #4's significant change MDS within 14 days of her admission to hospice care on 07/16/25.2. The facility failed to complete Resident #39's significant change MDS within 14 days of her admission to hospice care on 12/26/24.These failures could place residents at risk of not receiving necessary care/coordination of care.Findings Included:1. Record review of Resident #4's admission record dated 08/06/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease. Her admission record did not mention hospice.Record review of Resident #4's significant change MDS assessment completed on 08/05/25 revealed a BIMS score of 3 which indicated severely impaired cognition. Resident #4 was noted to be receiving hospice care While a Resident. The RN signature at Z0500 which indicated the assessment was complete was DON's signature.Record review of Resident #4's care plan completed on 05/14/25 revealed Resident #4 was on hospice and required hospice as evidenced by terminal illness.Record review of Resident #4's order summary dated 08/06/25 revealed no mention of hospice.Record review of Resident #4's hospice paperwork under the miscellaneous tab in her EHR revealed a certification for hospice care signed by her physician on 07/14/25 with an election date and effective date of 07/16/25. A voice order for hospice care was noted from Resident #4's attending physician on 07/16/25 at 09:30 AM.2. Record review of Resident #39's admission record dated 08/06/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, anxiety disorder, and Parkinsonism. Her admission record revealed her primary payer was Hospice Medicaid and listed the name of her hospice care provider.Record review of Resident #39's quarterly MDS completed 07/23/25 revealed a BIMS of 3 which indicated severely impaired cognition. Resident #39 was noted to be receiving hospice care While a Resident. The RN signature at Z0500 which indicated the assessment was complete was DON's signature.Record review of Resident #39's significant change MDS completed on 01/20/25 revealed a BIMS of 3 which indicated severely impaired cognition. Resident #39 was noted to be receiving hospice care While a Resident. The RN signature at Z0500 which indicated the assessment was complete was DON's signature.Record review of Resident #39's care plan completed on 06/03/25 revealed she required hospice as evidence by terminal illness.Record review of Resident #39's order summary dated 08/06/25 revealed one mention of hospice as noted in the following order: Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 4 hours as needed for anxiety/hospice related to ANXIETY DISORDER, UNSPECIFIED (F41.9) for 365 Days. Start date of order was 07/30/25.Record review of Resident #39's hospice paperwork under the miscellaneous tab in her EHR revealed a certification for hospice care with an election date of 12/26/24 and effective date of 12/26/24. A voice order for hospice care was noted from Resident #39's attending physician on 12/26/24 at 10:00 AM.During an interview on 08/07/25 at 09:29 AM LVN A stated MDS LVN was responsible for completing MDS assessments timely. She stated a possible negative outcome of a MDS assessment not being completed timely was staff would not have the correct information regarding resident care.During an interview on 08/07/25 at 09:46 AM DON stated MDS LVN was responsible for completing MDS assessments timely. She stated she (DON) signed off on the assessments as complete because she was an RN. DON stated MDS LVN sent her (DON) an email or came to her (DON's) office to let her know which MDS assessments were ready to be signed as completed. She stated she did not know why Resident #4 and Resident #39's significant change assessments were not signed as completed within the 14-day time frame provided by the RAI manual. She stated she could not think of a negative outcome to a resident if a significant change MDS was not completed timely. She stated it would affect facility funding which could, in turn, affect resident care negatively.During an observation and interview on 08/07/25 at 09:59 MDS LVN stated she was responsible for ensuring MDS assessments were completed timely. She stated the policy she followed when completing MDS assessments was the RAI. MDS LVN stated residents could be negatively impacted if a significant change MDS was not completed timely. She stated staff's ability to give the proper care to that resident could be negatively impacted. MDS LVN stated when an MDS assessment was ready for DON's signature she would let DON know. She demonstrated how DON could go into EHR and see which assessments were ready for her signature. MDS LVN stated she believed Resident #4 and Resident #39's significant change MDS assessments were completed timely. She stated the work for the assessments was completed within the 14 days allowed and it did not matter what date DON signed the assessments as complete.During an interview on 08/07/25 at 10:33 AM ADM stated MDS LVN was responsible for ensuring MDS assessments were completed timely. He stated, I'm not gonna speculate on what didn't happen regarding a possible negative outcome for residents when MDS assessments were not completed timely.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed a chart on page 38 with the following: Assessment Type.Significant Change.MDS Completion Date.no later than 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Significant Change in Status Assessment . Must be completed (item Z0500B) within 14 days after the determination that the criteria are met for a Significant Change in Status assessment.

Based on interviews and record reviews the facility failed to ensure residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 15 (Resident #19) reviewed for Resident Rights.The facility failed to ensure Resident #19 had a DNR in place which was signed by a physician and dated by the notary public.This failure could cause the loss of valuable time when dealing with a Resident's medical emergency and possible unwarranted death.Findings included:Review of Resident #19's admission record reflected Resident #19 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, unspecified, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Type 2 Diabetes Mellitus with Hypoglycemia without coma, Adult Failure to Thrive, Anxiety Disorder, unspecified, Covid-19, Insomnia, and Major Depressive Disorder, Single Episode, unspecified. Review of Resident #19's Quarterly MDS dated [DATE] revealed she required partial to moderate assistance with all elements of self-care and mobility. She had an indwelling catheter related to neuromuscular dysfunction of the bladder and was occasionally incontinent of bowel. Resident #19 had no nutritional issues with swallowing of liquids and solid foods but indicated some discomfort when chewing solid foods. Resident #19 received constant oxygen via nasal cannula at 2-5 lt./min. to keep oxygen saturation rates above 90% related to hypoxia and received Hospice services twice per week related to Diabetes Mellitus, Unknown Sepsis and Chronic Kidney Disease. Resident #19 had a BIMS score of 04, indicating severe cognitive impairment. Review of Resident #19's care plan dated 08/05/2025 reflected Resident #19 has an order for Do Not Resuscitate (DNR) with a Goal of Resident/Responsible Party decision for DNR will be honored over the next 90 days and an Intervention of In absence of blood pressure, pulse, respiration, CPR will not be initiated, notify MD of change of condition and Resident will be maintained at a level of comfort as ordered by physician.Review of Resident #19's physician orders revealed her active comfort medications were Fentanyl Transdermal Patch 72-Hour, 25MCG/HR, apply one patch transdermal every 72-hours for Pain and remove per schedule, and Morphine Sulfate (Concentrate) Oral Solution 20MG/ML, give 0.1ml. by moth every 4 hours as needed for pain level 7-10.Review of Resident #19's DNR revealed it was signed by the resident on 07/14/2021. The DNR was also signed by two witnesses on 07/14/2021 and notarized. The notary's signature and seal were not dated, and the DNR was not signed and dated by a physician.An interview with LVN A on 08/07/2025 at 10:28AM reflected Resident #19's DNR was not valid as it was not signed by a physician. She stated if the resident went into cardiac arrest, she would have to ask the DON for clarification of the DNR and how to proceed with Resident #19's care.An interview with the DON on 08/07/2025 at 10:35AM reflected the DNR was not valid as it was not signed by a physician and the notary had not dated her signature and seal. She stated if the resident went into cardiac arrest, the facility would have to send her to the ER via ambulance. The DON stated staff give EMS personnel the resident's code status while they prepare the resident for transport to the hospital. She stated the negative outcome of not having the DNR signed and dated by the physician and notary would be the loss of valuable life-saving time while the resident's representative was called to discuss the resident's code status wishes.An interview with the Administrator on 08/07/2025 at 11:21AM reflected Resident #19's DNR was not valid due to no signature and date by a physician, and the notary had not dated her signature and seal. He stated the facility had a book at the nurse's station with all the resident's code statuses and if Resident #19 had a red page in the book it indicated Do Not Resuscitate. If the book had a green page for the resident, it indicated the resident had requested CPR as a life-saving measure. He stated if Resident #19 went into cardiac arrest, staff would refer to the book instead of the resident's chart to determine the resident's code status. He stated he would not assume what would happen if Resident #19 went into cardiac arrest, since the DNR was not signed and dated by the physician and notary. The Administrator stated the resident's current sheet in the code status book would be invalid for these reasons.Review of the facility's undated policy Advance Directives Policy and Acknowledgment revealed the following:It is the Health Care Center's policy to provide all residents and/or responsible party members with information relating to an individual's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives. The Health Care Center respects the implementation of such rights and will follow all physicians' orders respecting such rights. Without physician's orders, Health Care Center's staff may be required to institute interventions that differ from the Advance Directive.The Health Care Center will clearly document in each resident's chart whether the resident has executed an Advanced Directive, and if so, what the directives will be. The Health Care Center will not discriminate against an individual based on whether the resident has executed an Advanced Directive. The Health Care Center agrees to provide the resident and/or responsible party with information regarding; Decisions concerning medical care, including the right to accept and refuse treatment when made in accordance with stated law. Valid Advance Directives made in accordance with stated law.If the resident has an invalid Advance Directive or no Advance Directive and the resident or the resident representative wishes to refuse, withhold, or withdraw life-sustaining medical treatment, such decisions shall be made consistent with state law and in conjunction with the Health Care Center's staff, management staff, and the attending physician. Full consideration shall be given to the applicable state law as interpreted by the Legal Department.Review of the facility's Code Status Listing Policy dated 01/28/2017 revealed the following:The facility will provide residents the opportunity to file an Advance Directive document declaring the resident/family/responsible party's end of life wishes and will provide education on options available.Procedure:Resident will be informed of their opportunity to file an Advance Directive document upon admission.The facility will utilize a colored sheet of paper at the front of each resident's chart to assist the staff in quickly identifying code status.Resident/family/responsible party electing DNR will have a red sheet.Resident/family/responsible party electing Full Code (CPR) will have a green sheet.Interdisciplinary team will discuss Advance Directive with the resident/family/responsible party during care plan meetings annually, when there is a significant positive change or a significant deterioration in the resident's clinical condition.

Based on observation, interview, 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 4 (LVN D, LVN E, CNA G, and CNA H) of 4 staff members and 2 of 2 residents (Resident #2 and Resident #45) in that: LVN E did not don PPE gown before administering ordered medications via Peg-tube to Resident #2 LVN E did not don PPE gown before administrating Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45 CNA G did not don PPE gown before assisting LVN E with Foley Catheter Care, Incontinent Care and Wound Care Stage 3 pressure ulcer to coccyx on Resident #45 CNA H did not don PPE gown before, assisting LVN E with Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45 LVN D did not don PPE gown before administering liquid feeding via Peg-tube to Resident #2 These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. Findings include: Observation on 7/17/24 at 8:50AM revealed LVN E did not don PPE gown for the administration of ordered medications for Resident #2's PEG-tube. PPE gown was not present inside room or in hallway outside the door of Resident #2's room. Record review of Resident #2's Admission Record states Resident #2 is a 48 y/o female admitted to facility on 7/1/2007. Medical diagnoses include a diagnosis of Cerebral Palsy. Care Plan dated 7/9/24 states Resident requires total assist with ADL needs, is incontinent of bowel and bladder, must maintain nutritional status via tube feeding related to inability to swallow, and receives all medications, feedings, and fluids via peg tube. Observation on 7/17/24 at 9:33AM revealed that LVN E, CNA G, and CNA H did not don PPE gowns during Foley catheter care, Incontinent bowel care followed by Wound care for Stage 3 pressure ulcer to coccyx for Resident #45. No gowns were used in any of the procedures performed. No gowns were in Resident #45's room or in the hallway outside Resident #45's door. Record review of Resident #45 Admission Record states Resident #45 is a 61 y/o male initially admitted to facility on 2/8/24. Medical diagnoses include Pressure Ulcer of Sacral Region Stage 3 and Obstructive and Reflux Uropathy. Care Plan dated 5/28/24 states; Resident is incontinent of bladder and requires an indwelling Foley catheter, Sacral pressure ulcer stage 3, needs staff assistance for ADLs, and 2 staff members to transfer. Observation on 7/17/24 at 11:45AM revealed LVN D did not don PPE gown, before administration of ordered feeding for Resident #2 via her Peg-tube. PPE gown was not present inside room or in hallway outside her room. Interview on 7/17/24 at 11:55AM LVN D stated she had not been told to wear a gown as part of PPE when using Peg-tube for feeding residents. She did not know what Enhanced Barrier Protection (EBP) meant. She stated a negative outcome of not donning a PPE gown during care is that germs can spread. Interview on 7/17/24 at 1:01PM CNA G stated she had never been told to wear a gown when changing or assisting with any resident care. She did not know what Enhanced Barrier Precautions (EBP) were. She stated a negative outcome of not donning a PPE gown could be Spread of Infection. Interview on 7/17/24 at 1:08PM CNA H stated she had heard talk about wearing a gown, she could not remember who had told her. She stated a negative outcome of not donning a PPE gown ring resident care could be, Infection to the resident. Interview on 7/17/24 at 1:28PM Charge Nurse LVN A stated she had never heard of Enhanced Barrier Precautions (EBP). She did not remember an in-service on EBP being done. She stated a negative outcome of not donning a PPE gown during resident care could be, Possibility of getting bacteria on clothes and transferring. Interview on 7/17/24 at 1:33PM DON stated she was not aware of EBP policy. She was not aware of any in-service or training for staff. When asked what a possible negative outcome could be for not donning a PPE gown during resident care she first stated, I don't know. Administrator was in room and stated to her, Organisms if there are any, and she repeated to Surveyor, Organisms if there are any. Interview on 7/17/24 at 1:38PM with Administrator. He stated he was aware of EBP policy. He stated there had been an in-service on it and he would find it. He stated he had gotten a resignation from facilities former DON who had been at facility for [AGE] years, on March 31, 2024. The current DON started in April of 2024. Current DON may not have known about EBP policy he stated. When asked what a possible negative outcome could be for not donning a PPE gown during resident care he stated, Possibility of transfer of organisms. Interview with LVN E attempted. Tried to contact by phone on 7/17/24 at1:45PM, 1:46PM and 7/18/24 at 9:49AM. Left Voicemails requesting call back. Unable to contact LVN E and she was not working at facility after 12:00PM on 716/24. Did not work through 7/18/24. Record review of facility provided policies, procedures, CMS, and CDC updates received, and in-service: Inservice Titled 'Infection Control, Don & Doffing, Enhanced Barrier Precaution-catheter/wound/peg-tube,' which included: Record review of facility provided Inservice document titled CMS OSO-24-08-NH Dated March 20,2024 effective April 1, 2024, revealed the following: .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO's) that employs targeted gown and glove use during high contact resident care activities.' .Examples of chronic wounds include, but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. .Indwelling medical device examples include central lines, urinary catheters, feeding tubes .EBP is employed when performing the following: Providing hygiene, Changing briefs or assisting with toileting, Device care or use .urinary catheter, feeding tube, wound care any skin opening requiring a dressing. Record Review of Facility provided Inservice document titled; 'CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO's)' updated July 12, 2022, under Key Points revealed: 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 4. Effective implementation of EBP requires staff training on proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at point of care. Record review of Facility provided Policy Titled: 'Enteral and Parenteral Feeding' dated 12/02/2017 under Procedure revealed: 12. Standard precautions, clean techniques, applicable nursing policies, and manufacturer's recommendations are followed by nursing personnel when dealing with nutrition support residents. DON and/or designee are responsible for training and monitoring of nursing personnel on Nutritional Support procedures, documentation, and orders. Record review of Facility provided Policy Titled: 'Administering Medications' dated December 2012 under Policy and implementation revealed: 22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications as applicable. Record review of Facility Policy Titled: 'Perineal Care Male' dated December 8, 2009, under Gather Supplies revealed: Gather needed supplies: i. Washcloths or Pre-moistened cleaning wipes ii. Towels iii. Soap or no-rinse perineal cleanser iv. Clean wash basin(s) or comfortably warm water v. Clean, disposable examination gloves vi. Overbed table vii. Disposable plastic bags for trash and linen viii. Incontinence pad(s) or brief ix. Additional supplies as needed if heavy soiling is present, i.e., toilet paper. Record review of Facility provided Policy Titled: 'Catheter Care dated February 13, 2007, under Procedure revealed: 1. Gather Supplies: a. Gloves b. Pre-moistened no-rinse disposable wash cloths c. Or wash cloths and basin (if using soap and water) Record review of Facility provided Policy Titled: 'Infection Control Plan': Overview dated 2018 under Facility Assessment revealed: At least annually and on an as needed basis the facility will conduct a facility wide assessment to determine the resources needed to maintain and efficient and up to date infection control program. The facility assessment can assist in determining the types of residents being cared for, what is needed to care for those residents, and what education facility staff need. 48221

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure pantry foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: In an observation of the walk-in pantry on [DATE] at 8:50 AM the following was observed: 1. (4) graham cracker pie crusts in a package, not sealed and open to air with no date or label. 2. (1) open gallon of Big Chief Imitation Vanilla Flavor expiration date [DATE], with no open date. In an observation of the freezer on [DATE] at 8:55 AM the following was observed: 1. (1) box of hamburger patties with approximately 20 patties in the box, open to air with no open date. A small amount of freezer burn on the top patties was observed. In an interview on [DATE] at 9:15 AM, the DC stated all employees were responsible for disposing of expired foods or foods that were not any good. The DC stated that the negative outcome for not throwing away expired items would be that residents could get sick. The DC stated that all employees were also responsible for labeling and sealing any items in the dry food area, refrigerator, and freezer area. In an interview on [DATE] at 9:20 AM, the DS stated that she and her employees were responsible for ensuring foods were labeled and sealed. The DS stated that all employees were responsible for disposing of expired items. The DS said that a possible negative outcome for expired or open foods would be that a resident could get sick or contact pathogens and that not sealing or labeling foods properly could cause freezer burn on the foods. In an interview/observation on [DATE] at 9:30 AM, the DS removed the open pie crusts from the shelf in the Dry Pantry and told Surveyor that she did not know when the item was opened as it was not labeled. Record review of facility provided policy (no date) titled Labeling and Dating Food stated in part: When the food item is removed from the original box, each item must be dated, or container must be dated. Once you open a food item, you must date it the day it was opened. Record review of facility provided policy (not date) titled Dry Storage and Supplies stated in part: Open packages of food are stored in closed containers with tight covers and dated as to when opened. Record review of facility provided policy (not date) Food Safety stated in part: Food is to be tightly wrapped or sealed and covered. Opened food shall be labeled, dated and stored properly. Do not keep potentially hazardous food past the labeled expiration date.

Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for1 of 14 (Resident #13) residents reviewed for bed rails. Resident #13 had (1) one-third bed rail, on the right side of her bed with no documentation of resident consent, or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Record Review of Resident #13's Face Sheet dated July 16, 2024revealed that a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include but not limited to weakness, cognitive communication deficit, unspecified dementia (memory loss) and major depressive order. Record Review of Resident #13's Quarterly MDS assessment dated [DATE] revealed Resident #13 had a BIMS score of 01 indicating that resident had severe cognitive impairment. The MDS revealed that Resident #13 required a 2 person assist with lying to sitting on side of bed, sitting to standing and chair to bed transfer. Record Review of Resident #13's Care plan dated 5/01/2024 revealed the following with no documentation relating to side/bed rail use. Focus: Dementia with cognitive impairment Interventions: Reorient resident as needed. Focus: Limited physical mobility Interventions: Provide supportive care, assistance with mobility as needed. Record Review of Resident #13's clinical record dated 10/09/2023 revealed physician's standing orders of side rails to be used when assessment revealed necessary. Record Review of Resident #13's clinical record under Assessments revealed no documentation of bed rail safety assessment for 1/3 size bed rails. Record Review of Resident #13's clinical record under Assessments revealed an assessment was completed on 10/09/2023 for 1/8 size bed rails. Record Review of Resident #13's clinical record for bed rail consents revealed no documentation of a signed bed rail consent for 1/3 size bed rails. Observation on 07/16/2024 at 10:42AM of Resident #13's bed revealed (1) 1/3 size bed rail on the right side of bed. Observation on 07/17/2024 at 8:30 AM of Resident #13's bed revealed bed rail was no longer on the bed. In an interview on 07/17/2024 at 9:40 AM, LVN A stated that assessment and consents were required for bed rail use. LVN A stated she did know that the bed rail had been taken off the bed but stated that maintenance was responsible for bed rails installation and removal. LVN A stated that a possible negative outcome for bedrails being used without assessments could be that it could cause entrapment, or a resident could try to crawl over the bed rail and get hurt. LVN A stated she did not know what size bed rails were on Resident #13's bed. In an interview/observation on 07/17/2024 at 2:00 PM, Resident #13 was sitting in her recliner. When asked about the bed rails being on her bed, Resident #13 waved her hands back and forth to the side saying, it doesn't matter. Resident #13 was bilingual and to ensure she understood surveyor, CNA C entered the room and relayed the question in Spanish concerning the bed rails. CNA C stated that that Resident #13 didn't care if bedrails were on or off the bed. In an interview on 07/17/2024 at 2:06 PM, the MS stated that he was directed by ADON to take bed rails off the bed on 07/16/2024. The MS stated that the bed rail on Resident #13's bed was 1/3 in size. In an interview on 07/17/2024 at 2:38 PM, the ADON stated she directed MS to take the bed rail off the bed because the family requested the removal. The ADON stated she did not know what size of bed rail was on Resident #13's bed. The ADON stated that a possible negative outcome for having bed rails on the bed was that a resident could be stuck in the bed. In an interview on 07/17/2024 at 2:40 PM, the DON stated that she did not know what size of the bed rails that were on the bed and stated that a possible negative outcome for unneeded bed rails on the bed would be that the resident wouldn't be able to get out of bed. Record Review of facility policy title Bed Rails dated November 8, 2016, revealed the following: Assessment-Prior to use of a bed rail the resident will be assessed to ensure the proper rail is utilized for the resident's need. The facility will re-evaluate the use of the rail on a periodic basis. Based on the resident assessment, the interdisciplinary team will make the determination for the plan of care as it relates to bed rail. Consent-The resident or resident representative will provide consent for the use of rails prior to installation.

Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 14 residents (Resident #4) reviewed for accommodation of needs. Resident #4's call light was not within her reach. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings included: Record review of Resident #4's face sheet, dated 07/17/2024, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, parkinsonism (slowed movements, tremors), urinary tract infection, dementia (memory loss), anxiety disorder, neuromuscular dysfunction of bladder (incomplete bladder emptying), and a history of falling. Record review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMS score of 00 out of 15 which indicated Resident #4 had severe cognitive impairment. Resident #4 required extensive two-person staff assistance with toileting hygiene, upper and lower body dressing, and personal hygiene. Record review of Resident #4's care plan, dated 05/07/2024, revealed, in part, Resident #4 had urinary/bowel incontinence with interventions to keep call light in easy reach and remind resident to call for assistance when urgency to eliminate was noted. Resident #4 was at risk for injuries from falling related to physical mobility and generalized weakness with interventions to ensure call light was in reach and answered promptly. During an observation and interview on 07/17/2024 at 8:34 AM, Resident #4 was sitting in her recliner in the middle of her room, she had a blanket covering her body. Resident #4 stated she needed to go to the bathroom. Observation of Resident #4's private room revealed that her designated call light located closest to her bed was on the floor. A second call light for that room that would have been designated for a roommate was located on Resident #4's bed out of reach from Resident #4. When asked about how long she was in the recliner needing help, Resident #4 did not answer the question. In an interview and observation on 07/17/2024 at 8:43 AM, CNA B stated that Resident #4 could not transfer herself and that she and another aide transferred her into her recliner. CNA B walked into Resident #4's room and noticed the call light was not in residents reach. CNA B apologized to surveyor for the call light being on the bed and not near Resident #4. CNA B stated that a possible negative outcome for not having the call light in reach could be that a resident could fall and would not be able to call for help. In an interview on 07/17/2024 at 9:40 AM, LVN A stated that it was protocol for call lights to be in reach of residents and the negative outcome for a resident not having a call light in reach would be that a resident could try to get up on their own and could hurt themselves. In an interview on 07/17/2024 at 2:37 PM, the ADON stated that it was protocol when residents were transferred from their bed to a chair in their room that the call light was to be placed near the resident. The ADON stated that the possible negative outcome for a call light out of reach of a resident could be that they could fall and need help. In an interview on 07/17/2024 at 2:40 PM, the DON stated that staff had been inserviced on call light placement and that a possible negative outcome for a resident that was not able to reach their call light could be that the resident would need help and not be able to call for help. Record Review of the policy titled Call light-use of dated 12/2017 revealed the following in part: .It is the policy of this home to ensure residents have a call light win reach that they are physically able to access and that have been instructed on its use. .All nursing personnel must be aware of call lights at all times. .When providing care to residents, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. .Be sure call lights are placed near the resident, never on the floor or bedside stand.

Based on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (Hall 200) and 1 of 1 medication room reviewed for drug labeling and storage and expired drugs. 4.5 pills were loose in the bottom of medication cart drawers of Hall 200 Medication cart. Medication room revealed a medication for Resident #36 that expired in June of 2023. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings included: Observation and interview on 07/16/2024 at 10:26 AM of medication room revealed a medication for Resident #36 that had an expiration date of 06/2023. LVN D stated that the medication was discontinued and was not sure why the medication was still in the medication room. LVN D was unable to give a negative outcome for having expired medication in the medication room. Observation on 07/16/2024 at 10:46 AM revealed 4.5 pills were found loose on the bottom of the medication cart drawers for medication cart for 200 Hall. MA was not able to identify any of the medications. Interview on 07/16/2024 at 10:54 AM, MA stated that the negative outcome for having lose medication could result in the resident not receiving their medications. Interview on 07/17/2024 at 11:11 AM with DON, requested policy for medication storage. DON was asked what a negative outcome would be for having loose medications in the medication cart. DON stated, missed dose. No further information was provided by DON. Record review of facility provided policy, titled Storage of Medications, revised April 2007, revealed the following: 1. Drugs and biological shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Record review of facility provided policy, titled Labeling of Medication Containers, revised April 2007, revealed the following: Policy Statement All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Record review of facility provided policy, titled Drug Destruction Policy, revised May 9, 2010, revealed the following: It is the policy of this facility to destroy dangerous and controlled medications according to the State of Texas law. .3. Nursing staff will submit to Director of Nursing any medication and any applicable log that has expired, been discontinued by physician or that had been prescribed to a resident who no longer resides at the facility. 48221

48208 Based on observation, record review, and interviews, the facility failed to keep resident rooms free from accident hazards for 3 of 3 residents (Residents #13, #19, #20) who were observed. The facility failed to follow smoking policy by Resident #13, Resident #19 and Resident #20 having smoking materials of lighters and cigarettes in rooms. This failure could place residents at risk of accident hazards. Findings included: Resident #13 Record review of Resident #13's face sheet dated 6/8/23 revealed a [AGE] year-old male admitted into the facility on [DATE]. Resident #13's diagnoses included: aphasia (communication deficiencies), muscle wasting and atrophy, cognitive communication deficit, mood disorder, chronic embolism and thrombosis (deep veins in the lower extremities), vascular dementia, nicotine dependence, and major depressive disorder. Record review of Resident #13's MDS assessment dated [DATE] revealed a BIMS score of 02 and required extensive assistance or two-person assist in all areas of daily living except locomotion on and off unit with limited assistance. Record review of Resident #13's care plan dated 5/23/23 revealed a focused goal for smoking and was at risk for injury with additional information that resident can smoke independently. Record review of Resident #13's smoking assessment dated [DATE] revealed that all resident's smoking materials will be kept at the nurses' station. Observation on 6/8/23 at 11:19 AM revealed two lighters, one pink and one yellow, sitting on Resident #13's rolling bed side table. Interview with Resident #13 on 6/8/23 at 11:19 AM revealed that Resident #19's cigarettes were kept in the med cart but can keep lighters. Resident #13 indicated that they are allowed to smoke independently. Resident #19 Record review of Resident #19's face sheet dated 6/8/2023 revealed resident was a [AGE] year-old female whose diagnoses included: malignant neoplasm of vertebral column (cancer of the spine), complications after genitourinary (reproductive) surgery, muscle wasting and atrophy (shrinkage), cognitive communication deficit, hyperglycemia (high blood sugar), lack of coordination, abnormalities of gait and mobility, ataxia (loss of coordination), anxiety disorder, gastro-esophageal reflux disorder, quadriplegia, major depressive disorder, c4 level cervical spinal cord, malignant neoplasm of brain (cancer). Record review of MDS assessment for Resident #19 dated 03/31/23 indicated a BIMS of 14. Record review of Resident #19's smoking assessment dated [DATE] revealed that all resident's smoking materials will be kept at the nurses' station. On 6/8/23, observation and at 7:49 AM revealed Resident #19 sitting in her wheelchair in her room. Resident #19 stated lighter was in room and a red lighter was observed to be on Resident #19's bed. In an interview on 6/8/23 at 7:49 AM with Resident #19, resident stated the lighter was in her room even though Resident #19 knew it was not supposed to be there. Resident #19 indicated that they were at the nurse's station. Resident #19 stated that assistance was needed to go smoke as Resident #19 was not able to transport independently outside. Record review of Resident #19's chart shows smoking assessment where Resident #19 is unable to smoke independently and uses assistive devices. Resident #20 Record review of Resident #20's face sheet dated 6/8/23 revealed a [AGE] year-old woman admitted into the facility on [DATE]. Resident #20 had diagnoses: morbid obesity, generalized anxiety disorder, heart failure, hypercholesterolemia (high cholesterol), schizoaffective disorder; depressive type, Type 2 Diabetes, nicotine dependence, and schizophrenia. Record review of Resident #20's care plan dated 5/16/23 revealed a focused goal of smoking without assistance. Record review of Resident #20's MDS assessment dated [DATE] revealed that resident had a BIMS score of 11 indicating cognitively intact. Resident #20 needed minimal/supervising assistance with areas of daily living. Record review of Resident #20's smoking assessment dated [DATE] revealed that resident smoking materials will be kept at nurses' station. Interview and observation with Resident #20 on 6/8/23 at 7:36 AM revealed that Resident #20 was allowed to smoke alone. Resident #20 showed smoking materials ofa blue lighter in left hand. Resident #20 also advised that cigarettes were kept at the medication cart. Observation on 6/8/23 at 11:35 AM showed two packages of Montego Gold 100's-one opened and one unopened. Observation on 6/8/23 at 11:48 AM, LVN E opened the medication cart to reveal one pack of Montego Blue 100's in the left drawer behind liquid items. Interview with LVN B at 11:32 AM revealed that there was one smoker on four hall at that time. LVN B stated Resident #20's smoking materials were kept in the facility at the medication cart. LVN B showed the surveyor where Resident #20's cigarettes were in the medication cart which was the top right corner. LVN B indicated that there were only two smokers in the building. LVN B stated that a negative outcome would be Fire hazard. LVN B indicated that Resident #19 had a lighter and cigarettes in room. LVN B stated, I know they are not supposed to. LVN B revealed that the Smoking policy stated they were not supposed to have anything in their rooms, and they were either kept in the medication cart or the medication room because they are locked. Interview with CNA F on 6/8/23 at 11:45 AM revealed one resident that smokes in five hall. Inquired which resident and identified Resident #13. CNA F stated that cigarettes were in the medication cart. CAN F stated Resident #13 keeps lighter and a negative outcome of the resident keeping the lighter would be a fire hazard. CNA F also stated that resident was allowed to have a lighter when resident was of sound mind. CNA F stated smoking policy revealed they were to be supervised while outside. Interview with LVN E on 6/8/23 at 11:48 AM revealed LVN E was not aware of Resident #13's lighter location and that resident has never had a lighter on him. LVN E stated a fire hazard as a possible negative outcome. LVN E indicated that lighters were not allowed in rooms. LVN E stated the smoking policy revealed, not without going back and looking at it. Interview on 6/8/23 at 1:49 PM with LVN B revealed new cigarettes in the med cart labeled Marlboro Red 100's with Resident #19's name in black marker in top right-hand corner. LVN B advised that cigarettes were brought back to the medication cart LVN B advised that CNA went into resident's room and returned them to the medication cart. Interview on 6/8/23 at 1:54 PM with DON. The DON advised there were no in-services on the smoking policy and training is completed upon initial hire date. DON advised the smoking policy is the residents are not allowed to go out without a staff member. DON indicated that smoking materials are kept in the medication cart. DON indicated that a negative outcome of residents keeping smoking materials in their room was would be confiscated; I don't know what you're asking. The DON responded with I don't know what you are asking, a lot of things can happen. Interview with the DON on 6/8/23 at 2:06 PM revealed that smoking assessments were completed upon admission and quarterly. Advised that RNs completed them upon admission and the ADON completed them quarterly. Interview with the ADON on 6/8/23 at 2:08 PM revealed that in-service for smoking was done upon hire. ADON advised that smoking policy stated smoking materials are in the medication carts separated from other items. The ADON also stated that there were three smokers in the building and a negative outcome of smoking materials being in resident's rooms would be a fire. Interview and record review with the DON, ADM, and ADON on 6/9/23 at 8:55 AM revealed that three policies were provided for smoking. One policy labeled Smoking Policy Resident/Family Copy (no date) identified residents were allowed to keep smoking paraphernalia in their room when supervised. DON indicated supervised meant they don't go by themselves, so they are supervised. The ADM indicated it meant that they know they have their smoking materials on them. The ADON walked into the room at 8:58 AM and indicated that the smoking assessment asked if they can be unsupervised, and verbiage is found on smoking assessment. ADM stated about smoking materials in resident's room, the care plan says that. ADON confirmed with head shake up and down. Interview with the ADM on 6/9/23 at 9:01 AM and inquired about record of policy in admission packet, policy provided to family, and facility policy with conflicting wording. Inquired which policy to go by since two were the same and Smoking Policy Resident/Family Copy (no date) stated smoking paraphernalia can be kept in room when supervised. The ADM stated, we will get that changed. Record review of policy named Items Not Allowed in Resident Room (no date), under Safety Hazards, last statement indicated Smoking or smoking materials-not allowed. Record review of policy named It is the policy of [the facility] to abide by the rules and regulations set forth by the Texas department of Aging and Disabilities, (no date), line 13 stated- Smoking tobacco, matches, lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession. Record review of Smoking Policy Resident/Family Copy (no date) revealed the following: Line 1, line (a) Smoking tobacco, matches, lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession with supervision.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored food was properly stored per food label. 2. The facility failed to practice proper hand sanitation while preparing food. Findings Included: Observation of shelved foods on 6/7/2023 at 10:00am revealed the following: 1. Plastic bottle labeled tartar sauce no expiration date noted ??? sitting on shelf with spice containers with a label on back indicated refrigerate after opening. Observation on 6/7/23 During an observation on 6/7/23 at 10:30 AM, observed Cook A preparing puree food. Cook A stopped prepping puree food, walked to trash can to discard a can, and returned to preparing puree food. Gloves were not worn, and no hand hygiene was practiced between these actions. During an interview on 6/8/2023 at 2:30pm with Cook A, DM, translated due to language barrier, stated that all kitchen staff are responsible for safe food preparation per their policy. Cook A stated that she would go to the Facility policy to see what the policy stated. Cook A stated that the negative outcome for not practicing hand hygiene would be cross contamination. Record review of in-service dated 1/9/23 at 1:30 PM, training contained hand washing and sanitation. Record review of policy titled Hand Washing, dated 2012, it stated that employees are too frequently perform hand washing. Record review of policy titled Handwashing: A Healthy Habit in the Kitchen, dated September 1, 2021, the policy stated : Clean: Wash Hands, Utensils, and Surfaces Often-Wash your hands often, especially during these key times when germs can spread: After touching garbage Record review of recommendations of the Food and Drug Administration (FDA), dated 1997, it states that the FDA has evaluated the labeling on foods that must be refrigerated to prevent outgrowth of pathogens- February 1997. Record review of FDA recommendations on Are You Storing Food Safely, dated 1/18/23, it stated Check storage directions on labels. Many items other than meats, vegetables, and dairy products need to be kept cold. If you've neglected to properly refrigerate something, it's usually best to throw it out.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 14 residents (Resident #1) reviewed for immunization records. The facility failed to ensure records regarding patient care, including bed rails, was accurate and complete. This deficient practice placed residents at risk for inaccurate records to ensure continuity of and appropriate care. Findings included: Record review of Resident #1's face sheet dated on 6/8/23 revealed a [AGE] year-old woman who was admitted into the facility on [DATE]. Diagnoses included encephalopathy (disease that affects the brain causing altered mental status), hyperlipidemia (elevated lipids), unspecified psychosis, disorientation, cardiac arrhythmia, hypo-osmolality and hyponatremia (low plasma). Record review of Resident #1's MDS assessment dated [DATE] indicated a brief interview for mental status of 05 indicating severe cognitive impact. Record review of Resident #1's bed rail assessment dated [DATE] showed not completed by the admitting nurse. Record review of Resident #1's bed rail consent dated 3/6/23 showed not completed by the admitting nurse and signed by the resident representative. Record review of Resident #1's Influenza Informed Consent (no date) showed not completed but signed by the resident representative. Record review of Resident #1's Pneumococcal Informed Consent dated 3/6/23 showed not completed but signed by the admitting nurse and resident representative. Interview with the DON on 06/09/23 at 10:52 AM revealed that the charge nurse did bed rail assessments when a resident was admitted . The DON stated what information was on the Bed Rail assessment. DON indicated the size of rail, if there was one, and what side. The DON revealed LVN C was a charge nurse. DON looked at the form, confirmed it was LVN C's signature and it was not completed correctly. The DON stated a negative outcome could be with an uncompleted assessment, she could have a rail and not need one. Interview with LVN C on 06/09/23 at 11:04 AM revealed needing a bed rail assessment is the reason for needing it and the patient's ok if they want to use them or not. The reasons why it would help them LVN C identified the resident or resident representative could sign the consent. LVN C stated a negative outcome could be entrapment if they are caught in the bed rail. If something was to happen to them. LVN C confirmed that LVN C's signature was on Resident #1's Bed Rail Assessment form dated 3/6/23. Interview and record review with the DON on 6/9/23 at 11:08 AM revealed the charge nurse completed bed rail assessments upon admission. The DON stated the type of rail that had been determined and the resident signature or the person giving consent was needed. The DON revealed that a negative outcome for an incomplete form if signed by both nurse and Representative/Resident meant it was completed without something being fully assessed. The DON confirmed the consent for Resident #1's bed rails was not completed and confirmed the signature on the form was LVN C's. Interview and record review with LVN C on 6/9/23 at 2:25 PM revealed Resident #1's influenza and pneumococcal consents were not completed. LVN C revealed obtaining the signatures before completing the forms. LVN C confirmed completed admission paperwork for Resident #1. LVN C stated LVN C called the clinic but it was close to end of shift. Told them (employees) if they call this is what we are looking for. I told them I just needed a record for chart. I know I messed up. It's my fault. LVN C confirmed did not get a yes or no on the Influenza Consent and that the Pneumococcal Consent was not filled out correctly with her signature at the bottom. LVN C identified a negative outcome of being unable to tell if resident has had the vaccine or needs the vaccine since forms were not completed. Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 indicates that documentation is the recording of all information in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 Under heading Goal-Line (1) states the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 under heading Procedure Line (3) Place all required and appropriately signed forms in the clinical record. Items such as copies of .consent for treatment, consents for specific procedures . will be placed behind labeled dividers inside the clinical record. Line (6) document completed assessments in a timely manner and per policy.

Based on observation, interview and or record review the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for 12 of 13 resident rooms reviewed, in that: The facility failed to ensure Twelve of 13 resident rooms, occupied by 2 residents, had privacy curtains that were not missing and would provide full visual privacy (201, 202, 203, 205, 206, 207, 408, 503, 505, 512, 601, and 609). This failure could place residents at risk of being exposed while receiving personal care. The findings include: Observation on 4/25/22 at 3:06 PM revealed room 408 had Resident #4 and Resident #43. There was no privacy curtain at the foot of the B bed. A resident in the B bed could be viewed while receiving personal care if another resident went to the restroom which was located on the B bed side. Resident #4 resided on the B bed side and had a catheter. Observation on 4/25/22 at 3:42 PM revealed room 503 had Residents #31 and #32. There was no privacy curtain at the foot of the B bed and the restroom was on the B bed side. Observation on 4/25/22 at 3:53 PM revealed room 505 had Residents #47 and #3. There was no privacy curtain at the B bed foot. The restroom was located on the B bed side. Observation on 4/25/22 at 4:00 PM revealed room 512 had Residents #20 and #39. There was no privacy curtain at the foot of the B bed and the restroom was on the B side of the room. The following observations were made during a tour of rooms on halls 200 and 600 that had two residents residing in each room: Observation on 4/25/22 at 6:12 PM revealed room 601 had no privacy curtain at the foot of the A or B bed and the restroom was on the B side of the room. Residents #8 and #11 resided in this room. Observation on 4/25/22 at 6:13 PM revealed room 609 had no privacy curtain at the foot of the B bed and the restroom was on the B side of the room Observation on 4/25/22 at 6:14 PM revealed room 201 had no privacy curtain at the foot of the B bed and the restroom was on the A side of the room but residents on the B side could still be viewed. Observation on 4/25/22 at 6:15 PM revealed room 202 had no privacy curtain on the foot of the B bed and the restroom was on the B side of the room. Observation on 4/25/22 at 6:15 PM revealed room 203 had no privacy curtain at the foot of the B bed and the restroom was on the A side of the room but residents on the B side could still be viewed. Observation on 4/25/22 at 6:15 PM revealed room 205 had no privacy curtain at the foot of the B bed and the restroom was on the A side of the room. Residents on the B side could still be viewed. Observation on 4/25/22 at 6:17 PM revealed room 206 had no privacy curtain at the foot of the B bed and the restroom was located on the B side of the room. Observation on 4/25/22 at 6:18 PM revealed room 207 had no privacy curtain at the foot of the B bed and the restroom was on the B side of the room. Observation on 4/27/22 at 11:14 AM revealed a posted certificate in the facility rotunda. It documented, Certificate of The Office of the State Fire Marshall. Fire Alarm Installation Certificate. [facility name] . State License . Completion Date 4/01/93, indicating initial certification was after this date. An interview on 4/26/22 at 8:40 AM with LVN B revealed in room 512 Resident #20 was occasionally incontinent. Her roommate Resident #39 was continent. Room 503, Resident #31 was incontinent of bowel and bladder and her roommate Resident #32 was incontinent of bladder occasionally at night and he could transfer. Room 505 had Resident #47 who was incontinent of bowel and bladder and could not walk or self-transferred. His roommate Resident #3 was incontinent of bowel and bladder and he transferred with assistant. An interview on 4/26/22 at 8:54 AM with LVN A revealed Resident #4 had a catheter and was incontinent of bowel. He could walk with a walker and transfer with assistance. Resident #43 was incontinent of bowel and bladder and couldn't transfer but could wheel himself in his wheelchair. An interview on 4/27/22 at 10:00 AM with the Maintenance Supervisor revealed the facility had no privacy screens or other additional types of privacy equipment. He also stated, housekeeping was over privacy curtains. An interview on 4/27/22 at 10:13 AM with BOM/Housekeeping Laundry Supervisor, she stated she had been over the laundry and housekeeping for approximately 2 years. She stated, Maintenance was responsible for taking them down and putting them up. An interview on 4/27/22 at 11:00 AM with the Maintenance Supervisor, he stated he did not know why the privacy curtains were missing at the B beds. he was told to put one in the middle and one by the door. He stated, the result for the resident not having a privacy curtain was the resident could be embarrassed. He further stated, he didn't know how long the privacy curtain had been down. Staff took them down during COVID. An interview on 4/27/22 at 11:09 AM with the Administrator regarding privacy. He stated, I took the curtains down in COVID. They harbor COVID. The Administrator stated that the privacy curtains should be put up once a second person was in the room. An interview on 4/27/22 at 11:24 AM , the Administrator stated the facility had no specific policy on privacy curtains. Record review of the facility document titled M DCP admission packet, revealed the following documentation, Resident Bill of Rights. Our facility will protect and promote each of the following rights . privacy and confidentiality. 18. You have the right to personal privacy and confidentiality of your personal and clinical records. Personal privacy includes privacy in accommodations, medical treatment, written and telephone communications, personal care .

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in 3 of 3 resident baths (hall 100/200, hall 400 and hall 500/600) and 1 of 1 soiled linen room (hall 400) reviewed, in that: 1. The facility failed to ensure chemicals were stored in a manner to prevent contamination of resident use items in resident baths (3 of 3 baths (100/200, 400 and 500/600). 2. The facility failed to ensure chemicals were stored in a secure area (hall 400 soiled linen room). 3. The facility failed to ensure shower chair mesh and vinyl was not soiled and in disrepair (3 of 3 baths (100/200, 400 and 500/600)). These failures could place residents at risk of chemical related injuries. The findings include: Observation on 4/25/22 at 3:20 PM revealed One of two shower chairs, on 400 hall, had the mesh back that was frayed and pulled away from the frame and there was a buildup of residue and dirt on the mesh back that included the bariatric chair. The sharps container was not secured to the wall. The locked cabinet in the room had a spray bottle of KQuat Select Cleaner and Disinfectant stored next to the washcloths, deodorant, skin and hair cleaner, body wash, toothpaste and shaving cream. The label on the bottle stated Danger . Corrosive. Causes irreversible eye damage. Harmful if swallowed or absorbed through the skin . Observation on 4/25/22 at 3:27 PM revealed the soil linen room on hall 400 had a door which was lockable but was unlocked. There were spray bottles of cleaners on the upper shelves which included KQuat Select. There was an unlocked sink cabinet which contained Clorox Clean Up Cleaner and Bleach which was labeled, Warning. Causes substantial but temporary eye injury. There were two spray bottles in the unlocked cabinet. The top shelf contained [NAME] Tub and Tile Cleaner which was labeled . May cause eye and skin irritation . This same observation was made on 4/25/22 at 6:05 PM and on 4/26/22 at 8:22 AM and at 3:58 PM. Observation on 4/25/22 at 3:34 PM of hall 500/600 bath revealed one of three shower chairs had a heavy buildup on the mesh back of dirt and residue, this was the pink shower chair. The cabinet in the room had shower body wash, lotion, shaving cream on the same shelf with a spray bottle of KQuat Select cleaner. One of two shower stalls had no privacy curtain, it had been removed from the track. There was no privacy curtain at the toilet and the curtain had been removed from the track. Observation on 4/25/22 at 5:52 PM of the hall 100/200 bath revealed a cabinet in the bath that contained KQuat Select and it was stored amongst shaving cream and resident toiletries. Two of the four shower chairs in the room had mesh backs which were dirty with residue and dirt. Two of the four shower chairs also had frayed mesh. The lounge shower chair had cracked vinyl on the headrest, the back pad and leg rest. When you press the headrest the water that was soiled would flow out of it. There was also dirt behind the leg rest vinyl and on the leg rest. Observation on 4/25/22 at 5:58 PM of the hall 500/600 bath revealed the cabinet had KQuat Select cleaner stored with body wash, shower shaving cream and resident toiletries. Observation on 4/26/22 at 8:26 AM of the hall 400 shower revealed there was a sign posted on the paper towel dispenser titled CNA Monday List, with the following documentation, . Shower cabinet . Keep it locked at all times. Cleaner needs to be inside shower cabinet, not on rail where resident can get to it . In the cabinet there was KQuat Select cleaner stored next to razors, toothpaste, toilet tissue and open container body wash. In an interview with CNA A on 4/26/22 at 8:30 AM, he stated, he had not noticed the sharps container was not secured to the wall. He said they were instructed to put the cleaners in the cabinet as was documented on the post a sign. Observation on 4/26/22 at 3:55 PM of hall 400 bath revealed the door was not lockable. The cabinet had KQuat Select cleaner stored next to toilet tissue and body wash. There was a sign posted in the bath that stated that cleaner should be stored in the cabinet. The sharps container was not secured to the wall and the light in the shower stall was not operational. Observation on 4/26/22 at 4:00 PM of hall 500/600 bath revealed the entrance door was not lockable, the cabinet was unlocked and contained KQuat Select cleaner stored on the shelf with body wash and resident toiletries and a scrub puff. One of three (pink) shower chairs had a buildup on the mesh back of dirt and residue. The ceiling heating unit fan was not operational, and the heating element did not work. Observation on 4/26/22 at 4:59 PM of the hall 100/200 bath revealed the door was not lockable. The cabinet contained K Quat cleaner in a thin plastic bag and was still on the shelf with body wash and resident toiletries. Two or four shower chairs had frayed mesh back with buildup, residue and dirt, this was the blue bariatric and the small blue shower chairs. The pink lounger shower chair had the same cracked vinyl on the headrest back rest and the leg rest. The surface underneath the leg rest was dirty and had to build up of dirt when you press the headrest water streamed out of the headrest that was soiled. In an interview on 4/27/22 at 9:50 AM with the hall 200 Nurse Aide A revealed staff wiped and sanitized them between residents. She stated she didn't know, regarding deep cleaning. She stated, she didn't know anything about the cracked vinyl or the soiled water that leaked out of the headrest. She stated the result of residents using equipment that was not clean could be infection if the resident has a wound. She stated, the facility kept the chemical in the cabinet to keep residents from getting ahold of it. She stated, if the facility continued to store chemicals with their toiletries the chemicals could get into the toiletries and contaminate and cause irritation to the resident. She stated they were instructed to store chemicals in the cabinet. She stated, another worker told her to store chemicals in a cabinet. At that time it was noted KQuat Select cleaner was stored in a thin plastic bag in a bin with resident hair conditioner cuticle sticks and razors. There was also the CNA Monday List sign posted in the cabinet that stated to store the cleaner in the cabinet. Observation on 4/27/22 at 10:18 AM of the 500/600 bath revealed one of three shower chairs was heavily soiled on the mesh back. In the cabinet KQuat Select was stored with resident toiletries there was no sign on the cabinets saying to store the chemical there. There was also body wash located in the cabinet. Interview on 4/27/22 at 10:25 AM with hall 500 CNA B revealed they washed the shower chairs, between residents, with this disinfectant spray. She then showed the state surveyor a spray bottle of KQuat Select that was in the cabinet. She stated, they had not mentioned storage of chemicals in any trainings. She stated they usually had it hanging on the glove box bracket on the wall. She added, after use they stored in the cabinet. She stated the result for the resident if chemicals were stored amongst their toiletries was it could explode. She added, deep cleaning was done on Saturdays and Sundays. Everything was cleaned. She stated, residents could get a rash and the soil/dirt could get on their skin if residents used soiled shower chairs. Interview on 4/27/22 at 10:35 AM with the DON , she stated regarding chemical storage in the baths, it should remain locked up. They were trained to store chemicals in the locked cabinet She stated the chemicals shouldn't be stored together. She stated, I'm not going to speculate the result of residents being showered on a soiled shower chair. She added, all chairs were cleaned three times a week on the night shift. They were wiped down with disinfectant. The Administrator stated at this time that ultimately the CNA was responsible for ensuring the shower chairs were cleaned and in good repair. Housekeeping did deep cleaning in the showers. CNA's were to report repairs to the administrator and maintenance. During and observation and interview on 4/27/22 at 1:32 PM of the hall 400 soil linen room revealed the door was unlocked and the same chemicals (KQuat Select and [NAME] Tub and Tile) were on the top shelf and in the unlocked sink cabinet. The Administrator stated at this time, The chemicals should be stored next door (housekeeping closet). Record review of the facility's policy titled Environment of Care Policy and Procedure Manual 2003, HM03 - 6.0, revealed the following documentation, Storage and Handling of Hazardous Chemicals . 3. Chemicals will be stored in properly labeled containers with special attention given to hazardous warnings. Their warnings will alert employees using the chemicals not to store incompatible materials in the same area. Chemicals need to be stored by their potential hazard, not alphabetically . 5 . Compressed gas cylinders should be secured and supported. 6. Each employee should read the manufacturer or suppliers directions before using any product noting the possible hazards, both physical and health, of the product .

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 3 of 6 residents (Residents #4, #31 and #100) reviewed, in that: The facility failed to ensure Residents #4, #31 and #100 received pureed foods according to physician orders. This failure could place residents at risk of choking or aspiration incidents. The findings include: Record review of the facility's Order Listing Report Dated: 04/25/2022 revealed 5 residents were ordered puree consistency diets; Residents #4, #8, #21, #31, #47. Record review of the facility's Order Listing Report Dated: 04/25/2022 revealed the following residents also had orders for pureed diets: [Resident #21], regular diet. Puree texture, regular consistency, for difficulty swallowing, order status Active, revision date 10/20/2021 .[Resident #8], regular diet. Puree texture, regular consistency, for difficulty swallowing, order status active, revision date 3/19/2021 .[Resident #47], regular diet. Pureed texture, regular consistency, for double portions with plate guard, order status active, revision date 7/13/2020. 1. Record review of the face sheet for Resident #100 revealed the resident was admitted to the facility on [DATE] and was an [AGE] year-old male. Resident #100 had diagnoses which included, unspecified severe protein-calorie Malnutrition (reduced protein and calories). Record review of the physician order summary report for Resident #100, dated 4/27/22, revealed the resident had a diet order of, regular diet pureed texture, regular consistency, for pockets food, needs cueing to swallow regular consistency, order status active, order date 4/26/22 Record reviews of the admission MDS for Resident #100, dated 4/14/22, revealed the resident had a swallowing disorder listed as . Coughing or choking during meals or when swallowing medications and Complaints of difficulty or pain with swallowing . Record review of the current undated care plan for Resident #100 revealed the resident had a Focus stating, Resident is on a regular diet . Listed under Interventions/ task the care plan stated, Offered diet as ordered . 2. Record review of the face sheet for Resident #31 revealed a [AGE] year-old female admitted to the facility initially on 7/01/07 and readmitted on [DATE]. Resident #31 had diagnoses which included Dysphagia, Unspecified (swallowing disorder), Other Symptoms and Signs Involving Cognitive Functions and Awareness, Mild Protein-Calorie Malnutrition, Other Symptoms and Signs Involving Cognitive Functions Following Other [CONDITION(S)] Disease, And Other Speech and Language Deficits Following Unspecified [CONDITION(S)] Disease. Record review of the physician Order Summary Report dated 4/27/22, and facility Order Listing Report dated 04/25/ 2022, revealed Resident #31 had a diet of No salt on tray. Pureed texture, regular consistency, Order Status Active, Revision Date 2/26/2021 . Record review of the quarterly MDS for Resident #31, dated 3/09/22, revealed the resident had a Swallowing Disorder listed as Loss of liquid/solids from mouth when eating or drinking, Holding food and mouth/cheeks or residual food in mouth after meals, Coughing or choking during meals or when swallowing medications and Complaints of difficulty or pain with swallowing . Record review of the current undated care plan for Resident #31 revealed a Focus stating, Resident is on a therapeutic diet. NSOT (No salt on tray) Puree. Interventions/task listed stated . Offered diet as ordered . 3. Record review of the face sheet for Resident #4 revealed an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included Rhabdomyolysis and Dysphagia, Unspecified (swallowing disorder). Record review of the physician Order Summary Report dated 4/27/22 and facility Order Listing Report Dated: 04/25/2022 revealed Resident #4 was on a regular diet. Pureed texture, regular consistency, order status active, revision date 5/24/2021. Record reviews of the quarterly MDS for Resident #4, dated 1/18/22, revealed the resident had a Swallowing Disorder listed as . Coughing or choking during meals or when swallowing medications and Complaints of difficulty or pain with swallowing . Record review of the current care plan for Resident #4 revealed a Focus stating, Resident is on a regular diet: puree . Interventions/task stated . Offer diet as ordered . Record review of the Menu Matrix, Monday, (Facility) S S 2022 5 week NAV - week - 5 dinner menu revealed the following foods to be served for a regular pureed diet: pureed salmon croquette, puree cheesy ranch potatoes, puree green beans, pureed dinner roll and puree canned fruit. Record review of the Menu Matrix, Tuesday (Facility) S S 2022 5 week NAV - week - 5 noon menu revealed the following pureed foods to be served at the noon meal: Puree pot roast, puree roasted new potatoes, puree parsley carrots, puree garlic cheese biscuit and puree canned fruit. Observation and interview on 4/25/22 at 4:25 PM, revealed puree preparation in the kitchen. The Dietary Manager stated, at this time, she prepared for 6 purees. She was observed pureeing the cheese potato dish. After pureeing the potatoes, which she had added an unknown amount of milk, she took the temperature, and it was 154.8 degrees Fahrenheit. All other foods had been pureed previously. Observation of these foods on the steam table revealed the following: Pureed fish had dark whole bits visible in the food in the pan. Puree diced potatoes/cheese potatoes had skin and bits visible in the pan Pureed green beans had no obvious issues visible. On 4/25/22 at 5:20 PM a test tray was requested of the pureed foods from the Dietary Manager. The result of the testing, at this time was: Pureed bread had some solid bits of bread in it Pureed fish had some whole bits of fish Puree green beans had some bits of whole vegetables and there was a green bean string. Pureed potatoes had skins and bits of potato. Observation and interview on 4/26/22 beginning at 11:07 AM and concluding at 11:49 AM of the kitchen revealed Dietary Staff A stated she prepared six purees. She pureed the stew meat/pot roast with an unknown amount of gravy and placed it on the steam table at 164.5 degrees Fahrenheit (taken by Dietary staff A). She then pureed sliced carrots and added an unknown amount of carrot juice to the processor pureed it in a gray processor pot which had a crack in the side. The temperature was 175.6 degrees (taken by Dietary staff A) and placed on a steam table. She then placed wedged cooked potatoes in the processor pot, added milk and puree the mixture. The temperature was 150.3 degrees Fahrenheit (taken by Dietary staff A) in the pan on the steam table. At that time skins and bits of potato could be seen in the puree. It was also noticed that she assembled the parts of the processor for the next puree and it was noted the white blade was damaged and had missing original pieces on the exterior but it looked as though it had been repaired with a hard adhesive of some kind. She then placed biscuits that had grated cheese on top in the processor, added milk and pureed the mixture. She took the temperature, and it was 166 degrees Fahrenheit after being reheated. Meal service started at 11:49 AM. On 4/26/22 at 11:53 AM a test sample was requested of the pureed foods from the Dietary Manager. On 4/26/22 at 11:54 AM the result of the test tray was: Pureed cheese biscuit were slightly gummy Pureed sliced carrots had some chunks of whole carrot and bits Pureed wedge potato had skins visible and tasted and hard bits of food. The texture was very thick. Puree stew meat/pot roast was not in a puree form. The meat had to be chewed to be consumed. The meat, if swallowed, balled up in an individual's mouth and was not smooth. An observation and interview on 4/26/22 at 12:15 PM the Dietary Manager stated revealed they just got the gray topped processor blade Observation of the white blade, at this time, revealed it looked like it had been repaired with a hard brown substance and had the original white portions missing The Dietary Manager stated they gave it (white blade) to maintenance and they put something on it. During an interview on 4/26/22 at 12:17 PM Dietary staff A stated, This new one (processor) don't blend as well. During an interview on 4/26/22 at 12:18 PM, the Dietary Manager stated, the staff had not had training. Most (staff) had been at the facility a long time. It's time to retrain regarding purees. She stated the correct puree consistency should be Pudding-like consistency. Observation and interview on 4/26/22 at 12:25 PM revealed Resident #4 in his room feeding himself. He had oxygen via nasal cannula and was seated in his wheelchair. He was served pureed carrots, Ready Care supplement chocolate milk, and pureed cheese biscuit which there were bits of whole biscuit visible in it. The pureed cooked wedge potatoes had visible skins and whole bits. The pureed stew meat/pot roast with brown gravy was also served. At that time the resident tried to eat the stew meat/beef and then removed a balled-up portion of the meat out of his mouth and placed it on his meal tray. The state surveyor asked him why he had removed the meat from his mouth. He stated, I couldn't eat it. Observation on 4/26/22 at 12:29 PM of the meal tray of confused Resident #100 revealed he was served pureed cheese roll, stew meat, carrots, and potatoes in which bits and skins were visible in the potatoes. Observation on 4/26/22 at 12:30 PM revealed the meal tray for confused Resident #31 was served and had pureed cheese roll, pureed stew meat (none was consumed), pureed carrots, pureed fruit and pureed potatoes. There were visible bits and skins in the pureed potatoes. Interview on 4/26/22 at 12:31 PM with CNA B, she stated she fed Resident #31 lunch. She stated, the meat on his plate wasn't consumed because it wasn't pureed real good. She couldn't eat it. She tried a few bites. Interview on 4/26/22 at 12:56 PM with LVN A revealed Resident #4 was on a pureed diet because he had difficulty swallowing. Interview on 4/26/22 at 12:58 PM with LVN B revealed Residents #31 and #100 were on pureed diets because they had difficulty swallowing. Interview on 4/27/22 at 10:00 AM with the Maintenance Supervisor revealed He didn't remember fixing a kitchen blade. Interview on 4/27/22 at 10:49 AM with the Dietary Manager revealed they did not puree the foods long enough. At that time Dietary staff A also stated, Yesterday there was not enough pureeing time. The Dietary Manager further stated, (Dietary staff A) thought the new processor caused the puree problems. You have to leave this one on long. Dietary Manager stated, residents could choke and aspirate if the puree was not in the correct form. Dietary Manager stated, herself the cook and the helper were responsible for ensuring purees were in the proper form. The Dietary Manager stated she would retrain Staff on purees and she would train a new person. Interview on 4/27/22 at 1:37 PM with the Dietary Manager, she stated no dietary in-services were conducted in the last three months. She added, I'm doing a short one now. When asked about the cracked/damaged blade she stated, I pulled it. We can throw it away. Record review of the facility's policy titled Diet Manual 2014, revealed the following, Diet, The pureed diet is a texture modification of regular or therapeutic diets, designed to provide adequate nutrition for those persons with choking tendencies or difficulty with swallowing due to facial paralysis or other illness. This diet should be served only if no other consistency can be tolerated . The puree recipes are followed for regular diet items so that the consistency of pureed foods is that of a semisolid rather than a semi liquid. Pureed food should be the consistency of applesauce or pudding to Mashed potato consistency .

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible, in that: 1. The facility failed to ensure Oxygen was secured and transported in a safe manner in the resident transport van #1. This was in the presence of Resident #15 who required [CONDITION(S)] treatment transportation, and 2. The facility failed to ensure the resident transport van #1 was operated and maintained in a safe manner (unattended, unoccupied and engine running). These failures could place residents at risk for injuries related to compressed gas explosions or vehicle failure. The findings include: Record review of the physician Order Summary, dated 4/27/22, for Resident #15 revealed the resident was admitted on [DATE] and was a [AGE] years old female. The resident had diagnoses which included [CONDITION(S)] and other chronic diseases classified elsewhere, hypertensive chronic kidney disease with stage five chronic kidney disease and end stage renal disease, dementia and other diseases classified elsewhere without behavioral disturbance, Alzheimer's disease, age related [CONDITION(S)] without current pathological fracture, cognitive communication deficit, other symptoms and signs involving cognitive functions and awareness and end stage renal disease. Resident #15 had an order for oxygen at 2-4 L/MIN via nasal cannula to keep O2 sats greater than 90% every shift or shortness of breath/PRN. The order date was 2/21/22. The resident also had an order stating, Resident to attend [CONDITION(S)] three times a week and PRN as dictated by nephrologist, order status active, order date 4/27/22. Record review of the annual MDS for the Resident #15, dated 11/18/21, revealed the resident was readmitted to the facility on [DATE] and initially admitted [DATE]. The MDS documented Special Treatments and Programs that included oxygen therapy and [CONDITION(S)] while a resident. An observation and interview on 4/25/22 at 12:26 PM of resident transportation van #1, which was parked outside of hall 400 where residents and staff smoked, revealed CNA A removed Resident #15 from the van in her wheelchair. He took the resident from the van, lowered her on the lift in her wheelchair, and took her into the facility through hall 400 exit, which passed through the resident smoking area. At that time, he left the van running unattended and unoccupied. He returned to the van at 12:27 PM and turned off the engine. An observation was made of Van #1's interior at this time and there was a small unsecured oxygen tank lying on its side in between the passenger and driver seat on the floor. The oxygen tank was filled and in the green dial zone at 1800 PSI. The label on the oxygen tank documented, DeVilble S S I Fill Personal Oxygen Station . Secure cylinder during storage and use . Do not drop . There was also a secured fire extinguisher, in the green dial zone (charged), that was next to the passenger side seat and unsecured oxygen tank on the floor. The extinguisher had no inspection tag. At that time CNA A stated, Resident #15 went to [CONDITION(S)] on Monday, Wednesday and Friday and identified her as the resident he had taken off the van and into the facility. During an interview and observation on 4/25/22 at 12:32 PM, CNA A stated, the oxygen tank needed to be secured and he would get it secured. He said there was no place to secure the oxygen in the van. Further observation of the interior of the van, at this time, revealed there were no devices available to secure the oxygen tank properly. CNA A stated he placed the tank in there van last week. He stated, he had been the van driver six months to a year. He added that he, the nurses and a few of the aides transport drive the van. He added, he took Resident #15 inside so she would not be cold. He added he tried to get them (residents) inside, then come back and turn the van off. He stated the van must be on for the lift to work. He stated, The Administrator and Maintenance conducted his training to be a transport aide. He stated he had not received any safety related training regarding not leaving the van running while unoccupied and unattended. He added, residents were not to be left in the van. During an interview on 4/25/22 at 1:06 PM with the Maintenance Supervisor revealed Regarding transportation aid training, he stated, he showed staff how the lift works, where the gas tank was and how to strap down the residents. He further added, the only time it's (van) left running is if the weather is hot or cold. He said the van is left running with no one in it (normally). During an interview on 4/25/22 at 6:11 PM with the Administrator regarding van transportation aide training documentation. He presented the Transportation Aide Job Description forms and stated this was the information was used to train transportation staff. In an interview on 4/27/22 at 10:00 AM with the Maintenance Supervisor revealed the van key was only a remote for locking the doors not for starting the engine. He stated, I have no idea why the oxygen was not secured. It (van) should have a (storage) bag on the side of it. He was also asked what the result could be if the oxygen was not secured. He stated, It could hit (something) and blow out. It could go (roll) under the brake pedal. He was also asked what the result could be if the van was left running unattended. He stated he was unaware of safety issues related to leaving the vehicle running, unoccupied and unattended. The surveyor then mentioned the possibility of theft and vehicle malfunction. He then added, It (van) could be stolen. On 4/27/22 at 1:40 PM an interview was conducted with CNA A regarding his use of the van #1 for transport. He stated, I used it for transport last week taking them to [CONDITION(S)], Monday, Wednesday and Friday. Record review of the Human Resources Manual 2003, Revised: June 16, 2005, JD03 - 3/2.0, Job Description revealed the following documentation, Title: Transportation Aide . Essential duties: 1. Transport residents to/from medical facilities and/or other activities as needed in a safe manner . 3. Identify and report any condition requiring management or clinical attention during the transport . Record review of the attached facility document titled Van Driver Training revealed there was no mention of transportation of oxygen safety. There was no mention of vehicle safety related to leaving the vehicle unoccupied, running and unattended. Record review of the World Health Organization document, dated 1/05/21 titled, Oxygen Cylinder Safety, Intended for Health Workers and All Personnel Managing Medical Oxygen, revealed the following documentation, .Do Transport Cylinders Correctly . Ensure cylinder (regardless of size) is firmly secured by a strong chain or strap, capable of preventing the cylinder from falling or being knocked over . Do Store Cylinders Correctly . Store all oxygen cylinders in upright position and nesting, with three points of contact . Keep oxygen sources several meters from ignition sources (for example, acetylene used in maintenance). Ensure appropriate fire extinguishers are kept nearby and are regularly inspected . Record review of the website Automotive Fleet (https://www.automotive-fleet.com/ 5/dangers-of-leaving-a-warming-up-vehicle#:~:text=Idling%20can%20strip%20away%20some,area%20where%20it%20is%20parked.) revealed the following documentation, Dangers of Leaving a Warming Up Vehicle, January 25, 2019, . First, leaving an unoccupied vehicle running invites theft . Thirdly, leaving an unoccupied vehicle running - even when it is in park - is never entirely safe. It causes excessive fumes in the area where it is parked. Moreover, motor vehicle systems do fail from time to time, and if the car should unexpectedly move or roll with no driver at the wheel, it could lead to a collision with another vehicle or a pedestrian . Record review of the facility policy titled Environment of Care Policy and Procedure Manual 2003, ME03 - 5.0, revealed the following documentation, Compressed Gases, Safe Handling of . 9. Never drop cylinders or permit them to strike against each other or against other surfaces violently. 10. When cylinders are moved, they should be securely chained to an appropriate transport vehicle. 11. When tanks are stored, all tanks and cylinders should be stored in a cylinder cart or securely chained in a secure storage area. Never leave cylinders freestanding. All cylinders must be individually secured by separate chains . Record review of the facility policy labeled Environment of Care Policy and Procedure Manual 2003, AD 03 - 5.0, revealed the following documentation, Environmental checklist. 1. An environmental checklist will be completed by the facility at least monthly. The environmental checklist is a self-audit that will bring to light unsafe conditions and unsafe practices within the facility and prevent accidents before they occur. Successful safety audit will assist the safety officer and the safety committee in understanding what improvements need to be made, and will provide a blueprint for the auditing team to follow in order to make changes to improve the safety of the environment within the facility . 3. Departmental supervisors may assist in their areas in completing the environmental checklist. Since the supervisors have direct contact with workers and are familiar with the practices of the department, they will play an integral part in safety audits. 4. Environmental audits will include the following areas . Building grounds and conditions .

F761 [NAME] Nursing and Rehabilitation Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in two out of four medication carts, in that: The facility failed to ensure medications were properly labeled. The facility failed to ensure expired medications were not stored in the medication cart. These failures could place residents at risk of receiving other resident's medications. The findings include: Observation on 04/27/22 at 10:36 AM of medication cart A revealed one tube of Hydrocortisone 1% cream for Resident #17 that had no name or date on the tube, only on the box; one tube of Anti-itch cream for Resident #3 that had no name or date on the tube, only the box; one tube of Benzoyl Peroxide for Resident #47 that had no name or date on the tube, only the box; one tube of [MEDICATION(S)] Cream for Resident #25 that had no name or date on the tube, only the box; one tube of Triamcinolone [MEDICATION(S)] Cream 0.5% that had no name or date on the tube, only the box; one bottle of Artificial Tears for Resident #32 that had no name or date on the bottle, only the box; and one bottle of Artificial Tears for Resident #100 that had no name or date on the bottle, only the box. Observation on 04/27/22 at 10:55 AM of medication cart B revealed one tube of [MEDICATION(S)] Sodium 1% gel and one bottle of [MEDICATION(S)] 0.4mg/tablet for Resident #11 with no name or date on the tube or bottle, only the box; one tube of [MEDICATION(S)]-[MEDICATION(S)] cream for Resident #8 with no name or date on the tube, only the box; two bottles of Alaway 0.025% solution eye drops for Resident #37 with no name or date on the bottles, only the box; and eight Chlorhexidine [MEDICATION(S)] 3.15% that expired on 01/22. In an interview on 04/27/22 at 10:45 AM, LVN C stated she did not know both the bottle and the box had to have the name and date on it. LVN C stated the medication carts were last checked by the pharmacy consultant last week. LVN C stated she did not know how these items were missed. LVN C stated all the nurses were responsible for checking the medication cart for properly labeled items. LVN C stated the residents were at risk for a possible drug reaction if they were given another residents medication. In an interview on 04/27/22 at 11:04 AM, LVN A stated she was not aware these needed to both be labeled. LVN A stated the medication cart was checked last week by the pharmacy consultant and she didn't know how the items were missed. LVN A stated all the nurses were responsible for checking the medication cart. LVN A stated the residents have a risk of allergic reaction if they were given another residents medications. In an interview on 04/27/22 at 11:15 AM, DON stated the medication carts were last checked last week by the pharmacy consultant. The DON stated she didn't know how these items were missed. The DON stated all the nurses are responsible for checking the medication cart for expired items and properly labeled medications every time they use the medication cart. DON stated the residents could have a reaction to a medication if it belonged to another resident. DON stated the medication may not work as well if were expired. Record review of the facility policy dated 2003 and titled, Medication labeling, reflected the following: Medications are labeled in accordance with facility requirements and state and federal laws Record review of the facility policy dated 2003 and titled, Storage of Medications, reflected the following: Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents ' goals and preferences, for four out of nine sampled residents (Resident #1, Resident #2, Resident #3 and Resident #4) that were reviewed for oxygen therapy. Resident #1, Resident #2, Resident #3, and Resident #4 all required oxygen therapy but did not have a documented physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] These failures could place residents who require oxygen at an increased risk for receiving oxygen at the wrong time and/or rate, which could lead to hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), shortness of breath or respiratory distress. Findings include: Record review of Resident #1's face sheet, dated 02/10/22, revealed a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's admission MDS, dated [DATE], revealed BIMS score of 10 out of 15 which indicated her cognition was moderately impaired. She required extensive, two-person assistance with bed mobility, transferring, dressing, and toilet use, extensive one-person assistance with personal hygiene, and she was independent with eating. The MDS documented a need for oxygen while not a resident and also as a resident within the last 14 days prior to the MDS assessment. Record review of Resident #1's care plan, dated 01/25/22, revealed, in part: Resident has episodes of shortness of breath and is at risk for respiratory distress/failure Allow O2 per order .Resident requires Oxygen therapy and uses a C-pap [form of airway pressure ventilation to manage sleep apnea] for sleep apnea .Administer oxygen as ordered. Record review of Resident #1's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 02/10/22 at 12:31 PM, Resident #1 was in a wheelchair, in her room, wearing O2 at 3 L/NC. She stated she did not have oxygen when she was at home or in the hospital, she started wearing it when she arrived at the facility. She stated she thought she was supposed to wear O2 all the time and usually staff kept this on her. She stated when she was walked in the hall or when she went to therapy, she was taken with her O2. During an interview on 02/10/22 at 8:15 PM, DON stated Resident #1 was new to the facility, but she could not find her oxygen order. DON confirmed she knew Resident #1 had an oxygen order, but she was not sure where the order was. Record review of Resident #2's face sheet, dated 02/10/22, revealed an [AGE] year-old male admitted on [DATE], readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 02 out of 15 which indicated his cognition was severely impaired. He required extensive one-person assistance with bed mobility, transferring, dressing, eating and toilet use, and limited one-person assistance with personal hygiene. The MDS documented oxygen was not needed while a resident within the last 14 days prior to the MDS assessment. Record review of Resident #2's care plan, dated 12/28/21, revealed, in part: Resident has episodes of shortness of breath .Apply O2 per order .Resident requires oxygen therapy .Administer oxygen as ordered . Record review of Resident #2's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 02/10/22 at 1:07 PM, Resident #2 was observed with an O2 concentrator turned on to 2L/NC that was sitting next to his bed. O2 tubing observed on the floor next to his recliner. Resident #2 did not appear to be in any distress. Resident #2 stated he wore O2 all the time but was not at that moment because he just ate lunch. When asked how long he had not been wearing O2, Resident #2 did not provide an audible answer. When asked if staff needed to put his oxygen on for him, he stated he was able to do it himself. He stated he did not feel bad since he had not been wearing his O2 after eating. Resident #2 stated he did not usually wear O2 when he was out of his room. During an interview on 02/10/22 at 8:15 PM, DON stated Resident #2 required PRN oxygen use and stated she knew this because ADON said it was PRN. DON stated Resident #2 would move about the facility and stated she was told by ADON that she thought his oxygen was needed for when he was in bed. DON stated Resident #2 was one of the original residents and they were flabbergasted that he did not have an oxygen order in his chart. Record review of Resident #3's face sheet, dated 02/10/22, revealed an [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS score of 08 out of 15 which indicated her cognition was moderately impaired. She required extensive two-person assistance with bed mobility, transferring, dressing and toilet use, and extensive one-person assistance with eating and personal hygiene. The MDS documented oxygen was required while not a resident and while a resident within the last 14 days prior to the MDS assessment. Record review of Resident #3's care plan, dated 01/25/22, revealed, in part: Resident has episodes of Shortness of breath .Apply O2 per order .Resident requires oxygen therapy .Administer oxygen as ordered Record review of Resident #3's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 02/10/22 at 3:07 PM, Resident #3 was in her room, sitting in a chair, watching television and did not appear to be in any distress. O2 concentrator turned on at 2L/NC, NC not on resident. Resident #3 stated she did not wear oxygen at all and did not know why it was in her room. She stated she got tired of telling the staff to turn the O2 concentrator off. During an interview on 02/10/22 at 3:09 PM, CNA A stated Resident #3 was supposed to have been wearing O2 all the time but sometimes she would take her O2 off. CNA A stated she would notice that Resident #3 would get confused if she was not wearing her O2. CNA A stated that Resident #3 was wearing O2 when she returned from physical therapy an hour ago. During an observation on 02/10/22 at 4:13 PM, Resident #3 was in her recliner, in her room, with her eyes closed. O2 being administered to resident via NC. During an interview on 02/10/22 at 8:15 PM, DON stated Resident #3 came with an oxygen order from the hospital, but they were not scanned into her electronic chart. DON stated she knew Resident #3 had some kind of order for oxygen, but she was not sure if it was for continuous or PRN oxygen use. Record review of Resident #4's face sheet, dated 02/10/22, revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Admission MDS revealed it was still in progress due to being a new admission. Record review of Resident #4's care plan, dated 02/07/22, revealed, in part: Resident has episodes of shortness of breath .Respiratory failure/sleep apnea .Apply O2 per order .Resident requires Oxygen therapy .Resident is non-compliant with leaving oxygen on. Resident has to be redirected and reminded to keep oxygen on to prevent from becoming short of breath. Record review of Resident #4's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 02@ 3-5 L/M via nasal canula, to keep 02 Sats above 90% .every shift .Active .Start Date 2/11/2022 06:00 .Revision Date 2/10/2022 . During an interview on 02/10/22 at 10:15 AM, family member Individual B stated that Resident #4 was normally on O2 at 2L/NC continuously and that he cannot breathe without it. He was currently in the emergency room for a low oxygen level discovered that morning by facility staff. During a telephone interview on 02/10/22 at 4:23 PM, Resident #4, who was in the emergency room awaiting transport back to facility, confirmed he wore oxygen. During an observation on 02/10/22 at 7:55 PM, Resident #4 was back in his room from the emergency room , watching television, wearing O2 via NC. He states he wears oxygen continuously. During an interview on 02/10/22 at 8:15 PM, DON stated Resident #4 was to be on continuous oxygen, he cannot breathe without it and stated she was not sure where his original oxygen order was, other than the oxygen order that was just put in his chart that day after he returned from the emergency room . During an interview on 02/10/22 at 8:15 PM, DON confirmed Residents #1, #2, #3 and #4 did require oxygen therapy but stated she did not know where their oxygen orders were. DON stated a lot of paperwork was in the MDS Coordinator's office, who was not currently at the facility, and some of the resident's oxygen orders could have been in her office. DON stated there was so much paperwork, she was not sure where the orders were at but that they might have been in a stack in the MDS Coordinator's office. DON stated some of the oxygen orders must have got missed with all the new admissions the facility had been receiving. DON stated oxygen orders should have been in the electronic chart under the orders tab. When asked what negative outcome could have resulted if a resident was supposed to have oxygen but did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . We check oxygen levels three times per shift whether the resident is on oxygen or not. They [staff] don't seem to be putting orders in on admission. Our nurses still have good assessment skills, they intervene quickly and implement whatever is necessary. DON stated she would not consider these resident's medical records as accurate due to the missing oxygen orders. DON stated she had not performed any training regarding accurate medical records or entering orders in a chart in a long time. DON was asked to provide a facility policy regarding accurate medical records or entering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 02/10/22 at 9:30 PM, DON stated the facility did not have a policy regarding accurate medical records or entering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review the facility failed to follow its written policies and procedures that prohibit neglect for 1 of 13 residents (Resident #4) when the facility failed to provide a physician's orders [REDACTED]. Resident #4 experienced severe pain related to amputation of the lower extremities, pressure ulcers to his coccyx and buttock and pain "all over" from a recent discovery of [MEDICAL CONDITION] from 11/29/13-12/2/13. These failures resulted in identification of an IJ (Immediate Jeopardy) on 12/3/13. While the immediacy of the IJ was removed on 12/3/13, the facility remained out of compliance at a severity level of actual harm and a scope of pattern, that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. This deficient practice placed 1 of 12 residents identified with chronic pain at risk for neglect, by not following physician orders [REDACTED]. Findings include: Record review of the facility's policy and procedure titled "Abuse/Neglect" dated 1/8/03 states the following: "The resident has the right to be free from abuse......The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. Definitions 1. Abuse: ....Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse as defined in 40 TAC 19.101(1). 6. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Neglect as defined in 40 TAC 19.101(81)." A facility submitted policy dated 2/13/07, entitled Pain Management, Assessment Scale states that complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. 2. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. 14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain. Record review of the Resident #4's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Resident #4 had a CAT scan that showed an abnormal liver, highly suspicious for metastatic disease. Record review of Resident #4's physician orders [REDACTED]. There is also an order [REDACTED]. Record review of Resident #4's pain assessment, dated 11/26/13, documented pain as a "5" on a scale of 1-10. A nursing assessment of pain on the evening shift of 11/28/13 document pain as an "8" and generalized, and only one dose of oral breakthrough pain medication of [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 7.5 mg/325 mg was given on that day. Only eight doses of [MEDICATION NAME] were documented as being given on the MAR indicated [REDACTED]. Review of the annual MDS assessment dated [DATE] documented that Resident #4 was oriented and his cognitive summary score was a 10 out of 15. It documented that he was independent with bed mobility and only needed one person for transfer. It documented that he used a wheelchair for mobility and also had a limb prosthesis and required extensive assistance with dressing. It documented that a pain assessment was conducted and that he received scheduled pain medication and as needed pain medication. He frequently had pain with an intensity of 8 out of 10. Review of Resident #4's care plan revealed that there was not a care plan implemented for pain until 12/2/13, after surveyor intervention. During an observation/interview on 12/2/13 at 11:35 am, Resident #4 was grimacing and attempting to shift his weight by moving side to side in his wheelchair that was against a wall at the nurses' station. He said he had just finished working with therapy and "his bottom was hurting". During an observation on 12/2/13 at 11:55 am, Resident #4 was in a reclining Geri-chair at the dining room table with his head lying on the headrest. Resident #4 requested he go to his room at 12:08 pm. He ate less than 10% of his meal. During an observation on 12/2/13 at 3:10 pm in Resident #4's room, the wound care nurse was preparing to provide the care to 3 separate wounds with CNA F and CNA G assisting with positioning, linen change, and applying a clean brief. Several times during the 45-minutes of care, Resident #4 winced in pain, moaning and grabbing his right leg and saying he was getting cramps to his leg. He also said "I promised myself that I would not cry but the pain is so bad." The wound care nurse said Resident #4 was given oral pain medication at 12 p.m. prior to the wound care. The pain medication was not effective in controlling his pain because Resident #4 continued to cry out in pain. During an observation/interview on 12/2/13 at 4:40 pm in Resident #4's room, MA D was asked by the surveyor if he had been given pain medication and she said he had [MEDICATION NAME] prior to the wound care and he had a pain patch on. The surveyor asked for the location of the [MEDICATION NAME]. MA D began checking Resident #4's chest and back area for the pain patch but was unable to locate it. During an interview on 12/2/13 at 4:45 pm with the DON, she said she did not know why the pain patch was not in place but would check into it. During an interview with the ADON on 12/2/13 at 5:45 pm, she said that she did not know if Resident #4 had the pain patch on when he returned to the facility, but it was to be continued and should have been placed on 11/29/13- but it was not administered. She said the patch was not at the facility at the time it was scheduled to be administered on 11/29/13. The ADON said the local pharmacy doesn't always have the medications, but they got it from another pharmacy. She said it never did get put on after they received it at the facility on 11/30/13. During an interview with CNA F on 12/3/13 at 11:12 am, she said that yesterday when she was assisting Resident #4 during the wound care, that he was "hurting real bad and that was the worse she had seen him". She said she would tell the charge nurse when someone is in pain. She said he was hurting all over and complaining of cramping in his legs. During an interview with Resident #4 on 12/3/13 at 10:15 am, he said that he had been hurting for 3 days. He said he is afraid that he keeps his roommate up because of the pain and his moaning. According to the Nursing 2013 Drug Handbook pp. 227-230, [MEDICATION NAME] is an opioid [MEDICATION NAME]. It is a category C Controlled substance schedule III. It is indicated for moderate to severe chronic pain in patients requiring continuous opioid [MEDICATION NAME] for an extended period of time. Each patch is intended to be worn for 7 days. Taper dosage before discontinuing [MEDICATION NAME]. The facility administrator and director of nursing were notified on 12/3/13 at 9:15 am that an IJ situation had been identified due to the above failures. The facility Plan of Removal was provided on 12/3/13 at 11:32 am. The Plan of Removal was accepted at 3:15 pm on 12/3/13. The facility took the following actions to remove the IJ: 1. Staff will be in-serviced prior to their next working shift on the following: a. The charge nurse will be immediately notified of any medication found not to be in house, as will the DON and the administrator. b. The charge nurse will initiate a medication error and will notify the physician of the situation, whether missed dose, late dose, or whatever the specific situation may be and receive further direction at that time. c. All ordered medications will be checked in to see if all ordered meds were received. All medications not received will immediately be followed up with the pharmacy and nursing administration. d. All admissions will have all medications checked for the presence of ordered medications, and will insure that medications are received. Nurses are to copy the orders on arrival, a quantity be placed beside the medication, and the admitting nurse will sign. Nursing administration will insure that it was completed properly. e. All medications will be ordered according to date, not quantity. f. All questions regarding medications and medication administration are to be addressed immediately by the charge nurse, on call nurse, ADON/DON. Answer to be received before proceeding. g. Medications will be checked against all orders to verify all ordered meds are available for administration. h. All new orders will be reviewed by nursing administration daily. 2. All staff that administers medications are to attend the in-service that will be provided by the pharmacy consultant regarding medication ordering, medication administration, notification, medication errors and documentation requirements. 3. All Silver Chair courses addressing medication errors are to be completed on or by the next worked shift. Silver Chair is the on-line training system that allows assignment of courses to a group of employees; that does step by step training and testing upon course completion. The following courses will be required: a. Medication Preparation Process b. Preventing Medication Errors c. Medication Pass d. Pain Assessment and Management 4. Pain assessments were completed on every resident on 12/2/13. Pain flow sheets were initiated for any and all residents whose assessment revealed pain. 5. Care Plans initiated for each resident whose assessment revealed pain. 6. Each resident receiving [MEDICATION NAME] medications were immediately checked for the presence of their patch and will be monitored each shift. This will be added to the medication administration sheet with a place to indicate location for each shift to initial. 7. Continuity of Care regarding pain management and overall clinical condition will be ensured by all clinical assessments, to include pain assessments, and will be completed upon admission/readmission; and the plan of care will be updated based on all the clinical assessments, and will reflect residents current condition and perception of pain. Nursing Administration will review the discharged medication lists from the discharging facility. Staff assuming care of the resident will verify date and time of last doses administered, and receive a thorough report from the discharge primary licensed nurse. In addition all admission assessments, including pain assessments, will be completed and initial care plan initiated as indicated. 8. PCP (Primary Care Physician) will be notified of all medications and will be reviewed with the PCP for orders of continuance, new medications, or discontinuations upon admission and readmission. 9. Pain assessment will be completed on admission/readmission, significant change, quarterly, and upon any notification by resident; or through the identification and initiation of the Stop and Watch Tool. This tool is an early warning tool that may be filled out by any person (employee or visitor) and given to the charge nurse. The forms are located on each hall and in the dining room. They are on bright neon orange paper and are reviewed each morning in QA meeting and covered in the employee orientation. 10. Any discrepancy with the assessments and available pain medications will be conveyed to the primary care physician for intervention, thus assuring that pain is controlled at an acceptable level as designated by the resident and as indicated by the plan of care. 11. Insurance of continuity of care will be monitored through the QAPI (Quality Assurance Program Improvement) Committee. Nursing administration will review all admissions/readmissions to determine the following: a. Received report b. Verification of last dose of medications c. admission orders [REDACTED] d. All assessments including pain assessments were completed timely 12. Each admission will be monitored in the daily stand-up meeting as the admission occurs. This review will be done with the QAPI Monitoring Tool. This monitoring will occur daily times two weeks; then randomly times 90 days. If any issues are identified it will be reported daily in the QA department head meeting, and reviewed in the monthly QAPI facility meeting. All issues will have immediate corrective action and the facility action plan will be updated. If no further issues are identified after 90 days, the deficiency will be considered resolved. Record review of the in-service, performed on 12/2/13 by the DON, revealed it was attended by 6 of the licensed nursing staff. It contained the following subjects: a. Any medication that is found to be out, the charge nurse is to be notified in addition to the DON and Administrator b. Physician will be notified by the charge nurse of situation, missed dose, late dose, etc. c. All medications will be checked in and signed in to identify any that were failed to be delivered. d. All medications not delivered will be followed up with the pharmacy and the DON/ADON. e. All medications that are not administered are to have a reason documented on the back of the MAR. f. All admissions will have medications checked for presence of ordered meds and will insure that medications are received. Nurses are to copy the orders and on arrival, a quantity will be placed beside the medication, and the admitting nurse will sign. g. Any questions regarding medications or medication administration will be directed to the charge nurse, ADON, or DON. The on-call nurse is always available. Obtain your answer before proceeding. h. All medications are to be ordered according to date. i. All staff administering medications are to attend the in-service that will be provided by our pharmacy consultant on 12/3/13 at 10:00 a.m. and are to complete the silver chair assignments on or by your next scheduled shift. Record review of the in-service training on 12/3/13 by the consultant pharmacist indicated the attendance of 12 staff members. The topics for this in-service were Medication Errors, Refill Reordering, and New Medications. Record Review of the checklist for residents with [MEDICATION NAME] medications performed on 12/2/13 at 5:43 p.m. shows 3 residents with [MEDICATION NAME] pain medication patches and 2 residents with [MEDICATION NAME]es in the facility. Record review of the check off sheets completed for the IJ, indicate that all residents in the facility were assessed for pain on 12/2/13. It also shows that all 12 residents in the facility with chronic pain had care plans updated for pain assessments. During interviews on 12/3/13 between 3:50 p.m. and 4:00 p.m. with LVN A and LVN B, both LVN's indicated they had been in-serviced on the new procedures for ordering and obtaining medications. Both LVN's had completed all or part of the Silver Chair Training and would finish during the current shift. They also were able to answer questions about assessing residents for pain and how to order medications. On 12/3/13 at 5:10 p.m., the Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of a pattern, that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. The CMS Form 672 dated 12/2/13 states a resident census of 49 residents, with 20 residents on a pain management program. A list submitted by the DON documented 12 residents experience chronic pain.

Based on observation, interview and record review, the facility failed to ensure 1 of 13 residents, Resident #4, reviewed for drug therapies, was free of significant medication error when the physician's orders [REDACTED]. Resident #4 experienced severe pain related to amputation of the left lower extremity and from pressure ulcers to his coccyx and buttock from 11/29/13-12/2/13. Resident #4 also had pain from a recent discovery of [MEDICAL CONDITION]. No care plan had been implemented for pain management. These failures resulted in identification of an IJ (Immediate Jeopardy) on 12/3/13. While the immediacy of the IJ was removed on 12/3/13, the facility remained out of compliance at a severity level of actual harm and a scope of a pattern ,that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. This failure to ensure medication was administered as ordered by the physician could affect all 49 residents who reside at the nursing facility and place the residents at risk for the potential of exacerbation of their [DIAGNOSES REDACTED]. Findings include: Record review of the Resident #4's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Record review of Resident #4's physician orders [REDACTED]. There was also an order [REDACTED]. Record review of Resident #4's pain assessment dated [DATE] documented pain as a "5" on a scale of 1-10. A nursing assessment of pain for the evening shift on 11/28/13 document pain as an "8" and generalized, and only one dose of breakthrough pain medication of [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 7.5 mg/325 mg was given orally on that day. Only eight doses of [MEDICATION NAME] were documented on the MAR as given since Resident #4 returned from the hospital on [DATE]. Review of the annual MDS assessment dated [DATE] documented that Resident #4 was oriented and his cognitive summary score was a 10 out of 15. It documented that he was independent with bed mobility and only needed one person for transfer. It documented that he used a wheelchair for mobility and also had a limb prosthesis and required extensive assistance with dressing. It documented that a pain assessment was conducted and documented that he received scheduled pain medication and as needed pain medication. He frequently had pain with an intensity of 8 out of 10. Review of Resident #4's care plan revealed that there was not a care plan implemented for pain until 12/2/13, after surveyor intervention. During an observation/interview on 12/2/13 at 11:35 am, Resident #4 was grimacing and attempting to shift his weight by moving side to side in his wheelchair that was against a wall at the nurses' station. He said he had just finished working with therapy and "his bottom was hurting". During an observation on 12/2/13 at 11:55 am, Resident #4 was in a reclining Geri-chair at the dining room table with his head lying on the headrest. Resident #4 requested he go to his room at 12:08 pm. He ate less than 10% of his meal. During an observation on 12/2/13 at 3:10 pm in Resident #4's room, the wound care nurse was preparing to provide the care to 3 separate wounds with CNA F and CNA G assisting with positioning, linen change, and applying a clean brief. Several times during the 45-minutes of care, Resident #4 winced in pain, moaning and grabbing his right leg and saying he was getting cramps to his leg. He also said "I promised myself that I would not cry but the pain is so bad." The wound care nurse said Resident #4 was given oral pain medication at 12 p.m. prior to the wound care. The medication was not effective in controlling his pain because Resident #4 continued to cry out in pain. During an observation/interview on 12/2/13 at 4:40 pm in Resident #4's room, MA D was asked by the surveyor if he had been given pain medication and she said he had [MEDICATION NAME] prior to the wound care and he had a pain patch on. The surveyor asked for the location of the [MEDICATION NAME]. MA D began checking Resident #4's chest and back area for the pain patch but was unable to locate it. During an interview on 12/2/13 at 4:45 pm with the DON, she said she did not know why the pain patch was not in place, but would check into it. During an interview with the ADON on 12/2/13 at 5:45 pm, she said that she did not know if Resident #4 had the pain patch on when he returned to the facility from the hospital, but it was to be continued and should have been placed on 11/29/13 - but it was not administered. She said the patch was not at the facility at the time it was scheduled to be administered on 11/29/13. The ADON said the local pharmacy doesn't always have the medications, but they got it from another pharmacy. She said the pain patch never did get put on after they received it at the facility. She said she asked the nurse that should have placed the pain patch when it was received why she did not place it on Resident #4 and she said the nurse did not have an answer. During an interview with the DON on 12/3/13 at 9:40 am, she said that MA G was the med aide that did not put the patch on the resident. The surveyor attempted to contact her but was unable to leave a message. The DON also said that MA G was supposed to attend the in-service at 10 am and she would have her come to talk to the surveyors but she did not. The DON said that the medication aide made a mistake and she was not sure who all was involved. During an interview with Resident #4 on 12/3/13 at 10:15 am, he said that he had been hurting for 3 days. He said he is afraid that he keeps his roommate up because of the pain and his moaning. During an interview with CNA F on 12/3/13 at 11:12 am, she said that yesterday when she was assisting Resident #4 during the wound care that he was, "Hurting real bad and that was the worse she had seen him". She said she would tell the charge nurse when someone is in pain. She said he was hurting all over and complaining of cramping in his legs. During an interview with the ADM on 12/3/13 at 11:30 am, he said "we have never had anything like this before and the young, inexperienced med aide made a mistake." The facility submitted a medication error form on 12/2/13 which stated the error occurred on 11/29/13 at 8 a.m. The incident was described as a med was not available and the medication was ordered from the pharmacy but it was not applied. (Patch) The facility submitted an undated policy from a Pharmacy Policy and Procedure Manual 2003 entitled Medication Incident Report Procedure which stated: 1. The facility staff will take whatever immediate action is necessary to protect the resident's safety and welfare in the event of a medication administration incident. 2. The attending physician and family member will be promptly notified of any medication administration incident. 3. Any physician's orders [REDACTED]. 5. Interventions will be put in place to attempt to prevent reoccurrence, i.e. staff education. The facility submitted an undated policy from a Pharmacy Policy and Procedure Manual 2003 entitled [MEDICATION NAME] Patch Administration which stated: Write the date and initials on the patch to be applied when possible, and indicate the location on the Medication Administration Record. A facility submitted policy dated 2/13/07, entitled Pain Management, Assessment Scale states that complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. 2. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. 14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain. According to the Nursing 2013 Drug Handbook pp. 227-230, [MEDICATION NAME] is an opioid [MEDICATION NAME]. It is a category C Controlled substance schedule III. It is indicated for moderate to severe chronic pain in patients requiring continuous opioid [MEDICATION NAME] for an extended period of time. Each patch is intended to be worn for 7 days. Taper dosage before discontinuing [MEDICATION NAME]. The facility administrator and director of nursing were notified on 12/3/13 at 9:15 a.m. that an IJ situation had been identified due to the above failures. The facility Plan of Removal was provided on 12/3/13 at 11:32 a.m. The Plan of Removal was accepted at 3:15 p.m. on 12/3/13. The facility took the following actions to remove the IJ: 1. Staff will be in-serviced prior to their next working shift on the following: a. The charge nurse will be immediately notified of any medication found not to be in house, as will the DON and the administrator. b. The charge nurse will initiate a medication error and will notify the physician of the situation, whether missed dose, late dose, or whatever the specific situation may be and receive further direction at that time. c. All ordered medications will be checked in to see if all ordered meds were received. All medications not received will immediately be followed up with the pharmacy and nursing administration. d. All admissions will have all medications checked for the presence of ordered medications, and will insure that medications are received. Nurses are to copy the orders on arrival, a quantity be placed beside the medication, and the admitting nurse will sign. Nursing administration will insure that it was completed properly. e. All medications will be ordered according to date, not quantity. f. All questions regarding medications and medication administration are to be addressed immediately by the charge nurse, on call nurse, ADON/DON. Answer to be received before proceeding. g. Medications will be checked against all orders to verify all ordered meds are available for administration. h. All new orders will be reviewed by nursing administration daily. 2. All staff that administers medications are to attend the in-service that will be provided by the pharmacy consultant regarding medication ordering, medication administration, notification, medication errors and documentation requirements. 3. All Silver Chair courses addressing medication errors are to be completed on or by the next worked shift. Silver Chair is the on-line training system that allows assignment of courses to a group of employees; that does step by step training and testing upon course completion. The following courses will be required: a. Medication Preparation Process b. Preventing Medication Errors c. Medication Pass d. Pain Assessment and Management 4. Pain assessments were completed on every resident on 12/2/13. Pain flow sheets were initiated for any and all residents whose assessment revealed pain. 5. Care Plans initiated for each resident whose assessment revealed pain. 6. Each resident receiving [MEDICATION NAME] medications were immediately checked for the presence of their patch and will be monitored each shift. This will be added to the medication administration sheet with a place to indicate location for each shift to initial. 7. Continuity of Care regarding pain management and overall clinical condition will be ensured by all clinical assessments, to include pain assessments, and will be completed upon admission/readmission; and the plan of care will be updated based on all the clinical assessments, and will reflect residents current condition and perception of pain. Nursing Administration will review the discharged medication lists from the discharging facility. Staff assuming care of the resident will verify date and time of last doses administered, and receive a thorough report from the discharge primary licensed nurse. In addition all admission assessments, including pain assessments, will be completed and initial care plan initiated as indicated. 8. PCP (Primary Care Physician) will be notified of all medications and will be reviewed with the PCP for orders of continuance, new medications, or discontinuations upon admission and readmission. 9. Pain assessment will be completed on admission/readmission, significant change, quarterly, and upon any notification by resident; or through the identification and initiation of the Stop and Watch Tool. This tool is an early warning tool that may be filled out by any person (employee or visitor) and given to the charge nurse. The forms are located on each hall and in the dining room. They are on bright neon orange paper and are reviewed each morning in QA meeting and covered in the employee orientation. 10. Any discrepancy with the assessments and available pain medications will be conveyed to the primary care physician for intervention, thus assuring that pain is controlled at an acceptable level as designated by the resident and as indicated by the plan of care. 11. Insurance of continuity of care will be monitored through the QAPI (Quality Assurance Program Improvement) Committee. Nursing administration will review all admissions/readmissions to determine the following: a. Received report b. Verification of last dose of medications c. admission orders [REDACTED] d. All assessments including pain assessments were completed timely 12. Each admission will be monitored in the daily stand-up meeting as the admission occurs. This review will be done with the QAPI Monitoring Tool. This monitoring will occur daily times two weeks; then randomly times 90 days. If any issues are identified it will be reported daily in the QA department head meeting, and reviewed in the monthly QAPI facility meeting. All issues will have immediate corrective action and the facility action plan will be updated. If no further issues are identified after 90 days, the deficiency will be considered resolved. Record review of the in-service, performed on 12/2/13 by the DON, revealed it was attended by 6 of the licensed nursing staff. It contained the following subjects: a. Any medication that is found to be out, the charge nurse is to be notified in addition to the DON and Administrator b. Physician will be notified by the charge nurse of situation, missed dose, late dose, etc. c. All medications will be checked in and signed in to identify any that were failed to be delivered. d. All medications not delivered will be followed up with the pharmacy and the DON/ADON. e. All medications that are not administered are to have a reason documented on the back of the MAR. f. All admissions will have medications checked for presence of ordered meds and will insure that medications are received. Nurses are to copy the orders and on arrival, a quantity will be placed beside the medication, and the admitting nurse will sign. g. Any questions regarding medications or medication administration will be directed to the charge nurse, ADON, or DON. The on-call nurse is always available. Obtain your answer before proceeding. h. All medications are to be ordered according to date. i. All staff administering medications are to attend the in-service that will be provided by our pharmacy consultant on 12/3/13 at 10:00 a.m. and are to complete the silver chair assignments on or by your next scheduled shift. Record review of the in-service training on 12/3/13 by the consultant pharmacist indicated the attendance of 12 staff members. The topics for this in-service were Medication Errors, Refill Reordering, and New Medications. Record Review of the checklist for residents with [MEDICATION NAME] medications performed on 12/2/13 at 5:43 p.m. shows 3 residents with [MEDICATION NAME] pain medication patches and 2 residents with [MEDICATION NAME]es in the facility. Record review of the check off sheets completed for the IJ, indicate that all residents in the facility were assessed for pain on 12/2/13. It also shows that all 12 residents in the facility with chronic pain had care plans updated for pain assessments. During interviews on 12/3/13 between 3:50 p.m. and 4:00 p.m. with LVN A and LVN B, both LVN's indicated they had been in-serviced on the new procedures for ordering and obtaining medications. Both LVN's had completed all or part of the Silver Chair Training and would finish during the current shift. They also were able to answer questions about assessing residents for pain and how to order medications. On 12/3/13 at 5:10 p.m., the Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of a pattern, that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. The CMS Form 672 dated 12/2/13 states a resident census of 49 residents, with 20 residents on a pain management program. A list submitted by the DON documented 12 residents experience chronic pain.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental and psychosocial needs for 1 of 13 residents (Resident #4) reviewed for care plans. The facility failed to implement a care plan to address chronic and acute pain issues for Resident #4 which would be used to determine effectiveness of pain management. Resident #4 experienced severe pain related to amputation of the lower extremities, pressure ulcers to his coccyx and buttock and pain "all over" from a recent discovery of [MEDICAL CONDITION] from 11/29/13-12/2/13. These failures resulted in identification of an IJ (Immediate Jeopardy) on 12/3/13. While the immediacy of the IJ was removed on 12/3/13, the facility remained out of compliance at a severity level of actual harm and a scope of pattern, that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. This failure affected 1 resident (Resident #4) and placed an additional 20 residents at risk for not receiving appropriate care and not having their needs evaluated and met. Findings include: Record review of the Resident #4's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Record review of Resident #4's physician orders [REDACTED]. There also was an order for [REDACTED]. Record review of Resident #4's pain assessment dated [DATE] documented pain as a "5" on a scale of 1-10. A nursing assessment of pain for the evening shift on 11/28/13 document pain as an "8" and generalized, and only one dose of breakthrough pain medication of [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 7.5 mg/325 mg was given on that day. Only eight doses of [MEDICATION NAME] were given since Resident #4 returned from the hospital on [DATE]. The facility became aware that Resident #4 did not have the pain patch on after surveyor intervention. Review of the annual MDS assessment dated [DATE] documented that Resident #4 was oriented and his cognitive summary score was a 10 out of 15. It documented that he was independent with bed mobility and only needed one person for transfer. It documented that he used a wheelchair for mobility and also had a limb prosthesis and required extensive assistance with dressing. It documented that a pain assessment was conducted and documented that he received scheduled pain medication and as needed pain medication. He frequently had pain with an intensity of 8 out of 10. Review of Resident #4's care plan revealed that there was not a care plan implemented for pain until 12/2/13, after surveyor intervention. During an observation/interview on 12/2/13 at 11:35 am, Resident #4 was grimacing and attempting to shift his weight by moving side to side in his wheelchair that was against a wall at the nurses' station. He said he had just finished working with therapy and "his bottom was hurting". During an observation on 12/2/13 at 11:55 am, Resident #4 was in a reclining Geri-chair at the dining room table with his head lying on the headrest. Resident #4 requested he go to his room at 12:08 pm. He ate less than 10% of his meal. During an observation on 12/2/13 at 3:10 pm in Resident #4's room, the wound care nurse was preparing to provide the care to 3 separate wounds with CNA F and CNA G assisting with positioning, linen change, and applying a clean brief. Several times during the 45-minutes of care, Resident #4 winced in pain, moaning and grabbing his right leg and saying he was getting cramps to his leg. He also said "I promised myself that I would not cry but the pain is so bad." The wound care nurse said Resident #4 was given oral pain medication at 12 p.m. prior to the wound care. The pain medication was not effective in controlling his pain because Resident #4 continued to cry out in pain. During an observation/interview on 12/2/13 at 4:40 pm in Resident #4's room, MA D was asked by the surveyor if he had been given pain medication and she said he had [MEDICATION NAME] prior to the wound care and he had a pain patch on. The surveyor asked for the location of the [MEDICATION NAME]. MA D began checking Resident #4's chest and back area for the pain patch but was unable to locate it. During an interview with the ADON on 12/2/13 at 5:45 pm, she said that she did not know if Resident #4 had the pain patch on when he returned to the facility from the hospital, but it was to be continued and should have been placed on 11/29/13 - but it was not administered. She said the patch was not at the facility at the time it was scheduled to be administered on 11/29/13. The ADON said the local pharmacy doesn't always have the medications, but they got it from another pharmacy. She said the pain patch never did get put on after they received it at the facility. She said she asked the nurse that should have placed the pain patch when it was received why she did not place it on Resident #4 and she said the nurse did not have an answer. During an interview with the DON on 12/3/13 at 9:40 am, she said that MA G was the med aide that did not put the patch on the resident. The surveyor attempted to contact her but was unable to leave a message. The DON also said that MA G was supposed to attend the in-service at 10:00 am and she would have her come to talk to the surveyors but she did not. The DON said that the medication aide made a mistake and she was not sure who all was involved. During an interview with Resident #4 on 12/3/13 at 10:15 am, he said that he had been hurting for 3 days. He said he is afraid that he keeps his roommate up because of the pain and his moaning. During an interview with CNA F on 12/3/13 at 11:12 am, she said that yesterday when she was assisting Resident #4 during the wound care that he was, "Hurting real bad and that was the worse she had seen him". She said she would tell the charge nurse when someone is in pain. She said he was hurting all over and complaining of cramping in his legs. During an interview with the ADM on 12/3/13 at 11:30 am, he said "we have never had anything like this before and the young, inexperienced med aide made a mistake." During an interview with the ADON on 12/3/13 at 8:30 a.m., she said that she could not find a previous care plan that addressed Resident #4's pain, but she implemented one yesterday on 12/2/13. The care plan implement on 12/2/13 stated the problem was pain "all over" and the approach was to assess effectiveness of medications and document same. A facility submitted policy dated 2/13/07, entitled Pain Management, Assessment Scale states that complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. 2. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. 14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain. Record review of the facility's policy and procedure titled "Comprehensive Care Plans" dated 2/13/07 states the following: "1. The facility will develop a comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet and residents' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. The care plan must describe the following: a. Services/Interventions that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. b. Problem statements to identify services that are required to maintain the resident's highest practicable physical, mental, and psychosocial well-being." According to the Nursing 2013 Drug Handbook pp .227-230, [MEDICATION NAME] is an opioid [MEDICATION NAME]. It is a category C Controlled substance schedule III. It is indicated for moderate to severe chronic pain in patients requiring continuous opioid [MEDICATION NAME] for an extended period of time. Each patch is intended to be worn for 7 days. Taper dosage before discontinuing [MEDICATION NAME]. The facility administrator and director of nursing were notified on 12/3/13 at 9:15 am that an IJ situation had been identified due to the above failures. The facility Plan of Removal was provided on 12/3/13 at 11:32 am. The Plan of Removal was accepted at 3:15 p.m. on 12/3/13. The facility took the following actions to remove the IJ: 1. Staff will be in-serviced prior to their next working shift on the following: a. The charge nurse will be immediately notified of any medication found not to be in house, as will the DON and the administrator. b. The charge nurse will initiate a medication error and will notify the physician of the situation, whether missed dose, late dose, or whatever the specific situation may be and receive further direction at that time. c. All ordered medications will be checked in to see if all ordered meds were received. All medications not received will immediately be followed up with the pharmacy and nursing administration. d. All admissions will have all medications checked for the presence of ordered medications, and will insure that medications are received. Nurses are to copy the orders on arrival, a quantity be placed beside the medication, and the admitting nurse will sign. Nursing administration will insure that it was completed properly. e. All medications will be ordered according to date, not quantity. f. All questions regarding medications and medication administration are to be addressed immediately by the charge nurse, on call nurse, ADON/DON. Answer to be received before proceeding. g. Medications will be checked against all orders to verify all ordered meds are available for administration. h. All new orders will be reviewed by nursing administration daily. 2. All staff that administers medications are to attend the in-service that will be provided by the pharmacy consultant regarding medication ordering, medication administration, notification, medication errors and documentation requirements. 3. All Silver Chair courses addressing medication errors are to be completed on or by the next worked shift. Silver Chair is the on-line training system that allows assignment of courses to a group of employees; that does step by step training and testing upon course completion. The following courses will be required: a. Medication Preparation Process b. Preventing Medication Errors c. Medication Pass d. Pain Assessment and Management 4. Pain assessments were completed on every resident on 12/2/13. Pain flow sheets were initiated for any and all residents whose assessment revealed pain. 5. Care Plans initiated for each resident whose assessment revealed pain. 6. Each resident receiving [MEDICATION NAME] medications were immediately checked for the presence of their patch and will be monitored each shift. This will be added to the medication administration sheet with a place to indicate location for each shift to initial. 7. Continuity of Care regarding pain management and overall clinical condition will be ensured by all clinical assessments, to include pain assessments, and will be completed upon admission/readmission; and the plan of care will be updated based on all the clinical assessments, and will reflect residents current condition and perception of pain. Nursing Administration will review the discharged medication lists from the discharging facility. Staff assuming care of the resident will verify date and time of last doses administered, and receive a thorough report from the discharge primary licensed nurse. In addition all admission assessments, including pain assessments, will be completed and initial care plan initiated as indicated. 8. PCP (Primary Care Physician) will be notified of all medications and will be reviewed with the PCP for orders of continuance, new medications, or discontinuations upon admission and readmission. 9. Pain assessment will be completed on admission/readmission, significant change, quarterly, and upon any notification by resident; or through the identification and initiation of the Stop and Watch Tool. This tool is an early warning tool that may be filled out by any person (employee or visitor) and given to the charge nurse. The forms are located on each hall and in the dining room. They are on bright neon orange paper and are reviewed each morning in QA meeting and covered in the employee orientation. 10. Any discrepancy with the assessments and available pain medications will be conveyed to the primary care physician for intervention, thus assuring that pain is controlled at an acceptable level as designated by the resident and as indicated by the plan of care. 11. Insurance of continuity of care will be monitored through the QAPI (Quality Assurance Program Improvement) Committee. Nursing administration will review all admissions/readmissions to determine the following: a. Received report b. Verification of last doses of medications c. admission orders [REDACTED] d. All assessments including pain assessments were completed timely 12. Each admission will be monitored in the daily stand-up meeting as the admission occurs. This review will be done with the QAPI Monitoring Tool. This monitoring will occur daily times two weeks; then randomly times 90 days. If any issues are identified it will be reported daily in the QA department head meeting, and reviewed in the monthly QAPI facility meeting. All issues will have immediate corrective action and the facility action plan will be updated. If no further issues are identified after 90 days, the deficiency will be considered resolved. Record review of the in-service, performed on 12/2/13 by the DON, revealed it was attended by 6 of the licensed nursing staff. It contained the following subjects: a. Any medication that is found to be out, the charge nurse is to be notified in addition to the DON and Administrator b. Physician will be notified by the charge nurse of situation, missed dose, late dose, etc. c. All medications will be checked in and signed in to identify any that were failed to be delivered. d. All medications not delivered will be followed up with the pharmacy and the DON/ADON. e. All medications that are not administered are to have a reason documented on the back of the MAR. f. All admissions will have medications checked for presence of ordered meds and will insure that medications are received. Nurses are to copy the orders and on arrival, a quantity will be placed beside the medication, and the admitting nurse will sign. g. Any questions regarding medications or medication administration will be directed to the charge nurse, ADON, or DON. The on-call nurse is always available. Obtain your answer before proceeding. h. All medications are to be ordered according to date. i. All staff administering medications are to attend the in-service that will be provided by our pharmacy consultant on 12/3/13 at 10:00 am and are to complete the silver chair assignments on or by your next scheduled shift. Record review of the in-service training on 12/3/13 by the consultant pharmacist indicated the attendance of 12 staff members. The topics for this in-service were Medication Errors, Refill Reordering, and New Medications. Record Review of the checklist for residents with [MEDICATION NAME] medications performed on 12/2/13 at 5:43 p.m. showed 3 residents with [MEDICATION NAME] pain medication patches and 2 residents with [MEDICATION NAME]es in the facility. Record review of the check off sheets completed for the IJ, indicate that all residents in the facility were assessed for pain on 12/2/13. It also shows that all 12 residents in the facility with chronic pain had care plans updated for pain assessments. During interviews on 12/3/13 between 3:50 and 4:00 p.m. with LVN A and LVN B, both LVN's indicated they had been in-serviced on the new procedures for ordering and obtaining medications. Both LVN's had completed all or part of the Silver Chair Training and would finish during the current shift. They also were able to answer questions about assessing residents for pain and how to order medications. On 12/3/13 at 5:10 p.m., the Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of a pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. The CMS Form 672 dated 12/2/13 states a resident census of 49 residents, with 20 residents on a pain management program. Review of a document provided by the facility on 12/3/13 documented there were 12 residents in the facility with chronic pain.

Based on observation, interview and record review the facility failed to provide the necessary care and services to ensure 1 of 3 residents (Resident #4) attained the highest practicable, physical, mental and psychosocial well-being when the facility failed to provide a physician's orders [REDACTED]. Resident #4 experienced severe pain related to amputation of the lower extremities, pressure ulcers to his coccyx and buttock and pain "all over" from a recent discovery of [MEDICAL CONDITION] from 11/29/13-12/2/13. These failures resulted in identification of an IJ (Immediate Jeopardy) on 12/3/13. While the immediacy of the IJ was removed on 12/3/13, the facility remained out of compliance at a severity level of actual harm and a scope of a pattern, that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. This deficient practice placed 1 of 12 residents identified with chronic pain in the facility at risk for neglect, by not managing pain symptoms and failing to ensure that the pain medication is given as ordered. Findings include: Record review of the Resident #4's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Record review of Resident #4's physician orders [REDACTED]. Resident #4 also had an order for [REDACTED]. Record review of the MAR for Resident #4 showed that he had been receiving a [MEDICATION NAME] for chronic pain since it was ordered on [DATE]. He was transferred to a local hospital on [DATE] and returned to the facility on [DATE] with an order to continue the [MEDICATION NAME]. The change of the pain patch was due on 11/29/13 on the MAR; it was circled as not administered by MA G. There was no documentation on why it was not placed, or that it was ever administered since his return to the facility. Record review of Resident #4's pain assessment dated [DATE] documented pain as a "5" on a scale of 1-10. The location of the pain intervention was documented as [MEDICATION NAME]. A nursing assessment of pain for the evening shift on 11/28/13 document pain as an "8" and generalized, and only one dose of breakthrough pain medication of [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 7.5 mg/325 mg was given orally on that day. Only eight doses of [MEDICATION NAME] were documented on the MAR as given since Resident #4 returned from the hospital on [DATE]. The facility had no documentation if a [MEDICATION NAME] was on Resident #4 when he returned to the facility on [DATE]. Review of the annual MDS assessment dated [DATE] documented that Resident #4 was oriented and his cognitive summary score was a 10 out of 15. It documented that he was independent with bed mobility and only needed one person for transfer. It documented that he used a wheelchair for mobility and also had a limb prosthesis and required extensive assistance with dressing. It documented that a pain assessment was conducted and documented that he received scheduled pain medication and as needed pain medication and he frequently had pain with an intensity of an 8 out of 10. Review of Resident #4's care plan revealed that there was not a care plan implemented for pain until 12/2/13, after surveyor intervention. During an observation/interview on 12/2/13 at 11:35 am, Resident #4 was grimacing and attempting to shift his weight by moving side to side in his wheelchair that was against a wall at the nurses' station. He said he had just finished working with therapy and "his bottom was hurting". During an observation on 12/2/13 at 11:55 am, Resident #4 was in a reclining Geri-chair at the dining room table with his head lying on the headrest. Resident #4 requested he go to his room at 12:08 pm. He ate less than 10% of his meal. During an observation on 12/2/13 at 3:10 pm in Resident #4's room, the wound care nurse was preparing to provide the care to 3 separate wounds with CNA F and CNA G assisting with positioning, linen change, and applying a clean brief. Several times during the 45-minutes of care, Resident #4 winced in pain, moaning and grabbing his right leg and saying he was getting cramps to his leg. He also said "I promised myself that I would not cry but the pain is so bad." The wound care nurse said Resident #4 was given oral pain medication at 12 pm prior to the wound care. The medication was not effective in controlling his pain because Resident #4 continued to cry out in pain. During an observation/interview on 12/2/13 at 4:40 pm in Resident #4's room, MA D was asked by the surveyor if he had been given pain medication and she said he had [MEDICATION NAME] prior to the wound care and he had a pain patch on. The surveyor asked for the location of the [MEDICATION NAME]. MA D began checking Resident #4's chest and back area for the pain patch but was unable to locate it. During an interview on 12/2/13 at 4:45 p.m. with the DON, she said she did not know why the pain patch was not in place, but would check into it. During an interview with the ADON on 12/2/13 at 5:45 p.m., she said that she did not know if Resident #4 had the pain patch on when he returned to the facility, but it was to be continued and should have been placed on 11/29/13 -but it was not administered. She said the patch was not at the facility at the time it was scheduled to be administered on 11/29/13. The ADON said the local pharmacy doesn't always have the medications, but they got it from another pharmacy. She said it never did get put on after they received it at the facility on 11/30/13. During an interview with the DON on 12/3/13 at 9:40 a.m., she said that MA G was the med aide that did not put the patch on the resident. The surveyor attempted to contact her but was unable to leave a message. The DON also said that MA G was supposed to attend the in-service at 10:00 a.m. and she would have her come to talk to the surveyors but she did not. The DON said that the medication aide made a mistake and she was not sure who all was involved. During an interview with CNA F on 12/3/13 at 11:12 am, she said that yesterday when she was assisting Resident #4 during the wound care that he was, "hurting real bad and that was the worse she had seen him". She said she would tell the charge nurse when someone is in pain. She said he was hurting all over and complaining of cramping in his legs. During an interview with Resident #4 on 12/3/13 at 10:15 am, he said that he had been hurting for 3 days. He said he is afraid that he keeps his roommate up because of the pain and his moaning. A facility submitted policy dated 2/13/07, entitled Pain Management, Assessment Scale states that complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. 2. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. 14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain. According to the Nursing 2013 Drug Handbook pp. 227-230, [MEDICATION NAME] is an opioid [MEDICATION NAME]. It is a category C Controlled substance schedule III. It is indicated for moderate to severe chronic pain in patients requiring continuous opioid [MEDICATION NAME] for an extended period of time. Each patch is intended to be worn for 7 days. Taper dosage before discontinuing [MEDICATION NAME]. The facility administrator and director of nursing were notified on 12/3/13 at 9:15 a.m. that an IJ situation had been identified due to the above failures. The facility Plan of Removal was provided on 12/3/13 at 11:32 a.m. The Plan of Removal was accepted at 3:15 p.m. on 12/3/13. The facility took the following actions to remove the IJ: 1. Staff will be in-serviced prior to their next working shift on the following: a. The charge nurse will be immediately notified of any medication found not to be in house, as will the DON and the administrator. b. The charge nurse will initiate a medication error and will notify the physician of the situation, whether missed dose, late dose, or whatever the specific situation may be and receive further direction at that time. c. All ordered medications will be checked in to see if all ordered meds were received. All medications not received will immediately be followed up with the pharmacy and nursing administration. d. All admissions will have all medications checked for the presence of ordered medications, and will insure that medications are received. Nurses are to copy the orders on arrival, a quantity be placed beside the medication, and the admitting nurse will sign. Nursing administration will insure that it was completed properly. e. All medications will be ordered according to date, not quantity. f. All questions regarding medications and medication administration are to be addressed immediately by the charge nurse, on call nurse, ADON/DON. Answer to be received before proceeding. g. Medications will be checked against all orders to verify all ordered meds are available for administration. h. All new orders will be reviewed by nursing administration daily. 2. All staff that administers medications are to attend the in-service that will be provided by the pharmacy consultant regarding medication ordering, medication administration, notification, medication errors and documentation requirements. 3. All Silver Chair courses addressing medication errors are to be completed on or by the next worked shift. Silver Chair is the on-line training system that allows assignment of courses to a group of employees; that does step by step training and testing upon course completion. The following courses will be required: a. Medication Preparation Process b. Preventing Medication Errors c. Medication Pass d. Pain Assessment and Management 4. Pain assessments were completed on every resident on 12/2/13. Pain flow sheets were initiated for any and all residents whose assessment revealed pain. 5. Care Plans initiated for each resident whose assessment revealed pain. 6. Each resident receiving [MEDICATION NAME] medications were immediately checked for the presence of their patch and will be monitored each shift. This will be added to the medication administration sheet with a place to indicate location for each shift to initial. 7. Continuity of Care regarding pain management and overall clinical condition will be ensured by all clinical assessments, to include pain assessments, and will be completed upon admission/readmission; and the plan of care will be updated based on all the clinical assessments, and will reflect residents' current condition and perception of pain. Nursing Administration will review the discharged medication lists from the discharging facility. Staff assuming care of the resident will verify date and time of last doses administered, and receive a thorough report from the discharge primary licensed nurse. In addition all admission assessments, including pain assessments, will be completed and initial care plan initiated as indicated. 8. PCP (Primary Care Physician) will be notified of all medications and will be reviewed with the PCP for orders of continuance, new medications, or discontinuations upon admission and readmission. 9. Pain assessment will be completed on admission/readmission, significant change, quarterly, and upon any notification by resident; or through the identification and initiation of the Stop and Watch Tool. This tool is an early warning tool that may be filled out by any person (employee or visitor) and given to the charge nurse. The forms are located on each hall and in the dining room. They are on bright neon orange paper and are reviewed each morning in QA meeting and covered in the employee orientation. 10. Any discrepancy with the assessments and available pain medications will be conveyed to the primary care physician for intervention, thus assuring that pain is controlled at an acceptable level as designated by the resident and as indicated by the plan of care. 11. Insurance of continuity of care will be monitored through the QAPI (Quality Assurance Program Improvement) Committee. Nursing administration will review all admissions/readmissions to determine the following: a. Received report b. Verification of last dose of medications c. admission orders [REDACTED] d. All assessments including pain assessments were completed timely 12. Each admission will be monitored in the daily stand-up meeting as the admission occurs. This review will be done with the QAPI Monitoring Tool. This monitoring will occur daily times two weeks; then randomly times 90 days. If any issues are identified it will be reported daily in the QA department head meeting, and reviewed in the monthly QAPI facility meeting. All issues will have immediate corrective action and the facility action plan will be updated. If no further issues are identified after 90 days, the deficiency will be considered resolved. Record review of the in-service, performed on 12/2/13 by the DON, revealed it was attended by 6 of the licensed nursing staff. It contained the following subjects: a. Any medication that is found to be out, the charge nurse is to be notified in addition to the DON and Administrator b. Physician will be notified by the charge nurse of situation, missed dose, late dose, etc. c. All medications will be checked in and signed in to identify any that were failed to be delivered. d. All medications not delivered will be followed up with the pharmacy and the DON/ADON. e. All medications that are not administered are to have a reason documented on the back of the MAR. f. All admissions will have medications checked for presence of ordered meds and will insure that medications are received. Nurses are to copy the orders and on arrival, a quantity will be placed beside the medication, and the admitting nurse will sign. g. Any questions regarding medications or medication administration will be directed to the charge nurse, ADON, or DON. The on-call nurse is always available. Obtain your answer before proceeding. h. All medications are to be ordered according to date. i. All staff administering medications are to attend the in-service that will be provided by our pharmacy consultant on 12/3/13 at 10:00 a.m. and are to complete the silver chair assignments on or by your next scheduled shift. Record review of the in-service training on 12/3/13 by the consultant pharmacist indicated the attendance of 12 staff members. The topics for this in-service were Medication Errors, Refill Reordering, and New Medications. Record Review of the checklist for residents with [MEDICATION NAME] medications performed on 12/2/13 at 5:43 p.m. showed 3 residents with [MEDICATION NAME] pain medication patches and 2 residents with [MEDICATION NAME]es in the facility. Record review of the check off sheets completed for the IJ, indicate that all residents in the facility were assessed for pain on 12/2/13. It also shows that all 12 residents in the facility with chronic pain had care plans updated for pain assessments. During interviews on 12/3/13 between 3:50 p.m. and 4:00 p.m. with LVN A and LVN B, both LVN's indicated they had been in-serviced on the new procedures for ordering and obtaining medications. Both LVN's had completed all or part of the Silver Chair Training and would finish during the current shift. They also were able to answer questions about assessing residents for pain and how to order medications. On 12/3/13 at 5:10 p.m., the Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of a pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. Review of the facility's CMS Form 672, Resident Census and Conditions of Residents dated 12/2/13 and signed by the DON, documented a census of 20 residents were on pain management. An additional list submitted by the DON documented 12 residents experienced chronic pain.

Based on observation, interview and record review the administrator failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administrator and DON failed to implement the facility policies for pain control so that the residents were not subjected to undue pain and suffering. Resident #4's pain was found to be at an extremely high level during observation of incontinent and wound care, and it was found that the physician ordered [MEDICATION NAME] pain medication patch was not on Resident #4 for 4 days until intervention from the surveyor. Resident #4 experienced severe pain related to the amputation of the lower extremities, pressure ulcers of his coccyx and buttocks and hurting "all over" from a recent discovery of [MEDICAL CONDITION] from 11/29/13 to 12/2/13. These failures resulted in identification of an IJ (Immediate Jeopardy) on 12/3/13. While the immediacy of the IJ was removed on 12/3/13, the facility remained out of compliance at a severity level of actual harm and a scope of a pattern,that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. This deficient practice could affect the 12 residents in the facility identified by the facility resident check sheet for pain assessment that suffer from chronic pain; and placed the 20 residents identified on the CMS form 802 as receiving pain management at risk of not receiving adequate assessments, medical care and services, and care for pain management. The findings were: Record review of the Resident #4's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Record review of Resident #4's physician orders [REDACTED]. There was also an order [REDACTED]. Record review of Resident #4's pain assessment dated [DATE] documented pain as a "5" on a scale of 1-10. The location of the pain intervention was documented as [MEDICATION NAME]. A nursing assessment of pain on 11/28/13 for the evening shift document pain as an "8" and generalized and only one dose of oral breakthrough pain medication of [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 7.5 mg/325 mg was given on that day. Only eight doses of [MEDICATION NAME] were documented on the MAR as given since Resident #4 had returned from the hospital on [DATE]. Review of the annual MDS assessment dated [DATE] documented that Resident #4 was oriented and his cognitive summary score was a 10 out of 15. It documented that he was independent with bed mobility and only needed one person for transfer. It documented that he used a wheelchair for mobility and also had a limb prosthesis and required extensive assistance with dressing. It documented that a pain assessment was conducted and documented that he received scheduled pain medication and as needed pain medication and he frequently had pain with an intensity of an 8 out of 10. Review of Resident #4's care plans revealed that there was not a care plan implemented for pain until 12/2/13. During an observation/interview on 12/2/13 at 11:35 am, Resident #4 was grimacing and attempting to shift his weight by moving side to side in his wheelchair that against a wall at the nurses' station. He said he had just finished working with therapy and "his bottom was hurting". During an observation on 12/2/13 at 11:55 am, Resident #4 was in a reclining Geri-chair at the dining room table with his head laying on the headrest. Resident #4 requested he go to his room at 12:08 pm. He ate less than 10% of his meal. During an observation on 12/2/13 at 3:10 pm in Resident #4's room, the wound care nurse was preparing to provide the care to 3 separate wounds with CNA F and CNA G assisting with positioning, linen change, and applying a clean brief. Several times during the 45-minutes of care, Resident #4 winced in pain, moaning and grabbing his right leg and saying he was getting cramps to his leg. He also said "I promised myself that I would not cry but the pain is so bad." The wound care nurse said Resident #4 was given oral pain medication at 12 p.m. prior to the wound care. The pain medication was not effective in controlling his pain because Resident #4 continued to cry out in pain. During an observation/interview on 12/2/13 at 4:40 pm in Resident #4's room, MA D was asked by the surveyor if he had been given pain medication and she said he had [MEDICATION NAME] prior to the wound care and he had a pain patch on. The surveyor asked for the location of the [MEDICATION NAME]. MA D began checking Resident #4's chest and back area for the pain patch but was unable to locate it. During an interview on 12/2/13 at 4:45 p.m. with the DON, she said she did not know why the pain patch was not in place, but would check into it. During an interview with the ADON on 12/2/13 at 5:45 p.m., she said that she did not know if Resident #4 had the pain patch on when he returned to the facility, but it was to be continued and should have been placed on 11/29/13 -but it was not administered. She said the patch was not at the facility at the time it was scheduled to be administered on 11/29/13. The ADON said the local pharmacy doesn't always have the medications, but they got it from another pharmacy. She said it never did get put on after they received it at the facility on 11/30/13. She said she asked the nurse that should have placed the pain patch when it was received why she did not place it on Resident #4 and she said the nurse did not have an answer. During an interview with the DON on 12/3/13 at 9:40 am, she said that MA G was the med aide that did not put the patch on the resident. The surveyor attempted to contact her but was unable to leave a message. The DON also said that MA G was suppose to attend the in-service at 10:00 a.m. and she would have her come to talk to the surveyors but she did not. The DON said that the medication aide made a mistake and she was not sure who all was involved. During an interview with the ADM on 12/3/13 at 11:30 am, he said "we have never had anything like this before." During an interview with CNA F on 12/3/13 at 11:12 am, she said that yesterday when she was assisting Resident #4 during the wound care that he was "hurting real bad and that was the worse she had seen him." She said she will tell the charge nurse when someone is in pain. She said he was hurting all over and complaining of cramping in his legs. During an interview with Resident #4 on 12/3/13 at 10:15 am, he said that he had been hurting for 3 days. He said he is afraid that he keeps his roommate up because of the pain and moaning. The facility submitted a medication error form on 12/2/13 which stated the error occurred on 11/29/13 at 8 a.m. The incident was described as a med was not available and the medication was ordered from the pharmacy but it was not applied. (Patch) The facility submitted an undated policy from a Pharmacy Policy and Procedure Manual 2003 entitled Medication Incident Report Procedure which stated: 1. The facility staff will take whatever immediate action is necessary to protect the resident's safety and welfare in the event of a medication administration incident. 2. The attending physician and family member will be promptly notified of any medication administration incident. 3. Any physician's orders [REDACTED]. 5. Interventions will be put in place to attempt to prevent reoccurrence, i.e. staff education. The facility submitted an undated policy from a Pharmacy Policy and Procedure Manual 2003 entitled [MEDICATION NAME] Patch Administration which stated: Write the date and initials on the patch to be applied when possible, and indicate the location on the Medication Administration Record. A facility submitted policy dated 2/13/07, entitled Pain Management, Assessment Scale states: That complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. 2. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. 14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain. According to the Nursing 2013 Drug Handbook pp. 227-230, [MEDICATION NAME] is an opioid [MEDICATION NAME]. It is a category C Controlled substance schedule III. It is indicated for moderate to severe chronic pain in patients requiring continuous opioid [MEDICATION NAME] for an extended period of time. Each patch is intended to be worn for 7 days. Taper dosage before discontinuing [MEDICATION NAME]. The facility administrator and director of nursing were notified on 12/3/13 at 9:15 am that an IJ situation had been identified due to the above failures. The facility Plan of Removal was provided on 12/3/13 at 11:32 am. The Plan of Removal was accepted at 3:15 pm on 12/3/13. The facility took the following actions to remove the IJ: 1. Staff will be in-serviced prior to their next working shift on the following: a. The charge nurse will be immediately notified of any medication found not to be in house, as will the DON and the administrator. b. The charge nurse will initiate a medication error and will notify the physician of the situation, whether missed dose, late dose, or whatever the specific situation may be and receive further direction at that time. c. All ordered medications will be checked in to see if all ordered meds were received. All medications not received will immediately be followed up with the pharmacy and nursing administration. d. All admissions will have all medications checked for the presence of ordered medications, and will insure that medications are received. Nurses are to copy the orders on arrival, a quantity be placed beside the medication, and the admitting nurse will sign. Nursing administration will insure that it was completed properly. e. All medications will be ordered according to date, not quantity. f. All questions regarding medications and medication administration are to be addressed immediately by the charge nurse, on call nurse, ADON/DON. Answer to be received before proceeding. g. Medications will be checked against all orders to verify all ordered meds are available for administration. h. All new orders will be reviewed by nursing administration daily. 2. All staff that administers medications are to attend the in-service that will be provided by the pharmacy consultant regarding medication ordering, medication administration, notification, medication errors and documentation requirements. 3. All Silver Chair courses addressing medication errors are to be completed on or by the next worked shift. Silver Chair is the on-line training system that allows assignment of courses to a group of employees; that does step by step training and testing upon course completion. The following courses will be required: a. Medication Preparation Process b. Preventing Medication Errors c. Medication Pass d. Pain Assessment and Management 4. Pain assessments were completed on every resident on 12/2/13. Pain flow sheets were initiated for any and all residents whose assessment revealed pain. 5. Care Plans initiated for each resident whose assessment revealed pain. 6. Each resident receiving [MEDICATION NAME] medications were immediately checked for the presence of their patch and will be monitored each shift. This will be added to the medication administration sheet with a place to indicate location for each shift to initial. 7. Continuity of Care regarding pain management and overall clinical condition will be ensured by all clinical assessments, to include pain assessments, and will be completed upon admission/readmission; and the plan of care will be updated based on all the clinical assessments, and will reflect residents current condition and perception of pain. Nursing Administration will review the discharged medication lists from the discharging facility. Staff assuming care of the resident will verify date and time of last doses administered, and receive a thorough report from the discharge primary licensed nurse. In addition all admission assessments, including pain assessments, will be completed and initial care plan initiated as indicated. 8. PCP (Primary Care Physician) will be notified of all medications and will be reviewed with the PCP for orders of continuance, new medications, or discontinuations upon admission and readmission. 9. Pain assessment will be completed on admission/readmission, significant change, quarterly, and upon any notification by resident; or through the identification and initiation of the Stop and Watch Tool. This tool is an early warning tool that may be filled out by any person (employee or visitor) and given to the charge nurse. The forms are located on each hall and in the dining room. They are on bright neon orange paper and are reviewed each morning in QA meeting and covered in the employee orientation. 10. Any discrepancy with the assessments and available pain medications will be conveyed to the primary care physician for intervention, thus assuring that pain is controlled at an acceptable level as designated by the resident and as indicated by the plan of care. 11. Insurance of continuity of care will be monitored through the QAPI (Quality Assurance Program Improvement) Committee. Nursing administration will review all admissions/readmissions to determine the following: a. Received report b. Verification of last dose of medications c. admission orders [REDACTED] d. All assessments including pain assessments were completed timely 12. Each admission will be monitored in the daily stand-up meeting as the admission occurs. This review will be done with the QAPI Monitoring Tool. This monitoring will occur daily times two weeks; then randomly times 90 days. If any issues are identified it will be reported daily in the QA department head meeting, and reviewed in the monthly QAPI facility meeting. All issues will have immediate corrective action and the facility action plan will be updated. If no further issues are identified after 90 days, the deficiency will be considered resolved. Record review of the in-service, performed on 12/2/13 by the DON, revealed it was attended by 6 of the licensed nursing staff. It contained the following subjects: a. Any medication that is found to be out, the charge nurse is to be notified in addition to the DON and Administrator b. Physician will be notified by the charge nurse of situation, missed dose, late dose, etc. c. All medications will be checked in and signed in to identify any that were failed to be delivered. d. All medications not delivered will be followed up with the pharmacy and the DON/ADON. e. All medications that are not administered are to have a reason documented on the back of the MAR. f. All admissions will have medications checked for presence of ordered meds and will insure that medications are received. Nurses are to copy the orders and on arrival, a quantity will be placed beside the medication, and the admitting nurse will sign. g. Any questions regarding medications or medication administration will be directed to the charge nurse, ADON, or DON. The on-call nurse is always available. Obtain your answer before proceeding. h. All medications are to be ordered according to date. i. All staff administering medications ate to attend the in-service that will be provided by our pharmacy consultant on 12/3/13 at 10:00 am and are to complete the silver chair assignments on or by your next scheduled shift. Record review of the in-service training on 12/3/13 by the consultant pharmacist indicated the attendance of 12 staff members. The topics for this in-service were Medication Errors, Refill Reordering, and New Medications. Record Review of the checklist for residents with [MEDICATION NAME] medications performed on 12/2/13 at 5:43 pm shows 3 residents with [MEDICATION NAME] pain medication patches and 2 residents with [MEDICATION NAME]es in the facility. Record review of the check off sheets completed for the IJ, indicate that all residents in the facility were assessed for pain on 12/2/13. It also shows that all 12 residents in the facility with chronic pain had care plans updated for pain assessments. During interviews on 12/3/13 between 3:50 pm and 4:00 pm with LVN A and LVN B, both LVN's indicated they had been in-serviced on the new procedures for ordering and obtaining medications. Both LVN's had completed all or part of the Silver Chair Training and would finish during the current shift. They also were able to answer questions about assessing residents for pain and how to order medications. On 12/3/13 at 5:10 pm, the Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. In an interview with the C ADM on 12/3/2013 at 4:50 pm, the C ADM agreed that there was a systems failure with Resident #4 not getting the pain medication patch when scheduled. During an interview with the DON on 12/4/13 at 12:15, the DON was asked who was responsible for making sure the staff is following policies, and the answer was the Administrator and the Director of Nursing. When asked what the DON's role is in this, she replied that she facilitates training and when problems are identified, they have to find solutions to make sure the staff are following the policies. The facility administrator and director of nursing were notified on 12/3/13 at 9:15 am that an IJ situation had been identified due to the above failures. The facility Plan of Removal was provided on 12/3/13 at 11:32 am. The Plan of Removal was accepted at 3:15 pm on 12/3/13. The facility took the following actions to remove the IJ: 1. Staff will be in-serviced prior to their next working shift on the following: a. The charge nurse will be immediately notified of any medication found not to be in house, as will the DON and the administrator. b. The charge nurse will initiate a medication error and will notify the physician of the situation, whether missed dose, late dose, or whatever the specific situation may be and receive further direction at that time. c. All ordered medications will be checked in to see if all ordered meds were received. All medications not received will immediately be followed up with the pharmacy and nursing administration. d. All admissions will have all medications checked for the presence of ordered medications, and will insure that medications are received. Nurses are to copy the orders on arrival, a quantity be placed beside the medication, and the admitting nurse will sign. Nursing administration will insure that it was completed properly. e. All medications will be ordered according to date, not quantity. f. All questions regarding medications and medication administration are to be addressed immediately by the charge nurse, on call nurse, ADON/DON. Answer to be received before proceeding. g. Medications will be checked against all orders to verify all ordered meds are available for administration. h. All new orders will be reviewed by nursing administration daily. 2. All staff that administers medications are to attend the in-service that will be provided by the pharmacy consultant regarding medication ordering, medication administration, notification, medication errors and documentation requirements. 3. All Silver Chair courses addressing medication errors are to be completed on or by the next worked shift. Silver Chair is the on-line training system that allows assignment of courses to a group of employees; that does step by step training and testing upon course completion. The following courses will be required: a. Medication Preparation Process b. Preventing Medication Errors c. Medication Pass d. Pain Assessment and Management 4. Pain assessments were completed on every resident on 12/2/13. Pain flow sheets were initiated for any and all residents whose assessment revealed pain. 5. Care Plans initiated for each resident whose assessment revealed pain. 6. Each resident receiving [MEDICATION NAME] medications were immediately checked for the presence of their patch and will be monitored each shift. This will be added to the medication administration sheet with a place to indicate location for each shift to initial. 7. Continuity of Care regarding pain management and overall clinical condition will be ensured by all clinical assessments, to include pain assessments, and will be completed upon admission/readmission; and the plan of care will be updated based on all the clinical assessments, and will reflect residents current condition and perception of pain. Nursing Administration will review the discharged medication lists from the discharging facility. Staff assuming care of the resident will verify date and time of last doses administered, and receive a thorough report from the discharge primary licensed nurse. In addition all admission assessments, including pain assessments, will be completed and initial care plan initiated as indicated. 8. PCP (Primary Care Physician) will be notified of all medications and will be reviewed with the PCP for orders of continuance, new medications, or discontinuations upon admission and readmission. 9. Pain assessment will be completed on admission/readmission, significant change, quarterly, and upon any notification by resident; or through the identification and initiation of the Stop and Watch Tool. This tool is an early warning tool that may be filled out by any person (employee or visitor) and given to the charge nurse. The forms are located on each hall and in the dining room. They are on bright neon orange paper and are reviewed each morning in QA meeting and covered in the employee orientation. 10. Any discrepancy with the assessments and available pain medications will be conveyed to the primary care physician for intervention, thus assuring that pain is controlled at an acceptable level as designated by the resident and as indicated by the plan of care. 11. Insurance of continuity of care will be monitored through the QAPI (Quality Assurance Program Improvement) Committee. Nursing administration will review all admissions/readmissions to determine the following: a. Received report b. Verification of last dose of medications c. admission orders [REDACTED] d. All assessments including pain assessments were completed timely 12. Each admission will be monitored in the daily stand-up meeting as the admission occurs. This review will be done with the QAPI Monitoring Tool. This monitoring will occur daily times two weeks; then randomly times 90 days. If any issues are identified it will be reported daily in the QA department head meeting, and reviewed in the monthly QAPI facility meeting. All issues will have immediate corrective action and the facility action plan will be updated. If no further issues are identified after 90 days, the deficiency will be considered resolved. Record review of the in-service performed on 12/2/13 by the DON was attended by 6 of the licensed nursing staff. It contained the following subjects: a. Any medication that is found to be out, the charge nurse is to be notified in addition to the DON and Administrator b. Physician will be notified by the charge nurse of situation, missed dose, late dose, etc. c. All medications will be checked in and signed in to identify any that were failed to be delivered. d. All medications not delivered will be followed up with the pharmacy and the DON/ADON. e. All medications that are not administered are to have a reason documented on the back of the MAR. f. All admissions will have medications checked for presence of ordered meds and will insure that medications are received. Nurses are to copy the orders and on arrival, a quantity will be placed beside the medication, and the admitting nurse will sign. g. Any questions regarding medications or medication administration will be directed to the charge nurse, ADON, or DON. The on-call nurse is always available. Obtain your answer before proceeding. h. All medications are to be ordered according to date. i. All staff administering medications ate to attend the in-service that will be provided by our pharmacy consultant on 12/3/13 at 10:00 am and are to complete the silver chair assignments on or by your next scheduled shift. Record review of the in-service training on 12/3/13 by the consultant pharmacist indicated the attendance of 12 staff members. The topics for this in-service were Medication Errors, Refill Reordering, and New Medications. Record Review of the checklist for residents with [MEDICATION NAME] medications performed on 12/2/13 at 5:43 pm shows 3 residents with [MEDICATION NAME] pain medication patches and 2 residents with [MEDICATION NAME]es in the facility. Record review of the check off sheets completed for the IJ, indicate that all residents in the facility were assessed for pain on 12/2/13. It also shows that all 12 residents in the facility with chronic pain had care plans updated for pain assessments. During interviews on 12/3/13 between 3:50 pm and 4:00 pm with LVN A and LVN B, both LVN's indicated they had been in-serviced on the new procedures for ordering and obtaining medications. Both LVN's had completed all or part of the Silver Chair Training and would finish during the current shift. They also were able to answer questions about assessing residents for pain and how to order medications. On 12/3/13 at 5:10 pm, the Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of a pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. Review of a document provided by the facility on 12/3/13 documented there were 12 residents in the facility with chronic pain as well as three residents who were receiving pain medication via a [MEDICATION NAME]. The CMS Form 672 dated 12/2/13 states a resident census of 49 residents, with 20 residents on a pain management program.

Based on observation, interview and record review, the facility failed to develop and/ or implement their policy and procedure to prohibit mistreatment, neglect and abuse for 1 of 13 residents (Resident #4) reviewed for neglect. The facility failed to provide a physician's orders [REDACTED]. Resident #4 experienced severe pain related to amputation of the lower extremities, pressure ulcers to his coccyx and buttock and pain "all over" from a recent discovery of [MEDICAL CONDITION] from 11/29/13-12/2/13. These failures resulted in identification of an IJ (Immediate Jeopardy) on 12/3/13. While the immediacy of the IJ was removed on 12/3/13, the facility remained out of compliance at a severity level of actual harm and a scope of pattern, that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. This deficient practice could place 12 residents identified with chronic pain at risk for neglect, by not following physician orders [REDACTED]. Findings include: Record review of the Resident #4's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Resident #4 had a CAT scan on 11/17/13 that showed an abnormal liver, highly suspicious for metastatic disease. Record review of Resident #4's physician orders [REDACTED]. There is also an order [REDACTED]. Record review of the MAR for Resident #4 showed that he had been receiving a [MEDICATION NAME] for chronic pain since it was ordered on [DATE]. He was transferred to a local hospital on [DATE] and returned to the facility on [DATE] with an order to continue the [MEDICATION NAME]. The change of the pain patch was due on 11/29/13 on the MAR; it was circled as not administered by MA G. There was no documentation on why it was not placed, or that it was ever administered since his return to the facility. Record review of Resident #4's pain assessment, dated 11/26/13, documented pain as a "5" on a scale of 1-10. A nursing assessment of pain on the evening shift of 11/28/13 document pain as an "8" and generalized, and only one dose of oral breakthrough pain medication of [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 7.5 mg/325 mg was given on that day. Only eight doses of [MEDICATION NAME] were documented as being given on the MAR indicated [REDACTED]. Review of the annual MDS assessment dated [DATE] documented that Resident #4 was oriented and his cognitive summary score was a 10 out of 15. It documented that he was independent with bed mobility and only needed one person for transfer. It documented that he used a wheelchair for mobility and also had a limb prosthesis and required extensive assistance with dressing. It documented that a pain assessment was conducted and that he received scheduled pain medication and as needed pain medication. He frequently had pain with an intensity of 8 out of 10. Review of Resident #4's care plan revealed that there was not a care plan implemented for pain until 12/2/13, after surveyor intervention. During an observation/interview on 12/2/13 at 11:35 am, Resident #4 was grimacing and attempting to shift his weight by moving side to side in his wheelchair that was against a wall at the nurses' station. He said he had just finished working with therapy and "his bottom was hurting". During an observation on 12/2/13 at 11:55 am, Resident #4 was in a reclining Geri-chair at the dining room table with his head lying on the headrest. Resident #4 requested he go to his room at 12:08 pm. He ate less than 10% of his meal. During an observation on 12/2/13 at 3:10 pm in Resident #4's room, the wound care nurse was preparing to provide the care to 3 separate wounds with CNA F and CNA G assisting with positioning, linen change, and applying a clean brief. Several times during the 45-minutes of care, Resident #4 winced in pain, moaning and grabbing his right leg and saying he was getting cramps to his leg. He also said "I promised myself that I would not cry but the pain is so bad." The wound care nurse said Resident #4 was given oral pain medication at 12 p.m. prior to the wound care. The pain medication was not effective in controlling his pain because Resident #4 continued to cry out in pain. During an observation/interview on 12/2/13 at 4:40 pm in Resident #4's room, MA D was asked by the surveyor if he had been given pain medication and she said he had [MEDICATION NAME] prior to the wound care and he had a pain patch on. The surveyor asked for the location of the [MEDICATION NAME]. MA D began checking Resident #4's chest and back area for the pain patch but was unable to locate it. During an interview on 12/2/13 at 4:45 pm with the DON, she said she did not know why the pain patch was not in place, but would check into it. During an interview with the ADON on 12/2/13 at 5:45 pm, she said that she did not know if Resident #4 had the pain patch on when he returned to the facility from the hospital, but it was to be continued and should have been placed on 11/29/13 - but it was not administered. She said the patch was not at the facility at the time it was scheduled to be administered on 11/29/13. The ADON said the local pharmacy doesn't always have the medications, but they got it from another pharmacy. She said the pain patch never did get put on after they received it at the facility. She said she asked the nurse that should have placed the pain patch when it was received why she did not place it on Resident #4 and she said the nurse did not have an answer. During an interview with the DON on 12/3/13 at 9:40 am, she said that MA G was the med aide that did not put the patch on the resident. The surveyor attempted to contact her but was unable to leave a message. The DON also said that MA G was supposed to attend the in-service at 10 am and she would have her come to talk to the surveyors but she did not. The DON said that the medication aide made a mistake and she was not sure who all was involved. During an interview with Resident #4 on 12/3/13 at 10:15 am, he said that he had been hurting for 3 days. He said he is afraid that he keeps his roommate up because of the pain and his moaning. During an interview with CNA F on 12/3/13 at 11:12 am, she said that yesterday when she was assisting Resident #4 during the wound care that he was, "Hurting real bad and that was the worse she had seen him". She said she would tell the charge nurse when someone is in pain. She said he was hurting all over and complaining of cramping in his legs. During an interview with the ADM on 12/3/13 at 11:30 am, he said "we have never had anything like this before and the young, inexperienced med aide made a mistake." A facility submitted policy dated 2/13/07, entitled Pain Management, Assessment Scale states that complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. 2. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. 14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain. Record review of the facility's policy and procedure titled "Abuse/Neglect" dated 1/8/03 states the following: "The resident has the right to be free from abuse......The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. Definitions 1. Abuse: ....Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse as defined in 40 TAC 19.101(1). 6. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Neglect as defined in 40 TAC 19.101(81)." According to the Nursing 2013 Drug Handbook pp. 227-230, [MEDICATION NAME] is an opioid [MEDICATION NAME]. It is a category C Controlled substance schedule III. It is indicated for moderate to severe chronic pain in patients requiring continuous opioid [MEDICATION NAME] for an extended period of time. Each patch is intended to be worn for 7 days. Taper dosage before discontinuing [MEDICATION NAME]. The facility administrator and director of nursing were notified on 12/3/13 at 9:15 am that an IJ situation had been identified due to the above failures. The facility Plan of Removal was provided on 12/3/13 at 11:32 am. The Plan of Removal was accepted at 3:15 p.m. on 12/3/13. The facility took the following actions to remove the IJ: 1. Staff will be in-serviced prior to their next working shift on the following: a. The charge nurse will be immediately notified of any medication found not to be in house, as will the DON and the administrator. b. The charge nurse will initiate a medication error and will notify the physician of the situation, whether missed dose, late dose, or whatever the specific situation may be and receive further direction at that time. c. All ordered medications will be checked in to see if all ordered meds were received. All medications not received will immediately be followed up with the pharmacy and nursing administration. d. All admissions will have all medications checked for the presence of ordered medications, and will insure that medications are received. Nurses are to copy the orders on arrival, a quantity be placed beside the medication, and the admitting nurse will sign. Nursing administration will insure that it was completed properly. e. All medications will be ordered according to date, not quantity. f. All questions regarding medications and medication administration are to be addressed immediately by the charge nurse, on call nurse, ADON/DON. Answer to be received before proceeding. g. Medications will be checked against all orders to verify all ordered meds are available for administration. h. All new orders will be reviewed by nursing administration daily. 2. All staff that administers medications are to attend the in-service that will be provided by the pharmacy consultant regarding medication ordering, medication administration, notification, medication errors and documentation requirements. 3. All Silver Chair courses addressing medication errors are to be completed on or by the next worked shift. Silver Chair is the on-line training system that allows assignment of courses to a group of employees; that does step by step training and testing upon course completion. The following courses will be required: a. Medication Preparation Process b. Preventing Medication Errors c. Medication Pass d. Pain Assessment and Management 4. Pain assessments were completed on every resident on 12/2/13. Pain flow sheets were initiated for any and all residents whose assessment revealed pain. 5. Care Plans initiated for each resident whose assessment revealed pain. 6. Each resident receiving [MEDICATION NAME] medications were immediately checked for the presence of their patch and will be monitored each shift. This will be added to the medication administration sheet with a place to indicate location for each shift to initial. 7. Continuity of Care regarding pain management and overall clinical condition will be ensured by all clinical assessments, to include pain assessments, and will be completed upon admission/readmission; and the plan of care will be updated based on all the clinical assessments, and will reflect residents current condition and perception of pain. Nursing Administration will review the discharged medication lists from the discharging facility. Staff assuming care of the resident will verify date and time of last doses administered, and receive a thorough report from the discharge primary licensed nurse. In addition all admission assessments, including pain assessments, will be completed and initial care plan initiated as indicated. 8. PCP (Primary Care Physician) will be notified of all medications and will be reviewed with the PCP for orders of continuance, new medications, or discontinuations upon admission and readmission. 9. Pain assessment will be completed on admission/readmission, significant change, quarterly, and upon any notification by resident; or through the identification and initiation of the Stop and Watch Tool. This tool is an early warning tool that may be filled out by any person (employee or visitor) and given to the charge nurse. The forms are located on each hall and in the dining room. They are on bright neon orange paper and are reviewed each morning in QA meeting and covered in the employee orientation. 10. Any discrepancy with the assessments and available pain medications will be conveyed to the primary care physician for intervention, thus assuring that pain is controlled at an acceptable level as designated by the resident and as indicated by the plan of care. 11. Insurance of continuity of care will be monitored through the QAPI (Quality Assurance Program Improvement) Committee. Nursing administration will review all admissions/readmissions to determine the following: a. Received report b. Verification of last doses of medications c. admission orders [REDACTED] d. All assessments including pain assessments were completed timely 12. Each admission will be monitored in the daily stand-up meeting as the admission occurs. This review will be done with the QAPI Monitoring Tool. This monitoring will occur daily times two weeks; then randomly times 90 days. If any issues are identified it will be reported daily in the QA department head meeting, and reviewed in the monthly QAPI facility meeting. All issues will have immediate corrective action and the facility action plan will be updated. If no further issues are identified after 90 days, the deficiency will be considered resolved. Record review of the in-service, performed on 12/2/13 by the DON, revealed it was attended by 6 of the licensed nursing staff. It contained the following subjects: a. Any medication that is found to be out, the charge nurse is to be notified in addition to the DON and Administrator b. Physician will be notified by the charge nurse of situation, missed dose, late dose, etc. c. All medications will be checked in and signed in to identify any that were failed to be delivered. d. All medications not delivered will be followed up with the pharmacy and the DON/ADON. e. All medications that are not administered are to have a reason documented on the back of the MAR. f. All admissions will have medications checked for presence of ordered meds and will insure that medications are received. Nurses are to copy the orders and on arrival, a quantity will be placed beside the medication, and the admitting nurse will sign. g. Any questions regarding medications or medication administration will be directed to the charge nurse, ADON, or DON. The on-call nurse is always available. Obtain your answer before proceeding. h. All medications are to be ordered according to date. i. All staff administering medications are to attend the in-service that will be provided by our pharmacy consultant on 12/3/13 at 10:00 am and are to complete the silver chair assignments on or by your next scheduled shift. Record review of the in-service training on 12/3/13 by the consultant pharmacist indicated the attendance of 12 staff members. The topics for this in-service were Medication Errors, Refill Reordering, and New Medications. Record Review of the checklist for residents with [MEDICATION NAME] medications performed on 12/2/13 at 5:43 p.m. showed 3 residents with [MEDICATION NAME] pain medication patches and 2 residents with [MEDICATION NAME]es in the facility. Record review of the check off sheets completed for the IJ, indicate that all residents in the facility were assessed for pain on 12/2/13. It also shows that all 12 residents in the facility with chronic pain had care plans updated for pain assessments. During interviews on 12/3/13 between 3:50 and 4:00 p.m. with LVN A and LVN B, both LVN's indicated they had been in-serviced on the new procedures for ordering and obtaining medications. Both LVN's had completed all or part of the Silver Chair Training and would finish during the current shift. They also were able to answer questions about assessing residents for pain and how to order medications. On 12/3/13 at 5:10 p.m., the Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of a pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the of the corrective systems which were put into place. The CMS Form 672 dated 12/2/13 states a resident census of 49 residents, with 20 residents on a pain management program. A list submitted by the DON documented 12 residents experience chronic pain.