Every finding on record at Hillside Medical Lodge

Based on observations, interviews, 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 three (Residents #28, #46, and #91) of twelve residents reviewed for respiratory care. 1. The facility failed to ensure Resident #28's mask for BiPAP (bilevel positive airway pressure: normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) was properly stored when not in use on 12/09/2025. 2. The facility failed to ensure Resident #46's breathing mask was properly stored when not in use on 12/09/2025. 3. The facility failed to ensure Resident Residents #91's CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was properly stored when not in use on 12/10/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: 1. Record review of Resident #28's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea. Record review of Resident #28's Comprehensive MDS Assessment, dated 09/22/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a BiPAP. Record review of Resident #28's Comprehensive Care Plan on 12/09/2025, reflected the resident did not have a care plan for BiPAP. Record review of Resident #28's Physician Order, dated 04/21/2025, reflected BiPAP = Resident to wear BiPAP at night set at 14/7. Check placement, setting and functioning daily. every night shift. Record review of Resident #28's Progress Notes on 12/09/2025, reflected that there was no documentation that the resident was refusing to put his BiPAP in a plastic bag. Observation on 12/09/2025 at 9:15 AM, revealed Resident #28 was not inside the room. It was observed that the resident had a BiPAP machine on top of his bedside table with a mask connected to it, the mask was not bagged. In an interview on 12/09/2025 at 9:27 AM, LVN B stated Resident #28's BiPAP mask should be bagged to prevent respiratory infection. She said the resident was peculiar with his things and wanted it placed in certain areas. In an interview on 12/10/2025 at 10:09 AM, Resident #28 stated that nurses would put on his BiPAP and they were the one taking it off. He said he was quadriplegic and it would be difficult for him to put his BiPAP on or took it off. He said he would sometimes refuse to put on his BiPAP but he never told them to not bag his mask. 2. Record review of Resident #46's Face Sheet, dated 12/09/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure. Record review of Resident #46's Comprehensive MDS Assessment, dated 10/07/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had respiratory failure. Record review of Resident #46's Comprehensive Care Plan on 10/22/2025, reflected the resident used oxygen therapy and one of the interventions was to administer bronchodilators as ordered. Record review of Resident #46's Physician Order, dated 09/25/2025, reflected Ipratropium-Albuterol Solution 0.5 - 2.5 (3) MG/3ML 1 unit inhale orally via nebulizer three times a day for Medical Condition related to ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA (insufficient amount of oxygen in the body). Document V/S, lung sounds, and minutes spent prior to and post administration. During an observation and interview on 12/09/2025 at 9:11 AM, revealed Resident #46 was in her bed, awake. A nebulizer machine was on top of the resident's side table with a breathing mask attached. It was observed that the breathing mask was not bagged. Resident #46 said the nurse put it on every morning and the nurse also took it off. In an interview on 12/10/2025 at 9:27 AM, LVN B stated she administered Resident #46's breathing treatment and she was the one who took it off. She said she place the breathing mask on top of the nebulizer and did not bag it, she said it should be bagged to keep it clean. She said she would get a plastic bag for the resident's breathing mask. She said she would also clean the mask before putting it inside a plastic bag. 3. Record review of Resident #91's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea. Record review of Resident #91's Comprehensive MDS Assessment, dated 10/24/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a CPAP. Record review of Resident #91's Comprehensive Care Plan on 11/18/2025, reflected the resident did not have a care plan for CPAP. Record review of Resident #91's Physician Order, dated 12/01/2025, reflected CPAP = Resident to wear CPAP at night, 13/16. Check placement, setting and functioning daily. every night shift. Observation on 12/10/2025 at 9:42 AM, revealed Resident #91 was not inside her room. A CPAP machine was observed on top of the resident's side table with a mask attached to it, the CPAP mask was not bagged. During an observation and interview on 12/10/2025 at 9:44 AM, ADON L stated the CPAP mask should be inside a bag to prevent infection and to prevent it from falling to the floor. She went inside Resident #91's room and saw that the resident's CPAP was not bagged. She said the resident would sometimes take off her CPAP mask but the staff should be monitoring more if the CPAP was bagged. She said she would get a bag for the resident's CPAP mask. In an interview on 12/10/2025 at 9:48 AM, Resident #91 said she had been using a CPAP since June if she was not mistaken. She said she would sometimes take it off because no one would take it off. She said nobody told her to put it inside a bag. The resident then asked if she was the one responsible for putting her mask inside a bag. In an interview on 12/10/2025 at 10:04 AM, LVN E stated she should monitor if Resident #91's CPAP mask was bagged or not. She said the CPAP mask should be bagged when not in use to prevent any infection. In an interview on 12/11/2025 at 9:10 AM, ADON A stated the breathing mask, CPAP mask, and BiPAP mask should be bagged when not in use to prevent any respiratory infection and prevent cross contamination. She said the staff were responsible in bagging the masks. She said if the residents would sometimes take it off, the more the staff should check it. She said the expectation was for all the masks to be bagged when not in use. She said they already started an inservice about bagging the masks when not in use. In an interview on 12/11/2025 at 9:34 AM, the DON stated the breathing mask, CPAP mask, and BiPAP mask should be inside a plastic bag when not in use and not just hanging around or on top of the table, to maintain its cleanliness as well as its patency. She said bagging the masks was important to prevent the development of infections. She said she was responsible for making sure the staff was bagging the masks. She said the expectation was for the staff to bag the mask after taking it off and to monitor if the masks was bagged. She said she already started an in-service about bagging the masks when not in use. In an interview on 12/11/2025 at 9:50 AM, the Administrator stated that the masks should be bagged when not in use to prevent cross contamination and respiratory infection. She said the expectation was that the staff would be compliant in bagging the masks of the residents. She said she would coordinate with the DON and the ADONs to make sure that the staff was following the in-service about bagging the masks. Policy for bagging the masks requested via email on 12/10/2025 at 11:20 AM and on 12/11/2025 at 11:15 AM but was not provided prior to date and time of exit.

Based on interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for three (Residents #16, #28, and #91) of eight residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident Residents #16's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). 2. The facility failed to ensure Resident Residents #28's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on a BiPAP (bilevel positive airway pressure: normalizes breathing by delivering pressurized air into the upper airway leading into the lungs). 3. The facility failed to ensure Resident Residents #91's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on a CPAP. These failures could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health.Findings included: 1. Record review of Resident #16's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #16's Comprehensive MDS Assessment, dated 10/24/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 14. The Comprehensive MDS Assessment did not indicate the resident was using a CPAP.Record review of Resident #16's Comprehensive Care Plan, dated 09/29/2025, reflected the resident had sleep apnea and one of the interventions was to assist with CPAP equipment each time.Record review of Resident #16's Physician Order, dated 12/01/2025, reflected CPAP = Resident to wear CPAP @ bedtime, set at 6. Check placement, setting and functioning daily.Record review of Resident #16's Physician Order on 12/10/2025 reflected that the resident had been with CPAP since April 2025.An observation on 12/10/2025 at 9:02 AM, revealed Resident #16 was not inside her room. A CPAP machine was observed behind the resident's recliner chair. In an interview on 12/10/2025 at 9:36 AM, LVN M stated Resident #16 started using a CPAP maybe for 6 months. She said the resident would usually put her CPAP behind her chair. In an interview on 12/10/2025 on 1:36 PM, Resident #16 stated she had been using a CPAP for about five to six months. She said she used it every night. 2. Record review of Resident #28's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea. Record review of Resident #28's Comprehensive MDS Assessment, dated 09/22/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a BiPAP. Record review of Resident #28's Comprehensive Care Plan on 12/09/2025, reflected the resident did not have a care plan for BiPAP. Record review of Resident #28's Physician Order, dated 04/21/2025, reflected BiPAP = Resident to wear BiPAP at night set at 14/7. Check placement, setting and functioning daily. every night shift. Observation on 12/09/2025 at 9:15 AM, revealed Resident #28 was not inside the room. It was observed that the resident had a BiPAP machine at his side table. In an interview on 12/09/2025 at 9:27 AM, LVN B stated Resident #28 had been using a BiPAP for almost six months. In an interview on 12/10/2025 at 10:09 AM, Resident #28 stated he had been using his BiPAP for months but he cannot remember the exact number of months. 3. Record review of Resident #91's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea. Record review of Resident #91's Comprehensive MDS Assessment, dated 10/24/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a CPAP. Record review of Resident #91's Comprehensive Care Plan on 11/18/2025, reflected the resident did not have a care plan for CPAP. Record review of Resident #91's Physician Order, dated 12/01/2025, reflected CPAP = Resident to wear CPAP at night, 13/16. Check placement, setting and functioning daily. every night shift. Record review of Resident #91's Physician Order on 12/10/2025 reflected that the resident had been using a CPAP since June 2025. Observation on 12/10/2025 at 9:42 AM, revealed Resident #91 was not inside her room. A CPAP machine was observed on top of the resident's side table. In an interview on 12/10/2025 at 9:48 AM, Resident #91 said she had been using a CPAP since June if she was not mistaken. During an observation and interview on 12/10/2025 at 11:47 AM, MDS Nurse K stated that she was the one responsible in doing the residents' MDS. She said she did not know that Residents #16, #28, and #91 were using CPAPs and a BiPAP. She checked the resident's orders and saw that Resident #28 had an order for BiPAP and both Resident #16 and Resident #91 both had orders for CPAP. She checked the residents' MDS and saw that the residents was not coded for CPAP and BiPAP. She said she could not click CPAP and BiPAP because they were grayed out. She then pulled an RAI Guidelines. She said she would do the corrections and would re-submit the MDS. She said the MDS was for reimbursement but also to assess the residents' medical status. She said she would fix her oversight. In an interview on 12/11/2025 at 9:10 AM, ADON A stated she was not familiar with the MDS but if some residents was using CPAPs and a BiPAP, then it should be reflected in the residents' MDS. She said the MDS Coordinator was responsible for doing the MDS and if the assessment in the MDS was not accurate, the care given to the residents might not be accurate. In an interview on 12/11/2025 at 9:34 AM, the DON stated if the residents was using a BiPAP and CPAPs, their MDS should reflect that they were using them because sometimes the MDS was the basis of what should be included in the care plan. She said she would coordinate with the MDS Coordinator to fix the issue and audit the MDS of the residents. In an interview on 12/11/2025 at 9:50 AM, the Administrator stated if the MDS needed to reflect that a resident had a CPAP or a BiPAP, then the residents MDS should display it. She said she would coordinate with the DON on how to go through the issue. Record review of the facility policy, Accuracy of Assessments undated, reflected The assessment must accurately reflect the resident's status. Record review of the facility policy, Use of the Comprehensive Assessment undated, reflected The results of resident comprehensive assessments shall be used to develop, review, and revise each resident's plan of care.

Based on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for one (Resident #84's) of ten residents reviewed for privacy and confidentiality. The facility failed to ensure LVN B would not disclose Resident #84's medical treatment to her roommate on 12/09/25. This failure could place the residents at risk of their medical information or treatment being disclosed to unauthorized individuals.Findings included: Record review of Resident #84's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). The Face Sheet did not indicate that Resident #84's roommate was her responsible party. Record review of Resident #84's Comprehensive MDS Assessment, dated 10/08/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident had diabetes mellitus and was receiving insulin. Record review of Resident #84's Comprehensive Care Plan, dated 11/24/2025, reflected the resident had diabetes mellitus and one of the interventions was to administer diabetes medication as ordered. Record review of Resident #84's Physician Order, dated 12/01/2025, reflected Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 3 unit subcutaneously before meals for DM2 (adult-onset diabetes). Record review of Resident #84's Physician Order, dated 12/01/2025, reflected FINGERSTICK BLOOD SUGAR . Document results. An observation on 12/09/2025 at 11:12 AM, revealed that LVN B was about to check Resident #84's blood sugar. She prepared the things needed for blood sugar and went inside the resident's room. Resident #84 was in her wheelchair and had a roommate that was still in her bed. LVN B pulled the privacy curtain between the two residents. When she was about to start to prick Resident #84, the roommate coughed, LVN B pulled the curtain a little bit to check on the roommate. The roommate said she was ok. At that point, the roommate asked LVN B what was she doing, LVN B replied, I am getting her blood sugar. LVN B proceeded to check the blood sugar. LVN B did not ask Resident #84 if it was ok to tell her roommate what treatment she was currently getting. In an interview on 12/09/2025 at 11:24 AM, LVN B stated, She should have not answered the roommate. She said getting the blood sugar is medical treatment and should not be disclosed when asked by anybody that did not have anything to do with Resident #84's care. She said it would not be an issue if it was Resident #84 who replied to the roommate. She said she should be mindful before replying casually to questions about a resident's medical condition or treatment because their medical information should be confidential. In an interview on 12/11/2025 at 9:10 AM, ADON A stated getting a blood sugar was a medical procedure and Resident #84's roommate was not her responsible party. She said LVN B should have just replied that she was just doing something. She said it did not matter if the resident's roommate already knew that Resident #84 was receiving insulin but the mere fact that a staff disclosed a medical procedure to somebody that had nothing to do with the resident's care could be a HIPAA violation. She said even though the facility was a close-knitted facility, there should be a line drawn between being familiar with each other and what should be disclosed. She said they already started an in-service regarding HIPAA. In an interview on 12/11/2025 at 9:34 AM, the DON stated personal and medical information about a resident should not be disclosed to anybody that had nothing to do with the resident's care. She said the Resident #84's roommate was not her responsible party and the staff should not have told the roommate what she was doing. She said the staff should have not answered or should have replied that she was just doing something. She said it was just like leaving the computer open and somebody, who was unauthorized, saw that the resident needed her blood sugar to be checked. She said the health information of a resident should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said all employees were expected to provide full privacy and confidentiality of information for all residents. The DON stated she already started an in-service about HIPAA. In an interview on 12/11/2025 at 9:50 AM, the Administrator stated the staff should not disclose any medical information about a resident to another resident or other individuals that had nothing to do with a resident's care. She said, maybe, the staff and the residents in the facility became like family and it did not don on the staff that she was releasing information that was not supposed to be disclosed. She said she knew an in-service about HIPAA was already initiated but she would coordinate with the DON and the ADONs to monitor the staffs' compliance in providing privacy and confidentiality. Record review of the facility's policy, General Staff Responsibilities undated reflected, All staff are responsible for safeguarding the privacy of resident health information. Specific staff responsibilities under these privacy policies and procedures will be listed in the staff member's job description All staff members must . 1. Use and disclose protected health information only as authorized in their job description or as authorized by a supervisor . 2. Conduct oral discussions of personal health information with other staff or with patients and family members in a manner that limits the possibility of inadvertent disclosures.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #80) of eighteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident 80's room was in a position that was accessible to the resident on 12/09/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #80's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness, hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body). Record review of Resident #80's Comprehensive MDS Assessment, dated 10/27/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Quarterly MDS Assessment indicated the resident required maximal assistance for shower, dressing, bed mobility and transfer. Record review of Resident #80's Comprehensive Care Plan, dated 11/03/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 12/09/2025 on 9:38 AM, revealed Resident #80 was in her bed, awake. It was observed that the resident's call light was on top of the resident's side table along with the resident's leg rest for her wheelchair. When asked where her call light was, the resident looked at her side and then shrugged her shoulders. During an observation and interview on 12/09/2025 at 9:43, LVN C stated the call lights should be with the residents at all times in case the residents needed to call the staff for assistance. She checked on Resident #80 and saw the resident's call light on the side table below the resident's leg rests for the wheelchair. She took the call light and placed where the resident could reach it. She said the resident was transferred after eating breakfast and the aides maybe forgot to place it where the resident could reach it. she said she would talk to CNA F about the call light. In an interview on 12/09/2025 at 9:52 AM, CNA F stated she and CNA G transferred Resident #80 to her bed after breakfast. She said she left the room after the transfer and left CNA G with the resident. She said she should have made sure that the call light was with the resident before leaving the room or at least reminded CNA G to place the resident's call light within reach. She said the call lights should be within reach in case the resident needed something. She said the call lights were for all the residents. she said the CNAs and the nurses were responsible in ensuring the call lights were with the residents. In an interview on 12/09/2025 at 12:08 PM, CNA G stated he did transfer Resident #80 to her bed after breakfast and he cannot remember if he placed the resident's call light when he left the room. He said the call lights should be with the residents because the residents used the call lights to call the staff if they needed assistance. In an interview on 12/11/2025 at 9:10 AM, ADON A stated the call lights should always be with the residents in case they needed assistance with something like a refill of water or the resident needed a pain medication. She said when a resident was already in the wheelchair, the call light should be on top of the bed so the resident could still call the staff if needed. She said the staff should make sure that the call lights were with the residents before they left the room. She said they already started an in-service about call light within reach at all times. In an interview on 12/11/2025 at 9:34 AM, the DON stated call lights were inside the residents' rooms so they can call the staff for assistance, for pain medication, or because they wanted to get up. The DON said if the call lights were not within reach, their needs would not be met and the residents might get upset because there was no way to call the staff. The DON said all the staff were responsible for the call lights. The DON said the expectation was for the staff to scan the residents' room when they did their rounds and ensure the call lights were within reach of the residents before they leave the room. she said she already started an in-service about call lights within reach. In an interview on 12/11/2025 at 9:50 AM, the Administrator stated call lights should be with the residents all the time in case they need help. She said the call lights were for all the residents whether dependent or independent. She said the aides where primarily responsible for the call lights but everybody was responsible in making sure the call lights were with the residents to prevent any falls. She said she would coordinate with the DON and the ADONs to make sure that the staff were following the in-service about call lights. Record review of the facility's policy, Call Lights undated reflected Purpose: To respond to a resident's call light for their needs . Procedure . 9. The call light must always be within resident's reach before you leave the room.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #8) of two residents reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure LVN D would flush the g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) before administering medications and flush after with the amount indicated in the physician order on 12/10/2025. This failure could place residents with g-tubes at risk for blockage, aspiration, discomfort, and overhydration.Findings included: Record review of Resident #8's Face Sheet, dated 12/10/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #8's Comprehensive MDS Assessment, dated 07/28/2025, reflected the resident had a severe impairment in cognition with a BIMS score. The Comprehensive MDS Assessment indicated the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #8's Comprehensive Care Plan, dated 07/28/2025, reflected the resident required a peg-tube (a flexible feeding tube inserted directly to the stomach) and one of the goals was the resident would not experience adverse effects. Record review of Resident #8's Physician Order, dated 12/01/2025, reflected every shift G-TUBE (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) - MED ADMINISTRATION = Flush w/30cc H2O BEFORE med administration. Give EACH medication separately, mixed w/small amount H2O to mix/dissolve. Flush BETWEEN EACH MED w/5 - 30 ml H2O. Flush w/30cc H2O AFTER med administration. Record review of Resident #8's Physician Order, dated 12/09/2025, reflected Dantrolene Sodium Oral Capsule 25 MG (Dantrolene Sodium). Give 2 capsule via PEG-Tube three times a day for muscle relaxer. Record review of Resident #8's Physician Order, dated 12/09/2025, reflected Baclofen Oral Tablet 20 MG (Baclofen) Give 1 tablet via PEG-Tube three times a day for contractures (tightening or shortening of the muscles). During an observation and interview on 12/10/2025 at 1:09 PM, revealed LVN D was about to administer Resident #8's medication via g-tube. She said she would be administering two medications for the resident. LVN D sanitized her hands and put on a pair of gloves. She placed the medications in a cup separately, crushed one of the medications, and returned the crushed medication to its respective small plastic cup. One of the medications was a capsule, she opened it and placed its content in a cup. She placed what she prepared on a tray, went inside the room, and placed the tray on top of the resident's overbed table. She also brought with her a cup of water and placed it on the tray. She put on a gown, raised the resident's bed and took the g-tube from the abdominal binder. She then pulled the plunger (movable part of the syringe that pulls or pushes liquid into the syringe) of a 60 ml piston syringe and connected it to the g-tube. She pushed the plunger to check the placement of the g-tube and then pulled the plunger to check for the residual. She disconnected the syringe and pulled the plunger all the way and connected the syringe without the plunger. She then put approximately 10 ml of water on each medication and stirred them using the plastic spoon. She then started to administer the first medication and then flushed it with 15 ml of water. she did not flush the g-tube before administering the first medication. She then gave the second medication and flushed it with 15 ml of water. After flushing with 15 ml of water, she said she would flush it again. She flushed the g-tube with 30 ml of water for four times totaling to 120 ml. After flushing the g-tube, she put back on the abdominal binder, washed her hands, and cleaned the syringe. During an observation and interview on 12/10/2025 at 1:32 PM, LVN D stated she was supposed to flush the g-tube with warm water before medication administration to make sure that the tube was not clogged. She said she was not sure why she forgot to flush it before administering the first medication. She opened Resident #8 profile and saw the order to flush 30 ml before medication administration. She also saw to flush 30 ml after medication administration. She said she flushed 120 ml. She said she needed to follow the order to prevent aspiration. She said too much water could also cause fluid overload and bloating of the stomach. In an interview on 12/11/2025 at 9:10 AM, ADON A stated it was important to flush the g-tube to prevent clogging the tubing and to make sure that the medications administered went through. She said there was certain amounts of water ordered for flushing before and after medication administration and in between medications. She said more than or less than the ordered amount of water could have an effect on the resident. She said less fluid could cause dehydration and more water could cause fluid overload, vomiting, and aspiration. She said flushing a medication with more than 100 ml of water was not right. She said an in-service was already initiated regarding medication administration via g-tube and about following the physician's order. In an interview on 12/11/2025 at 9:34 AM, the DON stated there was a specific amount of water incorporated during medication administration via g-tube to avoid dehydration, overhydration, and aspiration. Too much water given for one flushing could lead to aspiration. She said the g-tube should be flushed before giving the medications to make sure the tube was not clogged. She said the expectation was that the staff would flush the g-tube before medication administration and to use the required amount of water for flushing. She said she already started an in-service about g-tube focusing on flushing before administering medications and about using the amount of water for flushing as ordered. In an interview on 12/11/2025 at 9:50 AM, the Administrator stated the expectation was for the staff to follow the right procedure in administering medications via g-tube and to follow the physician's order. She said she was not a clinician and would let the DON and the ADONs take the lead in educating the staff about the issue. Record review of the facility's policy Tube (Medication Administration) undated, reflected Purpose: To safely and accurately administer medications to residents who receive their entire oral intake via enteral feeding tube . 10. Flush tube with at least 5cc of water prior to medication administration . 15. Flush the tube with water and clamp to prevent medication from clogging tube.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one (Resident #100) of twenty residents reviewed for pharmaceutical services. The facility failed to ensure MA J did not leave Resident #100's Arginine inside the room for the resident to take by herself on 12/09/2025. This failure could place residents at risk of not receiving medications as ordered, potential overdose, and adverse effects.Findings include: Review of Resident #100's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hyponatremia (lower than normal level of sodium in the bloodstream). Review of Resident #100's Comprehensive MDS Assessment, dated 12/11/2025, reflected the resident had a severe impairment (requires significant assistance and support in daily life) in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had hyponatremia. Review of Resident #100's Comprehensive Care Plan, dated 12/08/2025, reflected the resident had a potential for weight loss and one of the interventions was to administer supplement as ordered. Record review of Resident #100's Physician Order, dated 12/08/2024, reflected Arginine Supplement Powder two times a day for RISK OF PROTEIN CALORIEMALNUTRITION/PROMOTE WOUND HEALING 1pkt mixed in 4-6 oz H20. Observation and interview on 08/17/2025 at 7:09 AM, revealed Resident #100 in her wheelchair, awake. It was observed that a cup of colored liquid was on top of the resident's overbed table. During an observation and interview on 12/09/2025 at 10:19 AM, LVN B stated the cup of colored liquid might be the protein supplement for Resident #100. She said the resident said she did not like it. She said the liquid was a supplement administered for weight loss and also to promote healing of wounds. She said it should not be left inside the room and whoever administered it should have waited for the resident to take it before leaving the room. She said other resident might consume it and might have an allergic reaction to it. She took the cup of colored liquid and throwed its content in the sink. In an interview on 12/09/2025 at 12:53 PM, MA J stated she was the one who left the arginine supplement inside Resident #100's room. She said she should have waited for the resident to drink it before leaving the room to make sure that the resident was the one who drank the supplement and not other residents. She said she would also know if the resident was drinking it or was refusing to drink it or had difficulty in swallowing. In an interview on 12/11/2025 at 9:10 AM, ADON A stated leaving any form of medication inside the room was a no-no because a lot of things could happen. She said the resident might choke and nobody would be there to help her. She said the staff should wait for the resident to be done taking the medication before leaving the room. She said arginine was a protein supplement that was being administered by the staff meaning the staff was responsible in making sure that the resident took it. She said confused residents might enter other residents' rooms and take the medication. She said the DON already initiated an in-service about medication administration and she already a one-on-one in-service with MA J. In an interview on 12/11/2025 at 9:34 AM, the DON stated the staff should never leave any form of medication inside the resident's room for them to take unsupervised. She said the resident might not take them, hide them, or take them with them along with the next dose. She said the resident could overdose or their underlying conditions were not getting well because they were not taking the medications. He said the staff should make sure that the medications, or even supplements, were consumed before leaving the room. She said she already initiated an in-service pertaining to not leaving any medication with the resident to take unsupervised. In an interview on 12/11/2025 at 9:50 AM, the Administrator stated no medications should be left inside the room for the resident to take unsupervised because the resident might overmedicate, not take it, or just throw it. She said the expectation was for the staff not to leave any medication inside the room for the resident to administer by himself. She said the DON already started an in-service about not leaving the medications with the resident, but she would closely coordinate with them that this incident wound never happen again. Policy for not leaving medications inside the rom unattended requested via email on 12/10/2025 at 11:20 AM and on 12/11/2025 at 11:15 AM but was not provided prior to date and time of exit.

Based on observation, interviews, and record review, the facility failed to develop a complete care plan that meets all of a resident's needs, with timeframes and actions that can be measured for two (Resident #28 and #91) of twelve residents reviewed for care plans. 1. The facility failed to ensure Resident #28 was care planned for a BiPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) on 12/09/2025. 2. The facility failed to ensure Resident #91 was care planned for a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) on 12/09/2025. These failures could place the residents at risk of not receiving the necessary care and services required.Findings include: 1. Record review of Resident #28's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea. Record review of Resident #28's Comprehensive MDS Assessment, dated 09/22/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a BiPAP. Record review of Resident #28's Comprehensive Care Plan on 12/09/2025, reflected the resident did not have a care plan for BiPAP. Record review of Resident #28's Physician Order, dated 04/21/2025, reflected BiPAP = Resident to wear BiPAP at night set at 14/7. Check placement, setting and functioning daily. every night shift. Observation on 12/09/2025 at 9:15 AM, revealed Resident #28 was not inside the room. It was observed that the resident had a BiPAP on top of his bedside table. In an interview on 12/09/2025 at 9:27 AM, LVN B stated Resident #28 had been using a BiPAP for almost six months. In an interview on 12/10/2025 at 10:09 AM, Resident #28 stated he had been using his BiPAP for months, but he cannot remember the exact number of months. 2. Record review of Resident #91's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea. Record review of Resident #91's Comprehensive MDS Assessment, dated 10/24/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a CPAP. Record review of Resident #91's Comprehensive Care Plan on 11/18/2025, reflected the resident did not have a care plan for CPAP. Record review of Resident #91's Physician Order, dated 12/01/2025, reflected CPAP = Resident to wear CPAP at night, 13/16. Check placement, setting and functioning daily. every night shift. Record review of Resident #91's Physician Order on 12/10/2025 reflected that the resident had been with CPAP since June 2025. Observation on 12/10/2025 at 9:42 AM, revealed Resident #91 was not inside her room. A CPAP machine was observed on top of the resident's side table. In an interview on 12/10/2025 at 9:48 AM, Resident #91 said she had been using a CPAP since June if she was not mistaken. During an observation and interview on 12/10/2025 at 11:47 AM, MDS Nurse K stated that she was the one responsible in doing the care plans of the residents. She opened the profile of Residents #28 and Resident #91 and saw that the residents had orders for a BiPAP and CPAP. She then checked the residents' care plans and saw that the residents did not have a care plan for CPAP and BiPAP. She said a care plan is a reflection of a resident's care and services being provided by the staff. She said it indicated the observations done by the staff to be able to provide the best care possible. She said if there was no care plan, the staff might miss something and the residents' needs will not be addressed. She said it was an oversight on her part that the said residents was not care planned for CPAP and BiPAP. She said she would add the needed care plans. In an interview on 12/11/2025 at 9:10 AM, ADON A stated everything done for the residents should be care planned to make sure the residents were being taken care for and were receiving the care needed. She said if residents had a CPAP and a BiPAP, then there should be a care plan for the CPAP and BiPAP. She said care plans should be in place so that the staff were in sync with the care being provided to the residents. In an interview on 12/11/2025 at 9:34 AM, the DON stated care plans should be in place so that the staff caring for the resident would be on the same page. She said if the resident had a CPAP and a BiPAP, then there should be a care plan for CPAP and BiPAP. She said every resident needed a comprehensive care plan to ensure the residents received the care needed and appropriate to their current conditions and functionality. She said the care plans reflect the resident's problem lists, the goals, and the interventions. She said without the care plan, there could be confusion with the care needed by the residents. She said the expectation was every resident had detailed care plans and they should be reflected on their profile. She said she would coordinate with the MDS Nurse to audit the care plans of the residents. In an interview on 12/11/2025 at 9:50 AM, the Administrator stated the expectations was the residents should be care planned accordingly to make sure the needed care were provided. She said she would coordinate with the DON about the issue. Record review of facility's policy, Comprehensive Person-Centered Resident Care Planning undated, reflected A comprehensive person-centered care plan is developed and implemented for each resident . to include measurable short-term and long-term objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based 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 two (Resident #8 and Resident 100) of twelve residents reviewed for infection control. 1. The facility failed to ensure CNA F and CNA G wore gowns and gloves while transferring Resident #8, who had a g-tube, on 12/10/2025. 2. The facility failed to ensure LVN C performed hand hygiene while connecting Resident #100's IV on 12/09/2025. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Review of Resident #8's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia. Review of Resident #8's Comprehensive MDS Assessment, dated 09/18/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube and was dependent on staff for transfer. Review of Resident #8's Comprehensive Care Plan, dated 10/01/2025, reflected the resident required a PEG tube and one of the interventions was to give enteral formula as ordered. The Care Plan indicated that the resident was dependent with ADLs and one of the interventions was to transfer via mechanical lift (a device used to lift, transfer, or position an individual with limited mobility). Observation on 12/10/2025 at 10:23 AM, revealed that CNA F and CNA G was about to transfer Resident #8 to his wheelchair via mechanical lift. The CNAs sanitized their hands before going inside the room. Upon entering, both CNAs went straight to the resident's bedside and started to prepare the resident for transfer. Neither of the CNAs put on gowns and gloves. Without any gloves and gowns on, CNA F went to the resident's left side and CNA G went to the right side. CNA G rolled the resident towards CNA F while CNA F assisted in rolling the resident. CNA G put the mechanical sling under the resident while CNA F was holding the resident. After putting the sling underneath the resident, both CNAs was about to roll the resident to the other side when Lead CNA N, who was also inside the resident's room, stopped them and told them to repeat the process. At this point the CNAs already had contact with the resident. It was observed that there was sign outside the resident's door that the resident was on enhanced barrier protection. It was also observed that there was a PPE cart inside the resident's room. In an interview on 12/10/2025 at 10:27 AM, Lead CNA N stated she stopped the transfer because the CNAs did not have any gloves and gowns on. She said she reviewed the process with the CNAs before transferring Resident #8 and they still forgot. She said the CNAs should be wearing gloves and gowns because the resident was on EBP due to his g-tube. She said there was also a sign outside indicating EBP should be practiced. She said PPE should have been worn to prevent any cross contamination. In an interview on 12/10/2025 at 10:39 AM, CNA G stated he should have worn a gown and gloves because Resident #8 had a g-tube and there was a sign outside the resident's door to remind them to put on a PPE. He said gloves and gowns was required to prevent cross contamination. In an interview on 12/10/2025 at 10:41 AM, CNA F stated she forgot to put on a pair of gloves and a gown before touching the resident because the resident was on EBP and required PPE when having contact with the resident. She said the resident had a g-tube and she should have worn a gown and gloves to prevent any transfer of microorganism. 2. Review of Resident #100's Face Sheet, dated 12/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with infection due to left internal hip prothesis. Review of Resident #100's Comprehensive MDS Assessment, dated 12/11/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had an infection due to left hip prothesis. Review of Resident #100's Comprehensive Care Plan, dated 12/08/2025, reflected the resident was receiving IV antibiotics and one of the interventions was to administer medications as ordered. Record review of Resident #100's Physician Order, dated 12/08/2024, reflected Vancomycin HCl in NaCl Intravenous Solution 1.25-0.9 GM/250ML-% (Vancomycin HCl-Sodium Chloride) Use 1.25 gram intravenously one time a day for INFECTED THA until 12/30/2025 08:59 RUN OVER 90 MINUTES . Administer Vanc between 830 and 840 on those days. Observation and interview on 08/17/2025 at 7:09 AM, revealed Resident #100 in her wheelchair, awake. It was observed that the resident had a PICC line to right upper arm. The resident said she had a PICC line because she was receiving an antibiotic for her infection due to her prosthesis. Observation on 12/09/2025 at 10:07 AM, revealed LVN B was about to connect Resident #100's IV. She washed her hands before putting on a pair of gloves and a gown. She then incorporated 250 ml of normal saline to the vancomycin powder to reconstitute it. She placed the antibiotics and the IV administration set in a tray and placed the tray on the resident's overbed table. She then realized the trash can was far from her. She took the trash can and placed it near her. She removed her gloves and put on a new pair of gloves. She did not sanitize her hands before putting on a new pair of gloves. She proceeded to connect the IV. In an interview on 12/09/2025 at 10:19 AM, LVN B stated hands should be sanitized before putting on a new pair of gloves, especially that she touched a trash can. She said sanitizing hands was to prevent any cross contamination and probable infection. In an interview on 12/11/2025 at 9:10 AM, ADON A stated staff must do hand hygiene before putting on a new pair of gloves to make sure that their hands was clean before touching the new pair of gloves, especially if the staff touched the trash can. She said the resident was being treated for infection and the staff should make sure that nothing could cause additional contamination. She said in transferring a resident with a g-tube, the CNAs should wear gowns and gloves. She said she did not even know why the CNAs did not even put on any gloves. She said there was a sign outside the door that Resident #8 was on EBP and required PPE when handling the residents. She said, even though somebody stopped the procedure, the CNAs already touched the resident without any gloves and gown. She said deviation from the said procedures could result to cross contamination and development of infection. She said the expectation was for the staff to be mindful and compliant with the policy of infection control. She said they already started an in-service about infection control, enhanced barrier precaution, and hand hygiene as soon as they heard the issues. In an interview on 12/11/2025 at 9:34 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said hands should be sanitized before donning a new pair of gloves to make sure the hands was clean when touching the new pair of gloves, especially after handling something soiled. She said a trash can was always deemed dirty so after touching it, the staff should have sanitized her hands before putting a pair of gloves. She said when transferring a resident with g-tube, the staff should wear a PPE, specifically gowns and gloves. She said the resident was on EBP and there was a sign outside to remind the staff to wear gowns and gloves when handling the resident. She said she heard that the process of transferring was halted but it was too late because the CNAs already touched the resident. She said the issues discussed could contribute to cross contamination, development of infection, and spread of infection. She said the expectation was for the staff to take the in-services seriously and compliant with it. She said the staff should do better to ensure they were providing the best care. She said she already started an in-service about infection control. She said she would do a check-off about infection control. In an interview on 12/11/2025 at 9:50 AM, the Administrator stated the expectation was for the staff to follow to the guidelines of infection control. She said hand hygiene should be done before putting on a new pair of gloves and PPE should have been worn when required. She said the staff should always make sure that not following the policy for infection control could be disadvantageous for the residents. She said she knew an in-service about infection control was already initiated but she would coordinate with the DON and ADONs to do monitor the staffs' compliance to the policy of infection control. Record review of the facility's policy, ENHANCED BARRIER PRECAUTIONS (EBP) INFECTION PREVENTION AND CONTROL PROGRAM undated, reflected EBP are indicated for residents with any of the following . indwelling medical device . Indwelling medical device examples include . feeding tubes. Record review of the facility's policy, Handwashing INFECTION PREVENTION AND CONTROL PROGRAM undated, reflected Policy: and washing is required before and after a procedure that involves direct or indirect contact with a resident, after contact with any wastes or contaminated materials, before handling any food or food receptacle, or at any time the hands are soiled.

Based on observations, interviews and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 4 Residents (Resident #1) reviewed for pharmaceutical services. MA A administered a non-prescribed 5 MG of Buspirone (a medication for anxiety) and non-prescribed 400 MG of Magnesium Oxide (a medication for heartburn, sour stomach, or acid indigestion) to R #1 on 11/14/2024. The noncompliance began on 11/14/2024 and ended on 11/14/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at the facility at risk of medication errors. Findings included: RR of R#1's AR, dated 1/28/2025, reflected a [AGE] year-old woman who admitted to the facility on [DATE]. She was diagnosed with Paroxysmal Atrial Fibrillation (which was a disease of the heart characterized by irregular and often faster heartbeat.) RR of R#1's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 12. A BIMS Score of 12 indicated the resident had moderate cognitive impairment. RR of a complaint, dated 11/15/2024, reflected R #1 was given a non-prescribed medication, in error, on 11/14/2024. The complaint alleged MA A, who was administering medications, was not being watched by the trainer at the time of the alleged medication error. RR of R #1's PN, in the resident's medical record, reflected a telehealth (video conference) visit, dated 11/14/2024 at 6:30 PM. The chief complaint was [R #1 received 5 MG of Buspirone and 400 MG of Magnesium Oxide. Physician subjective view was patient had no complaints, was seen on video, appeared non-distressed, denied chest pain or shortness of breath. Alert and oriented to time and place, following all commands appropriately. All vital signs were stable; BP generally runs lowish (Blood Pressure 100/57, Pulse 78, Oxygen Saturations 95%.) Denied lightheadedness or dizziness. Assessment/Plan inadvertent medication given to the patient, she received 5 MG of Buspirone and 400 MG of Magnesium Oxide about 20 minutes ago, alert, and oriented, non-sedated, no complaints, following all commands, vital signs stable, LVN was asked to monitor Vitals every 2 hours for 6 hours, cardiorespiratory, neuro checks per protocol. Call back if any concerns of cardiopulmonary depression or oversedation. Advised to hold tonight's Remeron (an anti-depressant sometimes used to stimulate hunger) and Melatonin (a medication used to help someone fall asleep) given potential sedation with 5 MG of Buspirone and 400 MG of Magnesium Oxide.] RR of a facility generated Medication Error Report, dated 11/14/2024 at 6:20 PM, reflected R #1 received a medication error on 11/14/2024. MA A administered the incorrect medication. Description of event: MA A was completing final checks on medications; trainer had clicked to next resident to start reviewing medications and MA A thought that was who she was giving medications. What contributed most to this error, was not confirming the 5 rights of medication administration. To prevent an error from happening again, MA A had education provided with additional days of training. The telehealth physician ordered withhold Remeron and Melatonin. RR of a facility generated Confidential Employee Corrective Action Form, dated 11/14/2024, reflected MA A received a coaching. Reason: Employee completed a medication error and gave medications to wrong patient. Conduct that was observed, or substantiated: 5 rights of medication administration were not followed. Areas to improve: MA A to be provided additional days of training. Signed by MA A, and the ADM, on 11/15/2024. RR of MA A's medication aide permit in Tulip (Texas Unified Licensure Information Portal) reflected an issue date of 11/4/2024; Expiration date of 11/4/2025. RR of MA A's medication administration check off form, dated 11/13/2024, reflected the MA met required tasks. INT and OBS on 1/28/2025 at 9:44 AM with R#1 revealed her in her wheelchair about to exit her room. She was fully dressed, appropriately groomed, and easy to engage. R #1 recalled the medication error from 11/14/2024. She stated the facility addressed the medication error when it happened. She did not want to discuss it further and refused further interview. Resident alert, cordial, and lucid. INT and OBS on 1/28/2025 at 9:44 AM with MA B revealed she was trained to be an MA per policy, continuing education, and yearly reviews. She was observed, at med pass, looking at medication packaging and checking the information on the computer. She stated she was making sure the right medication made it to the right resident and was part of the 5 Rs (Rights) of medication administration. She did not recall any medication errors recently; Any medications errors were reported immediately. INT and OBS on 1/28/2025 at 10:07 AM with MA C revealed she went to school, to become an MA, for about three months and participated in supervised clinicals. There was training throughout the year and yearly check offs were performed. She stated she was trained to check the 5 Rs for accurate medication administration. The 5 Rs were right person, right time, right dose, right medication, and right route. She did not recall any medication errors recently; Any medications errors were reported immediately. INT on 1/28/2025 at 11:33 AM with R #1's NP revealed that 5 mg of Buspirone was a small dosage of a gentle anti-anxiety medication. The goal, for this medication, was to take it multiple times a day to build up the anti-anxiety effect. The NP did not think the individual 5 MG of Buspirone would have had much of a negative effect on the resident, if any. She may have had a slight headache, or some nausea, but it was unlikely the medication error caused her any significant harm. The Magnesium 400 MG was a medication for upset stomach, or constipation. The dosage R #1 received, was a normal dosage. The resident may have suffered diarrhea, if she received more of the medication, but the initial, and singular administration, probably did not have any significant effect. The NP did not recall the resident to have had any complaints. INT and RR on 1/28/2025 at 12:11 PM with the DON revealed new medication aides go through orientation, when hired, and all medication aides went through specific training to become authorized to pass medications. After the medication error on 11/14/2024, the DON stated the MA A was taken off nights and went to day shift for an additional 3 more days of training. After the 3 additional days, MA A transitioned back to the night shift. The DON stated there were no medication errors since 11/14/2024. RR of the medication error binder reflected no medication errors since 11/14/2024. The DON felt the incorrectly administered Buspirone 5 MG may have made the resident drowsy, but the resident did not have any significant negative effect. The Magnesium Oxide 400 MG was a normal dosage. The Magnesium Oxide 400 MG could have caused loose stools, but the resident only had one dose and did not exhibit any significant gastrointestinal or bowel concerns. Safeguards in place to avoid medication errors were the MA training, MA skill check offs, and on-the-spot checks by senior staff. INT on 1/28/2025 at 1:15 PM with the ADM revealed facility medication aides were trained to administer medications per policy. The ADM felt the facility medication administration policy and the training MA A received addressed the appropriate information to avoid medication errors. The failure that caused R #1 to receive a non-prescribed medication fell upon communication and human error. Safeguards in place to prevent medication errors were the training program, nurse management monitoring, continued education, and yearly reviews. RR of the facility's Medication Administration Policy, undated, reflected the MA was supposed to have identified the correct resident prior to medication administration; supposed to have read medication orders on medication sheet; remove medication container and compare label with medication sheet; place appropriate dosage in cup; re-read label and medication sheet. Repeat procedure with each resident who was supposed to receive medication. RR of the facility's in-service education for 5 rights of Medication, dated 11/14/2024, reflected 20 staff, from both AM and PM shifts, in attendance. MA A was in attendance, marked by signature.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to ensure Dietary Aide C served food in accordance with professional standards and facility policy. These failures could place residents at risk of foodborne illnesses. Findings included: Observation on 08/13/24 12:00 PM of lunch service on 200 hall bistros. Dietary Aide C used her thumb and index finger on her right hand to pick up the pickles and onions and place them in the residents sandwich. She did not wear gloves or use a utensil for the pickles and onions. Surveyor observed her make 7 trays in this manner. ADON was observing as well and did not try to correct Dietary Aide C. In an interview on 08/13/24 12:48 PM Dietary Aide C stated she should have used utensils when grabbing the pickles and onions because of the risk for cross-contamination and possibly making the residents' sick. She stated it is the policy to use gloves or utensils when serving ready to eat foods. 08/13/24 01:00 PM In an interview ADON stated she observed Dietary Aide C touch the pickles and onions with her fingers, and she should not have done that because it is their policy not to touch the food with hands. She stated it is an infection control issue and she should have used gloves or utensils. In an interview on 08/13/24 at 02:00 PM, the DM stated she trained new kitchen staff herself after they go through general facility orientation which includes proper handling and serving of food, and she also trained all staff with regular in-services. She stated she does not have any documentation of the training. She also stated she was very surprised to hear of the issue with Dietary Aide C during lunch service in the bistro. She stated the crew knows better and she is disappointed. She further stated she tells her staff It only takes one little germ to make the residents sick. She stated the policy regarding plating food is to use utensils or gloves for ready to eat foods and she prefers for her staff to use utensils because there is less room for error. In an interview on 08/13/24 at 02:10 PM, the DON stated during orientation nursing staff were trained on meal service and hand hygiene. Dietary Staff receive their own training by their manager. In an interview on 08/13/24 at 02:15 PM, the Administrator stated all new dietary personnel receive general facility orientation, job specific training through RELIAS, as well as three to five days on the job training with the dietary supervisor. She stated the dietary supervisor worked very closely with new staff and provided ongoing training through in-services. Record Review of RELIAS training on 8/13/2024 for seven dietary staff, including Dietary Aide C, reflected all received training on infection control and prevention, food safety fundamentals, and handling food safely. Record Review on 8/13/202 of in-service training dated 08/12/2024 reflected staff received training on hand hygiene proper policy/procedure and frequency including Dietary Aide C. Record Review on 8/13/2024 of Nutrition Services Indications for Glove Use and Sanitation facility policy dated 01/01/2010 reflected food employees may not contact ready- to-eat food or food that will not be subsequently cooked with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.

Based on observations, interviews, and record review , the facility failed to provide sufficient support personnel with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 5 (Dietary A, Dietary B, Dietary C, Dietary D, and Dietary E) of 9 dietary staff. The facility did not ensure 5 (Dietary A, Dietary B, Dietary C, Dietary D, and Dietary E) of 9 dietary staff had a current food handler's certificate from the date of hire until August 13, 2024 . This failure could place all residents who consumed food prepared from the kitchen at risk of foodborne illness. Findings included: Review of records dated 08/13/2024 revealed Dietary Staff A, Dietary Staff B, Dietary Staff C, Dietary Staff D, and Dietary Staff E did not have food handlers' certificates while employed at the facility. In an interview with the DM on 08/13/2024 at 03:25 PM she stated the employees were required to go through Relias (a computer-based education system) training and then work with her for on the job training and onboarding for multiple days, but at minimum 3 days. She acknowledged that it was required for all dietary staff to have an accredited food handlers' certificate before working in the kitchen. She said the last person was hired over 6 months ago. She stated that this could put the residents at risk for foodborne illness if not trained properly. In an interview with the Administrator on 08/13/2024 at 3:35 PM she stated that employees were required to spend the first week of employment completing the Relias training required by their corporate office. She said that she relied on corporate for training policies and a training system to ensure accreditation standards were up to date. She said she knew all kitchen staff needed a food handlers' certification, but thought Relias was accredited because of guidance from her corporate office. She refused to acknowledge the question about any potential negative outcomes due to a lapse in training. She stated that in-service training's were reactionary, and all staff departments were provided in-services after events had happened. She stated that there has been in-service training performed for dietary staff but failed to provide records for in-services. In an interview on 08/13/2024 at 3:40pm with the Relias customer service phone line he stated that Relias was not affiliated with any state level accreditation programs but has objectives that could serve to meet competencies. No in-service training for dietary aids was provided by the time of exit. Requested the policy for dietary new hire training but it was not available.

Based on observation, interview, and record review the facility failed to help prevent the development and transmission of communicable disease and infections on 2 of 3 ice chest observed for infection control. Ice chest on hall 100 revealed plastic cup stored inside laying on the ice. Ice chest on hall 400 revealed metal scoop inside laying on the ice. This failure placed residents at risk for cross contamination and/or spread of infection that could cause severe illness and decreased quality of life. Observation on 9/18/23 at 08:59 am of ice chest on hall 100 revealed Large Plastic cup inside lying on the ice. No storage container visible on ice chest. Observation on 9/18/23 at 09:17 am of ice chest on hall 400 revealed metal scoop inside lying on the ice. Scoop holder was attached to cart. Observation on 9/18/23 at 11:29 am of ice chest on hall 100 revealed large plastic cup inside lying on the ice. Interview on 9/18/23 at 10:45 CNA A stated he has been with the facility for 1 day (today is his first full day as a qualified CNA). He stated that the ice scoop should be placed in the holder attached to the cooler, not inside the cooler. Interview on 9/18/23 at 12:55 PM CNA B stated she knew the ice chests scoops were not supposed to be kept in the coolers themselves, but in a holster attached to the cart. Interview on 9/18/23 12:30 pm with DON, stated her expectation was that the proper scoop is used to pass out ice and that is be stored in the attached holster when not in use. She stated not using the proper equipment to pass ice and not properly storing the scoop can put the resident at risk for potential harm from cross contamination. Interview on 9/18/23 100 pm with ADM. Stated her expectations was that staff follow policy and procedures for the ice chest and use the proper equipment. She stated that not following the policy and procedure could potentially place residents at harm for illness duet to cross contamination. Record review on 9/18/23 1:15 pm of Policy Cleaning of Ice machine and scoops dated 1/1/10 states the ice scoop is stored in a clean container that allows water to drain.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #24)7 residents reviewed for care plans. The care plans for Residents #24 failed to address her dementia diagnosis and what services would be provided to maintain the resident's needs These failures could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: 1. Review of the MDS assessment dated [DATE] revealed Resident #24 was an [AGE] year-old female with BIMS score 12 who was admitted to the facility on [DATE]. The resident's diagnoses included: depression, bipolar (mood) disorder, and non-Alzheimer's dementia (mental decline). Review of Resident #24's Comprehensive Care Plan initiated 11/30/17 revealed it did not address Resident #24's dementia. Interview with REG N on 07/11/23 at 12:00 AM revealed facility staff overlooked Resident #24's MDS and missed the dementia diagnosis. REG N stated that if residents were admitted all their diagnosis should be in the care plan. REG N stated the purpose for the care plan was to put in place interventions so staff could properly manage residents' care. REG N stated that by Resident #24 having an incomplete care plan for dementia she could potentially become more confused. When asked who is responsible for ensuring care plans are complete, Reg N responded LVN A and LVN B are but are on leave. Interview with the DON on 07/11/23 at 12:25 PM revealed facility staff updated how they did care plans by doing standard care meetings. DON stated every week she reviews everything regarding the residents from admission and onwards and documents on a checklist during the standard of care meetings. Don stated that staff has a checklist to use for any changes that occurred with the resident( vitals, med profile, medications). DON stated the facility must have missed the diagnosis for Resident #24 by accident. The DON stated the dementia diagnosis should have been care planned. The DON stated that if Resident #24 was not properly care planned for dementia, that could lead to a decline in care and affect her daily activities. Review of the policy, Care plans, Comprehensive Person-Centered, undated, revealed the following. The facility develops a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan will describe: The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Any services that would otherwise be required but that are not provided due to the resident's exercise of rights, including the right to refuse treatment.

Based on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a Resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the Resident's advance directives for 1 of 6 Residents (Resident #1) reviewed for cardio-pulmonary resuscitation. LVN A failed to initiate life-saving measures (CPR) Cardiopulmonary Resuscitation when Resident #1, who had a code status of full code (meaning the person wants all resuscitation procedures provided if their heart stops beating and/or they stop breathing), was found unresponsive and expired. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:34 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope identified as isolated with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of death from not receiving life-saving measures if required. Findings include: Record review of the face sheet for Resident #, dated [DATE], reflected, Resident #1 was admitted to the facility on [DATE] at 04:30PM, with diagnosis which included sepsis unspecified organisms, atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls) of native coronary artery (when arteries struggle to supply the heart with enough blood) without angina pectoris (arteries that carry blood to the heart become narrowed and blocked), Presence of Cardiac Pacemaker (a small device implanted in the chest to help control the heartbeat), Chronic combined systolic (Congestive) Heart and Diastolic (Congestive) Heart failure(combined the ventricles cannot produce enough pressure in the contraction phase to push blood into circulation). Record review of admissions progress note dated [DATE], reflected Resident # 1 was admitted to the facility from the hospital, full Code, Cardiac diet (heart healthy diet an eating plan that emphasizes foods that promote heart health), Fluid restriction (a heart healthy diet which limits the amount of daily fluid consumption) 1800ML. Record review of Resident # 1 nursing admission assessment dated [DATE], reflected a code status of Full Code, vitals taken at 17:08(5:08PM) temp. 98.2, blood pressure ,d+[DATE], Pulse 70 regular, pacemaker, smoker. Vitals taken again at 00.09 (12:09am on [DATE]) reflected, temp. 97.9, blood pressure ,d+[DATE], Pulse 75bPM (beats per minute). Record review of the facility record of death dated [DATE], reflected Resident # 1 was admitted to the facility on [DATE] at 04:30PM and the date of death was [DATE] at 07:10AM. The record reflected the doctor was contacted at 07:10AM by the ADON advised Resident # 1 was absent of vital signs, had mottling of the skin (when blood flow to vessels under the skin is disrupted bluish-red color), and fixed pupils. The Doctor gave the time of death at 07:10AM. In an interview on [DATE] at 02:51PM with LVN A, revealed she entered Resident # 1's room about 0700am and was checking the vitals for Resident # 1's roommate. LVN A stated she could see Resident # 1 leg sticking out from under his cover and she could see the mottling of the leg. LVN A stated she checked Resident # 1, and he was unresponsive, stated she shook Resident # 1 and called him by name, and he was unresponsive, took vitals no vitals, no pulse, no respiration. LVN A stated she felt like she was in shock at the time and could not think, she stated she assessed at that time that Resident # 1 was deceased . LVN A stated she immediately called for the ADON who was on duty using her cell phone, she stated she never left Resident #1. LVN A stated the ADON came down to the room and verified Resident # 1 was unresponsive she stated she then verified Resident # 1 code status was Full Code. She stated the ADON went and called the doctor and advised the doctor Resident # 1 was unresponsive, mottling of the skin, and had no pulse she stated the doctor called the time of death at 07:10AM. LVN A stated she did not provide any emergency care for Resident #1, she stated this was her first time ever finding a Resident unresponsive and her adrenaline was going. LVN A stated the ADON did not advise her to start emergency services for Resident # 1, she stated the ADON also did not provide any emergency services to Resident # 1. LVN A stated she had been trained status code and knew that even if they were found unresponsive if they were full Code, they must start emergency services until EMS came and took over. LVN A stated she was certified in CPR and had been previously trained when she initially started at the facility 1 ,d+[DATE] year ago. LVN A stated she was in-serviced today on code status and procedures, she stated she also received personnel action. (Written warning). In an interview on [DATE] at 03:10PM, the ADON, stated LVN A called her to Resident # 1 room and stated she observed the Resident unresponsive. She stated she completed her own assessment of Resident # 1 by checking all vitals, stated there were no vital signs, the resident had mottling skin (when blood flow to vessels under the skin is disrupted bluish-red color) from feet up to his face, no pulse, stated the feet and hands had started to get cold, and Resident #1 had fixed pupils. The ADON stated she assessed at that time Resident # 1 was deceased . The ADON stated they looked at Resident # 1's code status and saw he was Full Code. She stated she then called the doctor from her cell phone and advised the doctor of the condition in which Resident # 1was found and stated the doctor pronounced Resident # 1 deceased at 07:10AM. The ADON stated she did not provide emergency services for Resident #1 she stated the person who initially found Resident #1 should have started emergency services. The ADON stated she did not advise LVN A to start emergency services. The ADON stated she had been trained on CPR and stated the protocol even if a resident was found unresponsive was to provide emergency services if they have a Full code status. ADON stated she was in-serviced on [DATE] on code status and received personnel action. (Written warning) Record review on [DATE] of the ADON personnel, reflected The ADON had received a written warning for her performance not providing emergency services for a resident with full code status. In an interview on [DATE] at 10:00am the DON, stated on [DATE] she was contacted that morning by the ADON and advised Resident # 1 had passed away. She stated the ADON advised she had already contacted the doctor and the doctor pronounced Resident # 1 deceased at 0710am. The DON stated the ADON advised her Resident # 1 had a Full Code status, she stated she asked if they provided emergency services and the ADON said no. The DON stated when she asked why the ADON reported because Resident # 1 had mottled skin (when blood flow to vessels under the skin is disrupted bluish-red color) up to his hip area, had no vitals, and no respirations. The DON stated once she made it to the office, she spoke with both the ADON and LVN A, and emergency rescue services should have been started and 911 should have been called even if they knew the Resident was deceased . The DON stated she called the doctor, and the doctor advised her she was under the impression Resident # 1 was a DNR status. The DON stated she advised the doctor of the corrective action she took with the nurses and the in-services she started with the staff. The DON stated she advised the ADM of the situation, and they called in the report to HHSC (Health and Human Service Commission). In an interview on [DATE] at 10:20am with the ADM, he stated he was made aware Resident # 1 had passed away when he got in the office about 07:45AM. He stated after speaking with the DON she was made aware the nursing staff did not follow the Full Code procedure and provide emergency care or call 911 for Resident #1. The ADM stated he gathered all the information and called in the report to HHSC (Health and Human Services Commission). He stated it was his expectation the nursing staff followed their training and provided the appropriate services to the residents. He stated Resident#1 had a Full Code status, they should have followed that protocol and provided emergency services. In an interview on [DATE] at 5:30PM with the PCP, revealed she was contacted by the ADON and advised of the condition in which Resident # 1 was found. The PCP reported the ADON advised Resident # 1 was assessed and was found unresponsive, had fixed pupils, and mottling of the skin (when blood flow to vessels under the skin is disrupted bluish-red color). The PCP stated she pronounced Resident # 1 deceased at 07:10AM. She stated she was not advised at that time Resident # 1 had a Full Code status by the ADON. The PCP stated had she been provided that information she would have asked if emergency services were provided, if 911 was called, if and the family had been contacted to see if they wanted emergency services provided. The PCP stated she learned later from the DON, Resident # 1 had a Full code status. The PCP stated Resident # 1 was admitted to the facility on [DATE] and expired on [DATE]. She stated she was not able to meet and assess Resident # 1, however when Resident # 1 was admitted he was very sick, from the hospital records she received. Record review of hospital discharge records, dated [DATE], reflected Resident # 1 was Full Code status. Resident # 1 was admitted to the hospital on [DATE]. Resident #1 was seen for compression of the spinal cord at the L5 and S1 level (the transition region between the lumbar spine and sacral spine in the lower back)., The Resident had frequent falls and continued to decline. Resident #1 discharged to a SNF for continued therapy services and expected the SNF stay approximately 30 days with progress of therapy services. Record review of Resident report Code status dated [DATE], reflected the facility had 68 Residents who had a Full Code Status, and Resident # 1 code status was Full Code. Record review of the facility in-service dated [DATE] for Full Code status procedures, abuse/ neglect, documentation, reflected this training was started and being completed by all nursing staff. Record review of the facility's, undated, Emergency Procedure policy reflected the following: To provide early treatment to maintain adequate oxygenation and circulation. This is a Resident who have requested CPR in their advance directives, who have not formulated an advance directive, and who don't have a valid DNR order, or do not show signs of clinical death. Record review of the facility's, undated, Resident rights policy, reflected: Competent adult Residents may issue directives or medical power of attorney for health in accordance with legal representation Policy. An elderly individual may make a living will by executing a directive under the Natural Death Act. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:45PM p.m. due to the above failures. The ADM and DON were provided with the Immediate Jeopardy (IJ) template on [DATE] at 1:45 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 6:00PM. PLAN OF REMOVAL Immediate action: Purpose: The purpose of this action plan is to take steps to correct the system failures in failing to follow facility policy and procedure in providing emergency services to Resident 1 that potentially contributed to his death. This failure included services as not calling 911 at the time of the emergency and not providing cardio-pulmonary resuscitation (CPR) as indicated in his medical record. There was the potential of 68 other Residents to be affected by the practice. Immediate Actions to Correct the Following System Failures 1. The two nurses involved in this incident were reprimanded by DON on date of occurrence for not following facility policy and procedures on Resident Emergency Services and both were included in the facility overall in-service training on Emergency Procedures concerning Resident emergencies to include notification to 911 and initiating CPR procedure when a Resident is a full code. These two nurses were LVN A and ADON. Completed [DATE]. The DON will be responsible to ensure that the staff reprimanded will comply and follow correctly the facility's Resident Emergency Service Policy and Procedures. 2. An in-service training was accomplished by DON on [DATE] with all nursing staff to include CNAs, all licensed nurses and the two nurses involved in this incident. All other staff on leave or new will be in-serviced prior to starting or returning. This training included the facility policy and procedure in Resident Emergency Services and specifically covered calling 911 and the beginning of the emergency and if required to do so will initiate CPR to the Resident if the Resident is a full code. Completed [DATE]. The DON will be responsible to ensure follow correctly the facility's Resident Emergency Service Policy and Procedures. 3. The DON implemented a sign -in sheet on [DATE] whereas the staff on duty, to include Nurses, CNAs, and CMAs, will be required to sign-in and ascertain that Resident rounds were completed every 2 hours to ensure Resident safety, their needs being met and any identifiable evidence that the Resident was experiencing any signs or duress that would require initiating an emergency response. This documentation will be kept at the nurse's station. DON conducted this in-service, also covered in this in-service training required charge nurses to document during their shift on any new admissions any changes in conditions and interaction with the Resident or family. This documentation is kept in Point Click Care. Any changes in condition will be reported directly to the facility DON 7 days a week, 24 hours a day. All staff attending were trained on the items covered in this in-service and this was implemented immediately. All other staff on leave or new will be in-serviced prior to starting or returning. The sign-in sheets will be monitored daily, 7 days a week by the two ADONS. Any deviations from the policy will warrant re-training of the staff member not following policy. Completed [DATE] and on-going. The DON will be responsible to ensure Resident safety, their needs being met and any identifiable evidence that the Resident was experiencing any signs or duress that would require initiating an emergency response. Also, the DON or ADON will ensure staff document during their shift, on any new admissions, any changes in conditions and interaction with the Resident or family. ADONs and DON are responsible for reviewing documentation in Point Click Care Daily. 4. The facility Administrator conducted an in-service training on [DATE] with all staff concerning the policy and procedure in identifying abuse and Neglect and reporting the Abuse or Neglect to the facility Abuse Coordinator which is the Administrator. All other staff on leave or new will be in-serviced prior to starting or returning. Completed [DATE]. The Administrator is responsible to ensure that staff follow facility Abuse and Neglect guidelines in identifying abuse and neglect and reporting these to him immediately. 5. The Administrator instructed the Medical Record Staff member to do a code status audit of all Residents in the facility. A daily update of Resident code statuses by the night shift charge nurse member will be placed on the facility emergency crash cart and is also available at the nurse station with all Resident face sheets that identify their code status. The facility charge nurse is responsible to see that the crash cart is equipped with a daily list of all current Resident, to include new admissions, of their code statuses. The Don is responsible to ensure that the code list is being updated daily. Completed [DATE] and on-going. 6. The facility Medical Directors MD1 and MD2. and the attending physician for Resident 1, PCP1 was immediately notified of this incident, and have received a copy of this Action Plan. 7. The Quality Assessment and Assurance Committee will meet monthly starting [DATE] and on- going to monitor these systems and ensure that corrections are in place and working to prevent any reoccurrences of these deficient practices. The Quality Assessment and Performance Improvement committee will meet report monthly to discuss progress of these plans. In conclusion, the facility management team feels that they have addressed all issues concerning the system failures in failing to follow facility policy and procedure in providing emergency services on date of incident that potentially contributed to a Resident's death. This failure included services as not calling 911 at the time of the emergency and not providing cardio-pulmonary resuscitation (CPR) as indicated in his medical record. All staff has received the proper in-service training and direction. Monitoring is in place so that management can be assured that these systems are effective and working to prevent these issues from reoccurring. Monitoring of the Plan of Removal on [DATE] Observation on [DATE] at 6:05PM revealed sign-off roster for rounds completed for each shift: Day shift staff signed roster for rounds completed sign-off rosters for reach shift for rounds located at the nurse's station for each hall and staff working that hall each shift to sign off the rounds had been completed. Observation on [DATE] at 6:10PM, revealed the crash cart sign-off sheet for cart checks completed. Observation on [DATE] at 6:10PM, revealed resident code status book placed on the roster for easy access for staff to review. Interviewed 4 nurses reported they have been trained and understood the process for Full Code Residents. Interview on [DATE] at 3:30PM, LVN B stated she had been trained on Full Code status, abuse/ neglect, rounds, and documentation. LVN B stated she was certified in CPR, and as a nurse when a resident had a Full code status you must provide emergency services, call for help, have them call 911, and continue emergency services until EMS arrived to take over. Interview on ,d+[DATE] at 3:40PM, LVN C stated she had been trained on Full Code status, abuse/ neglect, rounds, and documentation. LVN C stated she was certified in CPR, and as a nurse when a resident had a Full code status you must provide emergency services, call for help, have them call 911, and continue emergency services until EMS arrived to take over. Interview on [DATE] at 3:50PM, LVN D stated she had been trained on Full Code status, abuse/ neglect, rounds, and documentation. LVN D stated she was certified in CPR, and as a nurse when a resident had a Full code status you must provide emergency services, call for help, have them call 911, and continue emergency services until EMS arrived to take over. Interview on [DATE] at 4:00PM, LVN E stated she had been trained on Full Code status, abuse/ neglect, rounds, and documentation. LVN E stated she was certified in CPR, and as a nurse when a resident had a Full code status you must provide emergency services, call for help, have them call 911, and continue emergency services until EMS arrived to take over. In an interview on [DATE] at 4:10PM, ADON B, stated she had been trained on Full Code status, abuse/ neglect, rounds, and documentation. ADON B stated she was certified in CPR, and as a nurse when a resident has a Full code status you must provide emergency services until EMS arrives to take over. During an interview on [DATE] at 6:15PM, the ADM reported that he verbally contacted the MD's 1 and 2, Resident # 1 PCP, over the phone and advised of the incident and sent a copy of the action plan on [DATE]. The ADM reported, QAPI was scheduled for [DATE]/ 2023 and this incident will be addressed Record review of CPR certifications on [DATE] for all nursing staff listed, reflected all CPR certifications for nursing staff in report to be current. Record review of personnel files reflected a written warning for LVN A and ADON signed and dated [DATE]. Record review of In-service, completed [DATE], revealed Full Code Policy/Procedure: Verified 34 staff members completed in in-service for Full Code emergency procedures which included LVN A and the ADON. Record review of in-service conducted on [DATE] revealed, 55 staff in-serviced on abuse/neglect, interviewed 6 nurses who knew and understood the process of reporting abuse/ neglect immediately if they saw or suspected a resident was being abused, and that the ADM was the abuse/neglect coordinator. Record review of the audit sheet for Resident status Code on crash cart, each Resident was identified and their code status. The ADM and DON were informed the Immediate Jeopardy (IJ)) was removed on [DATE]. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on record review and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standard of practice for one (Resident #1) of three residents reviewed for pain. The facility failed to ensure Resident #1 received a different medication when the ibuprofen was not effective for resident's pain. This failure placed residents of unnecessary pain and the risk of uncontrolled pain and diminished quality of life. Findings included: Record review of Resident #1's undated face sheet reflected he was a 40 -year-old male admitted to the facility on [DATE]. Diagnoses was not listed on the face sheet. Record review of Resident #1's Medical Diagnosis dated 01/26/2023 reflected resident had a diagnosis other seizure (a burst of uncontrolled electrical activity between brain cells causing uncontrolled shaking of the body or loss of awareness), unspecified dementia without behavior/ psychotic, mood, and anxiety disturbance. The medical diagnosis record was updated on 01/27/2023 with a diagnosis of down syndrome, unspecified (congenital malformations, deformations, and chromosomal abnormalities). Record review of Resident #1's Admission MDS assessment dated [DATE] reflected resident usually able to make self-understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time), resident usually understands others (misses some part/intent of message but comprehends most conversations). Resident #1 had a BIMS score of 4 indicated his cognition was severely impaired. Resident was not assessed of having any pain or received any medications for pain. Resident #1 did not have any issues with behaviors. Resident was also assessed to require extensive assistance with ADL's and needed two-person assistance. Record review of Resident #1's Comprehensive Care Plan dated 1/27/2023 reflected resident was at risk for psychosocial well-being. Interventions: Observe for psychosocial and mental status changes - document and report as indicated. Resident #1 was at risk for injury/immobility due to need for quarter or half side rails to assist with turning and repositioning. Monitor for changes in condition that may indicate a decline in mobility and report to physician. Resident requires assist with ADL's. Resident #1 was at risk for falls due to new environment, down's syndrome, and dementia. Call light in reach. Ensure resident was wearing appropriate footwear when mobilizing in wheelchair. Resident needs a save environment: clutter free and bed in low position at night. Resident had a seizure disorder. Resident was assessed to be at risk for pain. Record review of Resident #1's Physician Orders dated 02/01/2023 thru 02/28/2023 reflected effective date 01/26/2023 pain assessment every shift. Ask resident if they were currently in pain. Document level of pain (0- 10) and scale used to determine pain level. Document resident satisfaction with pain control in general every shift with end date of 2/23/2023. Tylenol 325 mg give 2 tablets orally every 6 hours as needed for pain. Document level of pain (0-10). In progress note describe pain scale used and location of pain and any pain behaviors observed. Do not exceed 3,000 mg/day of acetaminophen from all sources unless approved by MD. Ibuprofen oral tablet 200 mg give 3 tablets by mouth one time only for pain for one day give three tablets= 600 mg. order date 2/12/2023 and end date 2/13/2023. Review of Resident #1's Nurses notes dated 01/26/2023 thru 02/11/2023 reflected resident did not exhibit any pain. Review of Resident #1's Nurses Notes dated 02/12/2023 at 6:06 AM resident was transferred to ER related to seizure. Review of Resident #1's Nurses notes dated 02/12/2023 at 13:10 Resident returned from ER with no new orders noted. Recommended referral to neuro. Resident appeared fatigue and denied wanting to go to bed. Resident did have complaints of foot pain and yelled out when touched. PRN medication was administered and effective. Signed by ADON. Review of Resident #1's Nurses Notes dated 02/12/2023 at 15:46 reflected Resident had new order from NP for one time dose of 600 mg of ibuprofen. Signed by ADON. Review of Resident #1's Nurses Notes dated 02/13/2023 at 05:25 AM reflected Resident appears very tired and would not arouse when speaking to him. PRN medication given for R leg pain, effective. Signed by LVN A. (did not document pain level). Review of Resident #1's Nurses Notes dated 02/13/2023 at 12:48 a Stat X-ray was ordered for right hip. Signed by LVN B. Review of Resident #1's Nurses Notes dated 02/13/2023 at 17:30 Resident was transferred to hospital. Review of Nurse Practitioner of Resident #1's note dated 02/13/2023 (time not documented) reflected a [AGE] year-old male presented with concerns of pain. Resident #1 had a seizure and sent to hospital and returned without orders. On return resident complained of leg pain. He is found sitting in wheelchair, leaning forward yelling in pain. Resident was shaking and tachycardic (heart rate over 100 beats a minute). Resident had musculoskeletal and gastrointestinal pain. He had obvious signs of pain. Resident was assessed to have edema to bilateral feet and ankles. Residents diagnoses were Down's syndrome, epilepsy, and pain. Review of hospital records revealed his lactic acid was slightly elevated at 2.3 which could be related to seizure disorder, however, concerned of increased pain, tachycardia, and his blood pressure is lower than his baseline. Resident's plan: the nursing facility care subsequent unstable/ new problem. Supportive care, assist with ADL's. Oxcarbazepine 300 mg PO BID. Oxcarbazepine level pending 3. Stat UA/CS, stat KUB. Documented by [NAME] Nurse Practitioner. In an interview on 02/24/2023 at 7:00 PM, the R/P for Resident #1 stated when she visited Resident # 1 on 02/13/2023 approximately 11:00 AM, he was yelling. She stated she could hear him in the hallway yelling very loud. She stated when he yelled in a loud tone it frequently indicated he was in pain. She stated when she got to his room, she noticed his feet and legs had a lot of edema and this was not normal for him. She stated when she was looking at his legs and feet he would begin to yell louder when she would touch the area close to his right hip. She stated he was not acting like himself. She stated he was agitated. She stated when he is agitated, he would not be cooperative with her, and she stated he was not his normal self. She stated when she asked the nurse about his edema and his pain, she did not receive any answers except the nurses were giving him, as needed, over the counter medications for pain. She stated when her son was in pain, over the counter medications, did not help his pain. She stated she asked the nurse (did not know her name) why nothing had been done about him being in pain and getting some type of x-ray or something to determine what was causing his excruciating pain and edema. She stated he was not on any type of medications for edema. She stated she was frustrated with the facility staff for not doing something to determine what was wrong with her son. She stated the discharge records from hospital stated discharged to nursing home in good condition. She stated he was discharged from ER after having a seizure on 02/12/2023. She stated the NP was in the facility and had not ordered an x-ray or anything but over the counter, one-time new medication. She stated when she was at the facility, and he was given over the counter medication, it was not helping his pain. She stated he continued to yell and whenever he moved his legs especially the right leg he would yell and stated he was hurting. She stated he would report to her he was hurting in his leg, and it hurt a lot. She stated she had taken pictures of her sons' legs having edema and she had a picture of his legs when they were normal. She stated she asked the nurse several times why he had edema and was screaming in pain. (She did not know the nurse she asked at the nurse's station - only one nurses' station). She stated he was not complaining of pain when she saw him in the emergency roiagnom on [DATE]. She stated was not in pain until he returned to the facility from the emergency roiagnom on [DATE]. In an interview on 02/25/2023 at 1:50 PM, Med-Aide C stated she did assist the transportation aide in propelling Resident #1 into the facility from the facility van. She stated Resident #1 was complaining about being in pain. She stated he was not able to specify at that time where he was hurting. She stated resident kept his legs together and would not pull his legs apart to place his legs on the wheelchair leg rests. She also stated it was difficult to propel resident without his feet on the leg rests. She stated in a few minutes, he did say his feet were hurting and he would yell out when either me or the transportation aide would touch his feet. She stated the Nurse Practioner was called on 02/12/2023 by the ADON. She stated the Nurse Practitioner only ordered one-time Ibuprophen. She stated she was not aware of any type of injury that occurred to Resident #1. She stated she knew on 02/11/2023 and 02/12/2023 it was not reported he had a fall or any type of injury. She stated she knew Resident #1 prior to him being admitted to the nursing home and he would have told her if he had fallen or if anything had happened to him. She stated she was related to Resident #1. In an interview on 02/25/2023 at 2:40 PM, CNA D stated she did not work on the same hall where Resident #1 resided. She stated she did work on 02/12/2023. She stated when she came into work approximately 5:30 AM on 02/12/2023, the resident was surrounded by staff. She stated she learned later that resident had a seizure and was sent to the ER. She stated she saw him when he returned from theER on [DATE]. She stated he was not himself. She stated he would laugh with her when she spoke to him, and he would talk about his mother and his dog. She stated he looked tired and was unable to get comfortable in his wheelchair. She stated he did not complain of pain when she saw him on 02/12/2023. She stated she could not recall the time she saw him. She stated it was in passing and she stopped to speak to him. She stated he was leaning to his left side. And could not put pressure on his right side. She stated she did report this to the ADON. In an interview on 02/25/2023 at 1:10 PM, ADON stated when Resident #1 returned fromER on [DATE], he appeared to be groggy and was not his usual self. She stated he was a little anxious and he was complaining of foot pain. She stated he had his head laying on bedside table in the hallway and was yelling with pain. She stated he did not want to go in his room due to his roommate yelling. She stated he would say ouch when she would touch his left and right foot. When the staff assisted him to bed, he kept saying ouch and would yell. She stated when she assessed him again, he would not specify the location of his pain. She stated later in the day she assessed him again and he complained of pain his feet and legs. She stated he was given PRN over the counter pain medication, and it would help approximately 1 hour, and he would be in pain after one hour. She stated she called the Nurse Practioner on 02/12/2023 and explained Resident #1 being in pain and this was unusual for him. The Nurse Practioner ordered Ibuprophen medication only to be given one time. She stated she noted resident did not have any redness or bruising on his legs. She stated she did notice it was difficult for resident to bear weight on his right side when he was assisted from bed to wheelchair. She stated his roommate was yelling and he wanted out of his room. She stated when she called the Nurse Practitioner on 02/12/2023 she did report to the Nurse Practitioner the resident had difficulty bearing weight to his right side and being in pain. She stated she thought the Nurse Practitioner would have ordered an x-ray, sent him to the ER, or ordered stronger pain medications. She stated Resident #1 needed stronger medications than Ibuprofen due to the intense level of pain. She stated she called his R/P and explained of resident complaining of pain. She did not recall the time she did make a phone call to his mother. In an interview on 02/25/2023 at 2:13 PM the Nurse Practioner stated she did not have her notes in front of her and could not recall all the details. She stated she was working in the emergency room and only had a few minutes to talk. She stated she did order him some Motrin on the day the ADON called about Resident #1's Pain. She stated she informed the ADON if there was no improvement with the pain to contact her. She stated she was in the facility all day on 02/13/2023. She stated when she assessed resident in the AM he was hurting. She also stated when she assessed him, she was aware he was in pain. She stated she was concerned, he had bowel obstruction or UTI. She stated she had lots of concerns, and this was why she first ordered lab work for resident. She also stated later in the day x-ray to right hip was ordered in the afternoon. She stated it was going to be a long wait for the resident to receive x-ray and get the lab work completed in a timely manner at the facility. She stated this was when she ordered resident be transferred to hospital for lab work and x-rays. Nurse Practioner did not answer any questions about his pain for 2 days and why was he not ordered anything stronger than one-time Motrin. Interview on 02/25/2023 at 11:05 AM, the Director of Nurses stated he was transferred to theER on [DATE] related to a seizure. She stated he returned to the facility on [DATE]. She stated she did not recall the times he was sent and returned from ER. She stated he returned fromER on [DATE] approximately 1:00 PM. She stated when she began asking questions about his pain on 02/13/2023, the Transport Aide typed a statement of what occurred when she went to the hospital to transfer Resident #1 to Nursing home facility. She stated once Transport Aide was at the facility, she required assistance with transferring him into the facility via wheelchair. She stated Med- Aide C assisted Transport Aide with propelling him into the facility. She stated during her investigation, Resident #1 was having severe pain and it was difficult to propel him in his wheelchair due to bending over and difficult for him to remain in one position. She stated PRN over the counter medication was given to Resident #1. She stated the resident continued to complain of pain throughout the day. She stated the Nurse Practioner was contacted about resident's pain and she ordered a one time over the counter medication to be given to Resident #1. She stated Resident #1 would not go to bed night of 02/12/2023 and stayed up in the common area. He did not want to go to his room due to his roommate yelling out and did not want to go to another room. She stated he frequently preferred to stay up in the common area near the nurse's desk. She stated it was a possibility the edema was from his sitting up all night. She also stated the Nurse Practitioner was at the facility all day on 02/13/2023. She stated the Nurse Practitioner assessed Resident #1. She stated he continued to complain of pain in his legs and at times he would say it was the bottom of his feet. She stated the pain did increase on 02/13/2023. She also stated the Nurse Practitioner assessed Resident #1 in the morning and stated she was going to order some lab work. She stated in the afternoon Resident #1's pain did not get any better; even with over-the-counter medications. She stated the Nurse Practioner ordered lab work and later ordered an x-ray to his right hip. She stated it was going to be longer for the facility to get the lab work and x-ray to his right hip and this was when the Nurse Practitioner agreed to transfer Resident #1 to the hospital for further evaluation. She stated he was transferred to hospital approximately 5:30 PM on 02/13/2023. She stated with the resident in severe pain on 02/12/2023, he should have been sent back to theER on [DATE]. She stated it was apparent the over-the-counter medications ordered was not helping his pain. She stated she thought the fracture was a spontaneous fracture from the seizure. She stated there was a potential something happened to Resident #1 when he was sent toER on [DATE] and when he returned to the facility. She stated he had a different type of pain and a different type of anxiety level. She stated Resident #1 was not himself at his normal baseline. She stated it was difficult to determine if his anxiety was from the pain or from his roommate yelling. She stated the facility should have pressured more for the Nurse Practitioner to send him out either the night of 02/12/2023 or in the early AM of 02/13/2023 due to his pain. She also stated when the resident returned from hospital, the facility staff did not do any assessment forms or pain assessment forms. She stated the nursing staff did narrative notes. She stated it was apparent when Resident #1 returned from hospital, the narrative note should have been more detailed about his overall physical condition and appearance. Resident was discharged on [DATE] related to seizure. She stated he was currently at the hospital and not in the facility. In an interview on 02/25/2023 at 4:00 PM, the Administrator stated if Resident #1 was in severe pain when he returned from theER on [DATE] and continued to be in pain on 02/13/2023, he should have been sent to theER on [DATE] or early AM on 02/13/2023. He stated stronger medications than Ibuprofen and Tylenol may have helped manage his pain. He stated it was the Nurse Supervisor's job to report any unusual pain or difference in behavior/ mood to the ADON or DON. He stated there was a potential of resident health declining and unable to treat him without knowing exactly where the pain was occurring on the resident. He stated Resident #1 was being assessed over a total of 5 hours by the Nurse Practioner on 02/13/2023. Record Review of Facility Policy Pain Assessment (not dated) reflected assess pain presence, assess pain intensity, medicate according to intensity of pain and evaluate effectiveness of pain medication. Assess the general level of pain the resident is experiencing every shift, using either the verbal pain scale or the PAINAD scale for non-verbal or cognitively impaired residents. If the resident complains of pain (other than the general pain assessment), assess the level of pain resident is experiencing. Give medication according to the level of pain. Document in the resident's chart: A. Complaint of pain voiced by the resident; location of pain; severity/level of pain; scale used to determine the severity/level of pain. B. Medication Administered C. Effectiveness of medication administered. D. Side effects or adverse reaction to medication administered. Record requested on 02/25/2023 at 4:30 from the Administrator of verbal pain scale and pained scale with instructions. These forms not provided at time of exit.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment of residents were reported within 2 hours to the state agency for one (Resident #1) of three residents reviewed. The facility failed to timely report an allegation of injury of unknown origin to the State Agency for Resident #1. This failure could affect all residents by placing them at risk of abuse or neglect. Findings included: Record review of Resident #1's undated face sheet reflected he was a 40 -year-old male admitted to the facility on [DATE]. Diagnosis was not listed on the face sheet. Record review of Resident #1's Medical Diagnosis dated 01/26/2023 reflected resident had a diagnosis other seizure (a burst of uncontrolled electrical activity between brain cells), unspecified dementia without behavior/ psychotic, mood, and anxiety disturbance. The medical diagnosis record was updated on 01/27/2023 with a diagnosis of down syndrome, unspecified (congenital malformations, deformations, and chromosomal abnormalities). Record review of Resident #1's Significant Change MDS assessment dated [DATE] reflected resident usually able to make self-understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time), resident usually understood others (misses some part/intent of message but comprehends most conversations). Resident #1 had a BIMS score of 5 indicated his cognition was severely impaired. Resident did not exhibit any issues with behaviors. Resident was also assessed to require extensive assistance with ADL's and needed two-person assistance. Resident had new diagnosis of hip fracture. He also had frequent pain during the MDS assessment period and received scheduled pain medication regimen. Record review of Resident #1's Comprehensive Care Plan dated 1/27/2023 and revised on 2/17/2023 reflected resident was at risk for psychosocial well-being. Interventions: Observe for psychosocial and mental status changes - document and report as indicated. Resident #1 was at risk for injury/immobility due to need for quarter or half side rails to assist with turning and repositioning. Monitor for changes in condition that may indicate a decline in mobility and report to physician. Resident requires assist with ADL's. Resident had limited physical mobility related to right hip fracture. Non-weight bearing to right lower extremity. Resident was non-weight bearing to right lower extremity. Monitor/ document/ report PRN any signs/ symptoms of immobility: contractures forming, worsening, thrombus formation or skin breakdown. PT and OT referrals as ordered, PRN. Resident #1 was at risk for falls due to new environment, down's syndrome, and dementia. Call light in reach. Ensure resident was wearing appropriate footwear when mobilizing in wheelchair. Resident needs a save environment: clutter free and bed in low position at night. Resident had a seizure disorder. Resident was assessed to be at risk for pain. Interview on 02/25/2023 at 11:05 AM, the Director of Nurses stated she notified the Administrator on 02/13/2023 after the facility received results of right fracture hip late in evening on 02/13/2023. She stated she did not know the exact time. She stated the Administrator was the abuse coordinator and at that time no one knew what happened and this is when the investigation began of the interviews with staff. She stated resident was transferred to hospital on 02/13/2023 approximately 5:30 PM. She also stated someone from the hospital called the facility on 02/13/2023 and spoke to a nurse and reported resident had a right hip fracture. She stated the nurse supervisor called her with the information. She stated it was not documented in nurses notes of the phone calls from the hospital, from nurse supervisor, or when I called the administrator. She stated Resident #1 returned to the facility on [DATE]. Interview on 02/25/2023 at 4:00 PM, the Administrator stated he was notified on 02/13/2023 by the DON of the health condition of Resident #1. He stated the DON reported Resident #1 had hip fracture of unknown origin. He stated Resident #1 was in the hospital on 02/12/2023 due to seizures and returned to facility on 02/12/2023. Resident #1 was complaining of some pain and the nurse practitioner ordered an x-ray on 02/13/2023 and it was not going to be as soon as she wanted the x-ray and decided to transfer him to the hospital on 02/13/2023. He stated this was when it was reported that he had a fractured right hip. He stated someone from hospital called on 02/13/2023 and spoke to one of the nurses (not sure name of the nurse) and reported he had a fracture right hip. He stated he was to report this incident to the Texas State of Human Services within 2 hours of being notified as stated in the federal regulations. He stated he did not attempt to report it until 02/19/2023. He stated he had difficulty with the electronic site with the state website of where to report any type of incidents. He also stated he did not call in the incident to the state of Texas electronic system of reporting incidents. He stated he did not have an intake number. He stated he preferred not to call in incidents he preferred to complete incidents online with the electronic system with the state of Texas. He stated as of 02/25/2023 (at the time of the interview), the incident was not reported to Texas State Department of Health Services. He stated by him not reporting to state in a timely manner, it could become more negative about the situation such as not reporting of what happened and not notifying Texas State Department of Health. He stated it was his responsibility to report, to the State, about any unusual occurrences such as injury of unknown origin. Record Review of Provider self-reporting of LTC incidents dated 02/19/2023 was not completed and was not sent into the electronic records with the Health and Human Services self - reporting incidents. Record Review of Abuse/ Neglect Prohibition Policy (not dated) reflected any bruising or injuries of unknown origin of any resident must be documented upon discovery and reported immediately to their supervisor who in turn will report this immediately to the director of nurses or administrator. All efforts will be made to determine if abuse/neglect could have occurred concerning these bruises of injuries of unknown origin. The administrator or his/her designee will report the alleged abuse/neglect to the Texas Health and Human Services and/or other appropriate agency and /or the appropriate law enforcement agency per regulation.

Based on interview and record review, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 2 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1, and his Responsible Party received written notice prior to a room change. This failure could place residents at risk for decrease quality of life being in a new environment. Findings included: Record review of Resident #1's undated face sheet reflected he was a 40 -year-old male admitted to the facility on [DATE]. Diagnosis was not listed on the face sheet. Record review of Resident #1's Medical Diagnosis dated 01/26/2023 reflected resident had a diagnosis other seizure (a burst of uncontrolled electrical activity between brain cells), unspecified dementia without behavior/ psychotic, mood, and anxiety disturbance. The medical diagnosis record was updated on 01/27/2023 with a diagnosis of down syndrome, unspecified (congenital malformations, deformations, and chromosomal abnormalities). Record review of Resident #1's Significant Change MDS assessment dated [DATE] reflected resident usually able to make self-understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time), resident usually understands others (misses some part/intent of message but comprehends most conversations). Resident #1 had a BIMS score of 5 indicated his cognition was severely impaired. Resident did not exhibit any issues with behaviors. Resident was also assessed to require extensive assistance with ADL's and needed two-person assistance. Resident had new diagnosis of hip fracture. He also had frequent pain during the MDS assessment period and received scheduled pain medication regiment. Record review of Resident #1's Comprehensive Care Plan dated 1/27/2023 and revised on 2/17/2023 reflected resident was at risk for psychosocial well-being. Interventions: Observe for psychosocial and mental status changes - document and report as indicated. Record review of Resident #1's nurses notes dated 02/13/2023 at 5:25 AM reflected the resident slept in the common area most of this shift. Resident #1 would not arouse fully when speaking to him. Resident #1 appeared very tired and did not want to go to room. Staff attempted to transfer resident at 0300 into another empty bed on the hall and he woke up and stated that he wanted to get up. Resident #1 was transferred to wheelchair and assisted to the common area. Resident was pleasant with staff. Resident was administered PRN Tylenol for R leg pain. Signed by LVN A. Record review of Resident #1's nurses notes dated 02/13/2023 at 16:12 reflected Resident moved to 208 B; family aware/ consented. Signed by the Director of Nurses. Interview on 02/24/2023 at 7:00 PM, the R/P for Resident #1 stated when she visited Resident #1 on 02/13/2023 approximately 11:00 AM, he was not in his room. She stated she could hear him yelling but could not find him. She stated she asked someone (did not know name of person) and this person explained Resident # 1 had been moved to another room. She stated she could hear him yelling but could not find him. She stated she asked when he was moved, and she was informed by a nurse (did not know the nurses name) he was moved early in AM on 02/13/2023. She stated she was not notified of him being moved by a phone call or any written notice. She stated her son was not given a written notice. She also stated when she asked her son about the room change, he did not understand why he was moved. Interview on 02/25/2023 at 11:05 AM, the Director of Nurses stated Resident #1 did not want to remain in his room related to his roommate yelling. She stated the nurse's documentation on 02/13/2023 was expected to reflect why the staff was attempting to move Resident #1 at 3:00 AM She stated Resident #1 did not want to lay down in another room and preferred to remain up in his wheelchair in the common area near the only nurses' desk in the facility. She stated Resident #1 was awake most of the night, became tired, and was moved to room [ROOM NUMBER] B the morning of 02/13/2023. She stated she did not know the exact time he was moved into that room. She also stated no one documented the time of the exact move or if he was notified, he was being moved. She stated in the morning meeting on 02/13/2023 at 9:30 AM, Resident #1 needed to be moved to another room. She also stated she informed the Administrator, the R/P needed to be contacted concerning Resident #1 moved to another room. She stated no one called the mother (R/P) to inform her he was being moved. She stated Resident #1's Mother entered the facility and was unable to locate Resident #1. She stated the mother was upset and wanted to know where her son was located. She stated she did explain to the mother of the incident with the roommate yelling. She stated the mother was not happy about not being contacted about her son (Resident #1) being moved. She stated all R/P's were to be contacted of any type of room change. She stated there was no excuse of why any of the staff did not contact the mother concerning the room change. She stated they should have decided who was going to contact the mother during the morning meeting and have someone call the mother immediately after the meeting and prior to the room change. She stated she did document the R/P (Mother) was informed and consented in the nurses notes on 02/13/2023. She also stated the R/P (Mother) stated he had already been moved and she thought it would upset him if he was moved again and then she agreed/consented to the move. She stated the R/P (mother) did not sign any type of room change agreement or was notified by any staff prior to Resident #1 being moved. She stated with the R/P not knowing about the move, she was upset and thought something had happened to her Resident #1. She stated with the mother being upset, there was a potential of upsetting the resident. Attempted to contact LVN A via telephone on 02/25/2023 at 12:20 PM and was unable to leave message. In an interview on 02/25/2023 at 4:00 PM, the Administrator stated Resident #1 was moved on 02/13/2023 prior to his R/P visiting him on 02/13/2023. He stated he did not recall the exact time Resident #1 was moved. He stated he thought it was approximately 10:30 AM. He stated he did not remember if it was discussed in morning meeting to call his R/P of moving him to another room. He stated the morning meeting began at 9:30 AM and ended approximately 10:00 AM. He stated the R/P was required to be contacted before resident was moved. He stated if family came in the facility and was not aware their family member was moved to another room, the family had a potential of becoming distraught. He stated the family may believe their loved one was sick, something happened to their loved one and was sent to hospital. He also stated this incident of not notifying R/P of room change had a potential of causing a lot of unnecessary stress. Record review of the Facility Resident Care Policy (not dated) reflected the facility will prepare a written notice which contains: the reason and effective date of the relocation and the room to which the resident is being located to.

Based on observation, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one (Resident #1) of 11 residents reviewed for facility-acquired pressure ulcers. The facility failed to ensure Resident #1's skin wound was assessed correctly by a registered nurse which resulted in Resident #1 being incorrectly assessed by the licensed vocational nurse/treatment nurse. The facility failed to ensure the TREATMENT NURSE received training and monitoring to ensure residents wounds were treated within professional guidelines. These failures could result in residents receiving inadequate skin care for wounds, deterioration of wounds and decreased quality of life. Findings included: Review of Resident #1's face sheet dated 11/03/2022 revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of chronic kidney disease, high blood pressure, rheumatoid arthritis, morbid obesity, major depressive disorder and atrial fibrillation (irregular heartbeat that can cause blood clots). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 13 to indicate mildly impaired cognition. Resident #1 was noted to require total assistance by two or more staff members for bed mobility. Resident #1 was incontinent of bowel and bladder. Resident #1 was not noted to have any current skin issues and required a pressure relieving device on her bed. Review of Resident #1's care plan dated 11/02/2022 revealed Resident #1 had a stage 3 to left posterior thigh. Interventions included administer medications as ordered, administer treatments as ordered and monitor for effectiveness, follow facilities policies/procedures for skin breakdown and if the resident refuses treatment confer with the resident, IDT, and family to determine why and try alternative methods to gain compliance. Review of Resident #1's physician orders dated 10/26/2022 revealed Resident #1 was ordered wound treatment for Stage 3 pressure ulcer for left posterior thigh, cleanse with normal saline, gently pat dry, calcium alginate AG+, and cover with silicone super-absorbent dressing QD and PRN until resolved as needed for wound care. Review of Resident #1 wound assessment dated [DATE] revealed Resident #1 had a stage 3 pressure ulcer on left thigh (posterior) that was in-house acquired with measurements of 20.0 cm by 18.0 cm with a total area of 360.0 cm and no depth was noted. In an interview on 11/02/2022 at 12:23 PM, ADON A stated Resident #1 had excoriation (skin breakdown due to scratching or picking). on left buttock and thigh as Resident #1 kept scratching it causing open areas. ADON A stated it was first noted on 10/11/2022 and the TREATMENT NURSE likely staged it as a stage 3 pressure ulcer due to the open area caused by the scratching. ADON A stated there was not an open area caused by pressure. ADON A stated the TREATMENT NURSE should not have identified the excoriation as a stage 3 pressure ulcer. Interview on 11/02/2022 at 1:15 PM, Resident #1 stated she had redness on her left thigh on the back of it caused by being wet from brief and the pad underneath not being changed. Resident #1 stated there were times she did not realize she was wet or that the pad was wet and her skin became irritated by the wetness over extended amounts of time. Resident #1 stated sometime the facility was short staffed and it took awhile for staff to get to her to change her wet brief. Resident #1 stated the staff do the best they can and put barrier cream after each change of her brief. Interview on 11/03/2022 at 3:00 PM DON stated the Treatment Nurse was not educated properly on staging wounds. DON stated a couple of the residents were staged as worse than they actually were. DON stated the Treatment Nurse was an LVN with a moderate amount of experience prior to taking this position here as the Treatement Nurse. Observation on 11/02/2022 at 3:10 PM, revealed Resident #1 had a large area of reddened or excoriated skin to her left buttock. The area was 8 x 12 inches long and wide. Two small 0.5 cm areas of open skin were seen to the left buttock. Resident #1's skin had a large area of reddened skin, inflamed looking. She had small skin tears which appeared to be the result of the skin break down. IFollow-up interview on 11/02/2022 at 3:10 PM, DON stated Resident #1's skin had almost healed over and was being treated with barrier cream. DON stated not all the aides were putting on the barrier cream every brief change and Resident #1 skin had reddened again. Follow-up interview on 11/06/2022 at 10:20 AM, DON stated the facility had recognized in October 2022 that the Treatment Nurse needed more training and sent him to another facility to work with a tenured treatment nurse. DON stated there was not another nurse or RN verifying the staged wounds by the Treatment Nurse. DON stated in the October QAPI (Quality Assurance and Performance Improvement) meeting she realized along with the ADON that there was an increase in facility acquired pressure ulcers and planned for training of the Treatment Nurse and evaluation of the current wounds to ensure the information was correct. DON stated they had not completed the full evaluation of all wounds. DON stated there had been staffing issues and when needed the ADON assisted with coverage to ensure residents' needs were met. Interview on 11/06/2022 at 11:00 AM, Treatment Nurse stated he had not had training for staging of wounds or wound care except what he received in nursing school. Treatment Nurse stated he trained at another facility this past week on 11/01/2022 - 11/02/2022. Treatment Nurse stated he realized the assessments needed to be more accurate in that if a new wound or skin issue was discovered it should be on the skin assessment and then wound assessments and physician orders should match the current skin issue. Treatment Nurse stated Resident #1 was incorrectly staged to a stage 3 pressure ulcer due to the open areas caused by her scratching. Treatment Nurse stated the red area was excoriated skin and not a pressure ulcer. Treatment Nurse stated Resident #1 continued to be on the wound care protocol. Review of Resident #1's Total Skin Assessments from 10/10/2022 - 11/01/2022 revealed Resident #1 had no new skin issues. Review of Resident #1's Nursing Progress Note dated 10/10/2022 at 10:35 AM revealed CNA reported resident having an open area to buttock; area is approx. 25cm length by 20cm width presenting as DTI with masceration (deep tissue injury with skin softening). Area does have an open area with slight eschar and will be classified as a Stage 3 pressure ulcer to left posterior thigh. very scant drainage noted; Cleanse with normal saline, gently pat dry, apply anacept (antiseptic) place collagen sheets and cover with hydrocolloid dressing to area QD & PRN until resolved. Review of Resident #1's Wound assessment dated [DATE] revealed Resident #1 had an in-house acquired stage 3 pressure ulcer on her left rear thigh. The measurements were 25.0 cm x 20 cm with a total area of 500 cm squared. No depth was documented. Review of Resident #1's Wound assessment dated [DATE] revealed Resident #1 had an in-house acquired stage 3 pressure ulcer on her left rear thigh. The measurements were 25.0 cm x 20 cm with a total area of 500 cm squared. No depth was documented. Review of Resident #1's Wound assessment dated [DATE] revealed Resident #1 had an in-house acquired stage 3 pressure ulcer on her left rear thigh. The measurements were 20.0 cm x 18 cm with a total area of 360 cm squared. No depth was documented. Review of Resident #1's physician orders dated 10/11/2022 revealed Resident #1 was ordered Arginaid (supplement with amino acids to promote wound healing) two times per day for wound care protocol with instructions for one packet mixed in 4-6 oz of water. Review of Resident #1's physician orders dated 10/11/2022 revealed Resident #1 was ordered a liquid protein supplement 30 cc two times per day for wound care protocol. Review of Resident #1's physician orders dated 10/11/2022 revealed Resident #1 was ordered a lab for measurement of Resident #1's pre-albumin (pre-albumin levels indicate protein levels in the body needed for wound healing). Review of facility Wound Care Protocol dated 05/20/2022 revealed residents with wounds were supplemented with multivitamins and arginaid if stage 2, 3, or 4 pressure ulcer. The residents prealbumin would be checked and the RD would be notified for assessment of resident's protein needs. Review of TREATMENT NURSE'S Competency Check-off dated 07/07/2022 revealed TREATMENT NURSE demonstrated the competencies necessary to measure the wound correctly, stages wound following NPIAP (National Pressure Injury Advisory Panel) guidelines, .and document treatment in the EMR.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 2 Medication carts and 1 treatment cart reviewed for medication and treatment storage. The facility failed to ensure medication carts were locked and under direct observation of authorized staff in an area where residents could access it. This failure could place residents at risk for harm and possible distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber such as drug diversion. The findings include: 1. During an observation on 6/20/2022 at 11:16 a.m., LVN A failed to lock her medication cart during a medication administration in hallway 100. LVN A walked away from her medication cart without pressing the locking function of the cart, it was further observed and confirmed that the medication cart's drawer can be pulled open to access medications within the cart. The medication cart drawers faced the hallway and were accessible to individuals present in hallway 100. The medication cart was not under direct observation of authorized staff. During an interview on 6/20/2022 at 11:19 a.m., LVN A noticed her unlocked medication cart and stated, That was my fault., LVN A then proceeded to lock her medication cart. LVN A stated it was policy and procedure to keep all medication carts locked when unattended. LVN A demonstrated prescribed narcotics were locked in a separate drawer that needed a separate key. LVN A stated the risks associated with not properly securing medication care were residents may obtain medications that were not theirs and may take it, staff may also take medications as well . LVN A stated that she had forgotten to lock her cart as she walked away to administered medications. 2. During an observation on 6/20/2022 at 2:10 p.m., an unattended medication cart was located near the DON's office, with its drawers facing the door. Further observation revealed the medication cart was unlocked. The DON and CMA B exited out the office and they both observed the unlocked medication cart. CMA B proceeded to lock the medication cart. During an interview on 6/20/2022 at 2:22 p.m., CMA B stated she had to meet with the DON in her office, and she placed her cart near the office door. CMA B stated she did not lock the medication cart. CMA B stated that she had just stepped away from the medication cart because she had to meet with the DON, she stepped away from the cart without confirming the cart was locked by pushing the locking mechanism. CMA B stated it was policy to keep all medication carts locked and secured when unattended. She stated some risks associated with an unlocked medication cart were residents may take unprescribed medications and it could cause adverse reactions. 3. During an observation on 6/20/2022 at 2:12 p.m., while walking towards the conference room with the DON an observation of an unlocked and unattended treatment cart in hallway 100 was confirmed. The treatment cart's drawer was facing the hallway. The DON stated the treatment cart was being used by RN C . The DON proceeded to lock the treatment cart. During an interview with the DON on 6/20/2022 at 2:15 p.m., the DON stated all medication carts and treatment carts should be secured and always locked. The DON stated the risks associated with unlocked medication carts were residents may take medications that were not prescribed and have adverse reactions to the medications. The DON stated some risks associated with an unlocked treatment cart were residents may take items inside the cart, such as gauzes and antiseptics, and ingest items that could cause harm to residents. During an interview on 6/20/2022 at 2:38 p.m., RN C stated it was policy and procedure to lock and secure medication carts and treatment carts, and to lock and secure carts whenever they were unattended and/or when your back was turned away from the cart. RN C stated there were potentially harmful items in treatment carts as residents may ingest items that were placed in the cart's drawers. RN C stated that she had walked away from her cart and failed to confirm if she locked her cart. During an interview on 6/20/2022 at 2:45 p.m., the ADM stated that it was policy that medication carts were always locked and secured when unattended. Risks associated with unsecured and unlocked medication carts were residents may take unprescribed medications that could cause harm and injury to residents. Record review of the facility's Medication Cart, Administration of Drugs Policy, revealed .16. If the cart is left at any time during medication pass due to an emergency, it must be locked.

42566 45937 Based on observation, interview, and record review the facility failed to use appropriate alternatives prior to installing a side or bed rails, assess the resident for risk of entrapment, review the risk and benefits, and obtain informed consent prior to installation for 20 of 32 residents (Residents #4, #13, #15, #24, #34, #37, #38, #39, #41, #49, #51, #54, #57, #58, #77, #80, #99, #110, #119, and #126) reviewed for bedrails. The facility failed to assess and get signed consents for Residents #4, #13, #15, #24, #34, #37, #38, #39, #41, #49, #51, #54, #57, #58, #77, #80, #99, #110, #119, and #126 prior to installing bed rails. This deficient practice could affect residents who utilized bed rails by placing them at risk for unintended entrapment of the head, neck, or limbs, restraints, and injuries. The findings include: Record review of Resident #4's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of urinary tract infection. Record review of Resident #4's quarterly MDS dated [DATE] revealed no BIMS summary score. Record review of Resident #4's physician orders dated 2/11/2022 revealed the order, Safety Devices-Side Rails= May have half or quarter rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #4's care plan revealed a focus area initiated on 12/09/2021 that states, At risk for injury/immobility due to need for quarter or half side rails to assist with turning and repositioning. Record review of Resident #4's consents revealed no informed consent on file for the use of bedrails. Record review of Resident #4's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/1/2022 at 3:05 p.m., revealed Resident #4 was asleep in her bed with 1/4 inch metal side rails up on both sides of the head of the bed. Record review of Resident #13's clinical face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of repeated falls, muscle weakness, fracture of upper end of right humerus, and dementia. Record review of Resident #13's quarterly MDS dated [DATE] listed her with a BIMS of 11 indicating a mild cognitive impairment. Record review of Resident #13's physician orders reflected no orders for the use of side rails. Record review of Resident #13's Care Plan revealed a focus area initiated on 8/2/2021 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #13's consents reflected no bed rail consents. Record review of Resident #13's assessments reflected no assessment for entrapment related to side rails. Observation and interview on 5/1/2022 at 8:34 a.m., revealed Resident #13's bed had metal quarter rails at the head of the bed. Resident #13was sitting on the side of her bed, she stated she did not use her side rails and had never been injured or trapped by them. Record review of Resident #15's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of fracture of left femur, chronic kidney disease, muscle weakness, senile degeneration of the brain. Record review of Resident #15's quarterly MDS dated [DATE] listed him with a BIMS of 3, indicating severe cognitive impairment. Record review of Resident #15's physician orders dated 1/13/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #15's Care Plan revealed a focus area initiated on 12/7/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #15's Assessments revealed no risk assessment completed prior to instillation. Record review of Resident #15's Consents revealed no informed consent on file for the use of bedrails. During an observation on 5/1/2022 at 1:35 p.m., Resident #15 was asleep in his bed with 1/4 inch metal side rails up on both sides of the head of the bed. Record review of Resident #34's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes, low blood pressure, acute kidney failure, epilepsy, morbid obesity, depression, muscle weakness, heart disease, cognitive communication deficit. Record review of Resident #34's quarterly MDS dated [DATE] listed her with a BIMS of 4, indicating severe cognitive impairment. Record review of Resident #34's physician orders dated 6/14/2021 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #34's Care Plan revealed a focus area initiated on 12/7/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #34's consents revealed a Bed Rail Consent signed on 9/18/2019. Record review of assessments revealed there was not a risk assessment obtained prior to instillation of the bed rails. During an observation on 5/1/2022 at 8:45 a.m., Resident #34 was asleep in her bed with 1/4 inch metal side rails up on both sides of the head of the bed. Record review of Resident #37's clinical face sheet revealed a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction, encephalopathy, lack of coordination, abnormal posture, chronic kidney disease, acquired absence of right leg above knee, and acquired absence of left leg above knee. During an interview on 5/3/2022 at 12:27 p.m., Resident #37 stated that he has no problem with the rails, they can put them down or up, it does not matter. Record review of Resident #37's quarterly MDS dated [DATE] revealed a BIMS of 15, indicating an intact cognitive response. Record review of Resident #37's physician orders dated 7/19/2021 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #37's care plan revealed a focus area initiated 3/7/2019 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #37's consents revealed a Bed Rail Plan and Informed Consent dated 9/18/2019. Record review of Resident #37's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/1/2022 at 3:02 p.m., revealed Resident #37 was laying on his bed awake with 1/4 inch metal side rails up on both sides of the head of the bed. Record review of Resident #38's clinical face sheet revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses of Huntington's disease, reduced mobility, lack of coordination, auditory hallucinations, Parkinson's disease, psychotic disorder, mood disorders, history of falling, MDD, anxiety, unspecified convulsions, and cognitive communication deficit. Record review of Resident #38's annual MDS dated [DATE] revealed a BIMS of 04, indicating a severe cognitive impact. Record review of Resident #38's physician orders dated 10/21/2020 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #38's care plan revealed a focus area initiated on 9/17/19 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #38's consents revealed a Bed Rail Plan and Informed Consent dated 9/18/2019. Record review of Resident #38's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/1/2022 at 3:03 p.m., revealed Resident #38 was asleep in her bed with 1/4 inch metal side rails up on both sides of the head of the bed. Record review of Resident #39's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia, epilepsy, depression, morbid obesity, chronic pain, high blood pressure. Record review of Resident #39's quarterly MDS dated [DATE] listed her with a BIMS of 14, indicating she is cognitively intact. Record review of Resident #39's physician orders dated 12/9/2020 revealed an order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #39's Care Plan revealed no mention of the bed rails. Record review of Resident #39's consents revealed a Bed Rail Consent signed on 9/18/2019. There is not a risk assessment obtained prior to instillation of the bed rails. During an observation and interview on 5/1/2022 at 1:32 p.m., Resident #39 was lying in her bed awake with 1/4 inch metal side rails up on both sides of the head of the bed. Resident #39 stated she liked having the rails up on the bed, stated that they help keep her in the bed and that she utilizes them to assist her to lift herself up in the bed. She denies any injuries from the rails. Record review of Resident #41's face sheet revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses of MDD, acute kidney failure, muscle weakness, lack of coordination, cognitive communication deficit, and history of falling. Record review of Resident #41's quarterly MDS dated [DATE] revealed a vision of 4, indicating severely impaired, and a BIMS of 03, indicating severe cognitive impact. Record review of Resident #41's physician orders dated 12/8/2020 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #41's care plan revealed a focus area initiated on 9/14/2020 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #41's consents revealed no informed consent on file for the use of bedrails. Record review of Resident #41's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/3/2022 at 12:03 p.m. revealed Resident #41 was not in her room, further observation reveals 1/4 inch metal side rails up on both sides of the head of the bed. Record review of Resident #49's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of muscle weakness, cognitive communication deficit, difficulty swallowing, age-related physical debility. Record review of Resident #49's significant change MDS dated [DATE] listed him with a BIMS of 2, indicating severe cognitive impairment. Record review of Resident #49's physician orders dated 12/7/2020 revealed an order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #49's Care Plan revealed a focus area initiated on 12/7/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #49's consents and assessments did not reveal a consent for the Bed Rails and no risk assessment obtained prior to instillation. During an observation on 5/2/2022 at 8:45 a.m. revealed Resident #49 was asleep in his bed with 1/4 inch metal side rails up on both sides of the head of the bed. Record review of Resident #51's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of paraplegia, high blood pressure, bipolar disorder, depression, multiple sclerosis, obesity. Record review of Resident #51's quarterly assessment dated [DATE] listed him with a BIMS of 14 indicating he is cognitively intact. Record review of Resident #51's physician orders dated 12/15/2020 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #51's Care Plan revealed a focus area initiated on 9/23/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #51's consents revealed a Bed Rail Consent signed on 9/18/2019. There is not a risk assessment obtained prior to instillation of the bed rails. During an observation and interview on 5/1/2022 at 2:06 p.m., Resident #51 was sitting up in his bed with 1/4 inch metal side rails up on both sides of the head of the bed. Resident #51 stated he has lived at the facility for almost 6 years and likes the rails on his bed and has not obtained any injury on the rails. Record review of Resident #54's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of heart failure, high blood pressure, end-stage renal disease, diabetes, liver disease, dementia, bipolar disease. Record review of Resident #54's quarterly assessment dated [DATE] listed him with a BIMS of 14 indicating he is cognitively intact. Record review of Resident #54's physician orders dated 10/28/2021 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #54's Care Plan revealed a focus area initiated on 11/1/2021 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #54's consents and assessments did not reveal a consent for the Bed Rails and no risk assessment obtained prior to instillation. During an observation and interview on 5/1/2022 at 3:19 p.m., Resident #54 is sitting up in his bed with 1/4 inch metal side rails up on both sides of the head of the bed. Resident #54 stated that he uses the rails to help position himself in the bed and denies that he has obtained any injury from the rails. Record review of Resident #56's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified intellectual disabilities, affective disorder, bipolar disorder, convulsions, obstructive sleep apnea history of falling. Record review of Resident #56's significant change MDS dated [DATE] listed her with a BIMS of 3 indicating a severe cognitive impairment. Record review of Resident #56's physician orders dated 4/1/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #56's Care Plan revealed a focus area initiated on 11/15/2021 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #56's consents reflected no bed rail consents. Record review of Resident #56's assessments reflected no assessment for entrapment related to side rails. Observation and interview on 5/1/2022 at 8:34 a.m. revealed that Resident #56's bed had plastic quarter rails at the head of the bed. Resident #56 stated she used her side rails (but could not say exactly how) and has never been injured by or trapped by them. Record review of Resident #57's face sheet revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses of lack of coordination, abnormal posture, repeated falls, muscle weakness, MDD, and dementia. Record review of Resident #57's quarterly MDS dated [DATE] revealed no BIMS summary score. Record review of Resident #57's physician orders dated 6/29/2021 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #57's care plan revealed a focus area initiated on 3/19/2020 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #57's consents revealed a Bed Rail Plan and Informed Consent dated 9/17/2019. Record review of Resident #57's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/3/2022 at 12:13 p.m. revealed Resident #57 was not in her room, further observation reveals 1/4 inch metal side rails up on both sides of the head of the bed. Record review of Resident #77's clinical face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, unsteadiness on feet, muscle weakness, lack of coordination, cerebral infarction, seizures, anxiety disorder, displaced fracture of left humerus neck and shaft of left clavicle. Record review of Resident #77's 5-Day MDS dated [DATE] listed her with a BIMS of 9, indicating a moderate cognitive impairment. Record review of Resident #77's physician orders dated 2/21/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #77's Care Plan revealed a focus area initiated on 3/10/2022 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #77's consents reflected no bed rail consents. Record review of Resident #77's assessments reflected no assessment for entrapment related to side rails. Observation and interview on 5/1/2022 at 8:34 a.m., revealed that Resident #77's bed had plastic quarter rails at the head of the bed. Resident #77, who was lying in bed, stated she used her side rails to pull herself up and has never been injured by or trapped by them. Record review of Resident #58's clinical face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of repeated falls, unsteadiness on feet, stiffness of right and left shoulders, poly osteoarthritis, dementia, lack of coordination, abnormalities of gate and mobility, muscle weakness, and cervicalgia. Record review of Resident #58's quarterly MDS dated [DATE] listed him with a BIMS of 11 indicating a mild cognitive impairment. Record review of Resident #58's physician orders reflected no orders for the use of side rails. Record review of Resident #58's Care Plan revealed a focus area initiated on 3/23/2020 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #58's consents revealed a Bed Rail Consent signed on 6/6/2019. Record review of Resident #58's assessments reflected no assessment for entrapment related to side rails. Observation and interview on 5/1/2022 at 8:41 a.m., revealed Resident #58's bed had metal quarter rails at the head of the bed. Resident #58, who was lying in bed, stated he used his side rails to reposition himself and has never been injured by or trapped by them. Record review of Resident #80's clinical face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebrovascular disease, cerebral infarction, aphasia, dysphagia, and mild cognitive impairment. Record review of Resident #80's 5-Day MDS dated [DATE] listed him with a BIMS of 4 indicating a severe cognitive impairment. Record review of Resident #80's physician orders dated 1/6/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #80's Care Plan revealed a focus area initiated on 1/6/2022 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #80's consents reflected no bed rail consents. Record review of Resident #80's assessments reflected no assessment for entrapment related to side rails. Observation on 5/1/2022 at 8:34 a.m., revealed that Resident #80's bed had plastic quarter rails at the head of the bed. Resident #80 did not respond when addressed. Record review of Resident #99's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of bone infection, unsteadiness on feet, liver cancer, heart disease, type 2 diabetes, high blood pressure, chronic pain. Record review of Resident #99's significant change MDS dated [DATE] listed him with a BIMS of 14 indicating he is cognitively intact. Record review of Resident #99's physician orders dated 4/27/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #99's Care Plan revealed a focus area initiated on 9/26/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #99's consents revealed a Bed Rail Consent signed on 9/18/2019. There is not a risk assessment obtained prior to instillation of the bed rails. During an observation and interview on 5/3/2022 at 1:00 p.m., Resident #99 was lying in bed with 1/4 inch plastic bed rails up on both sides of the head of the bed. Resident #99 stated that he does not like the rails on his bed and is not sure why they have them there. He denies ever injuring himself on the rails. Record review of Resident #110's clinical face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of difficulty swallowing, high blood pressure, muscle weakness, chronic kidney disease, cognitive communication deficit. During an observation on 5/1/2022 at 9:00 a.m., Resident #110 was asleep in bed with 1/4 inch metal side rails up on both sides of the head of the bed. Record review of Resident #110's quarterly MDS dated [DATE] listed her with a BIMS of 6, indicating she is severely cognitively impaired. Record review of Resident #110's physician orders dated 12/11/2020 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #110's Care Plan revealed a focus area initiated on 9/17/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #110's consents revealed a Bed Rail Consent signed on 9/18/2019. There is not a risk assessment obtained prior to instillation of the bed rails. Record review of Resident #119's face sheet revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses of orthopedic aftercare, fracture right femur, transient paralysis, MDD, anxiety, spinal stenosis, osteoporosis, cognitive communication deficit, unspecific fracture of sacrum, complication of internal orthopedic prosthetic devices, repeated falls, atrophy, disorder of bone, and lack of coordination. Record review of Resident #119's quarterly MDS dated [DATE] revealed a BIMS of 08, indicating a moderate cognitive impairment. Record review of Resident #119's physician orders dated 4/13/2022 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #119's care plan revealed a focus area initiated on 5/15/2020 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #119's consents revealed no informed consent on file for the use of bedrails. Record review of Resident #119's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/3/2022 at 12:38 p.m., revealed Resident #119 with 1/4 inch metal side rails up on both sides of the head of her bed. Record review of Resident #126's face sheet revealed a [AGE] year-old-male admitted on [DATE] with a diagnoses of muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, and history of falling. During an interview on 5/3/2022 at 12:21 p.m., Resident #126 stated that he does not recall being tangled in his rails to cause any accidents. He stated that the rails no not bother him as he, does not usually use them for any support. Record review of Resident #126's quarterly MDS dated [DATE] revealed a BIMS of 11, indicating a moderate cognitive impairment. Record review of Resident #126's physician orders dated 7/8/2021 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #126's care plan revealed a focus area initiated on 7/8/2021 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #126's consents revealed no informed consent on file for the use of bedrails. Record review of Resident #126's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/3/2022 at 12:21 p.m., revealed Resident #126's 1/4 inch metal side rails up on both sides of the head of her bed. During an interview on 5/3/2022 at 1:42 p.m., DON stated that there are no entrapment assessments completed at the facility although she states based on corporate perspective, everyone is at a risk for entrapment, although she does state that not all residents have the same risks of entrapment, residents have specific needs and levels of care and for dangers. She does confirm that all residents should be individually assessed for entrapment. In the past they have had separate consents for bedrails, but now they are included in the admission packets. States that bedrail checks related to installation and maintenance are completed by [NAME] Branch. She states there are not any annual assessments completed for resident risk of entrapment, if there were related assessment to that perspective Therapy would make that type of suggestions for any gradual reduction of use or continued use. She states that nursing and therapy work together provide the best equipment to meet resident needs. She states that if the resident request to remove the bedrails, facility will follow steps to have them removed. During an interview on 5/3/2022 at 2:10 p.m., MAINT stated that checks on bedrails are done at a Quarterly schedule. He states they are checked for spacing and dimensions of the rails, if they are securely fastened, securely locked, connected, and tightened to bed. He does not recall any significant issues in the installment or any wear and tear on bedrails. Stated some risks for not assuring proper installation and maintenance on rails that it can cause entrapment, rails may be unsafe or loose, the resident may fall out the bed or be more at risks for falls. During an interview on 5/3/2022 at 2:31 p.m., ADM stated there are no resident centered assessments for entrapment completed. He states that there is no standard monitoring for standing orders for bed rail use. He adds that nursing considers that all residents are at a risk high for entrapment, so they do not have anyone monitoring it, he considers it like a standing order for the use of bedrails for falls. He states that therapy makes recommendation for bedrail use. States there is not difference in the metal or plastic bedrails, they are standard supplies that are given. He stated risks associated for not having resident assessed for entrapment routinely are, serious injuries to minor injuries. Resident can get stuck on rails, can get his or her arm or any items stuck and can also result in death in some cases. Record review of Bed Inspection Policy and Procedure updated 10/2002 revealed that, The Maintenance Supervisor will do a quarterly bed inspection of all bed frames, mattress, and bed rails, if any, to identify areas of possible entrapment. And that, A risk assessment has been completed for the person, and a determination made that bed rails are required for safety. Record review of the Nursing Facility Admission and Financial Agreement, Rev-Mar-2022, revealed that, This facility utilizes bed rails in certain situations upon Resident/Resident Representative consent. The benefits of bed rails include increased independence on mobility, better positioning in bed and increased sense of security. The inherent risks include the potential for injury resulting from, among other, entrapment or impingement which in the most extreme cases could result in fatality. Further record review Nursing Facility Admission and Financial Agreement-section Nursing admission/readmission Assessment V-2.0, Area O reveals Identified risk areas/intervention implemented.

Based on observations, interviews and record review the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and physician orders [REDACTED].#1) reviewed for skin assessments. The facility failed to effectively communicate physician orders [REDACTED].#1while she was wearing a temporary splint. Resident #1 developed an ulcer to her right foot that became infected. Resident #1's right lower leg was amputated on 1/28/19. This was determined to be past non-compliance at an immediate jeopardy level due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice could place other residents in need of skin assessments at risk of delayed care causing potential discomfort, pain and/or injury. Findings included: Review of Resident #1's face sheet revealed a [AGE] year old female who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's PPS 30 day MDS dated [DATE] revealed a BIMs score of 5 indicating severe cognitive impairment. Review of Resident #1's functional status revealed she was non-ambulatory and required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toileting and personal hygiene. Observation on 1/18/19 at 9:30am, in Resident #1's room, revealed her bandage on her right foot was being changed by the facility Wound Treatment Nurse. Resident #1 was noted to have a wound approximately 3 inches by 1.5 inches with a slightly red border and the entirety of the wound covered in a white/beige slough appearing substance. In addition, there were 3 dime sized wounds which were outside the borders of the large wound which had a firm dark brown scab over each. Resident #1 was noted to tolerate the dressing change without expressions of pain. Review of Resident #1's progress notes revealed the following - 12/14/18 at 9:45am: Nurse was walking by room when noted resident to be laying on the floor by the bed on fall mat. Resident unable to determine what happened. No injuries noted. X3 assist off floor. - 12/14/18 at 9:05pm: Resident of post fall day 2, extensive bruising to right ankle, resident says there is no pain to ankle. - 12/16/18 at 9:45am: Resident has been very combative today. When assistance was being provided resident kicked, punched, and tried to bite this nurse. While trying to give pain medication after fall resident knocked the syringe out of my hand. Resident has put herself on the floor twice this am. Has abrasion to right knee on the inside and outside of the knee. Has scratch to left inner ankle from her wheelchair wheel. Will continue to monitor - 12/16/18 at 5:43pm: Resident found on floor next to bed, s/t (skintear) noted to left elbow approx 1cm x 1cm; resident was found laying prone with left arm under body; no obvious signs of distress or pain noted, resident was reported to be agitated earlier in the day, however has been calm and non combative since 1pm - 12/17/18 at 3:41pm: New orders received for CXR with right rib series d/t increase pain after falls yesterday - 12/18/18 at 8:46pm: X-ray findings: (R) ankle: Impression: fibular fracture, study otherwise unremarkable . - 12/19/18 at 10:42am: (PA Name) notified. New orders to refer to orthopedic today. If unable too get in with ortho today send to ER. Family notified. - 12/19/18 at 12:32pm: Referral with xray report sent to (doctor's name) orthopedic office. Per (doctor) fracture can be stabilized with posterior splint wrapped with ace bandaged or immobilizer boot until appointment next Wednesday on 12/26/18 with daily skin checks. (PA) notified. New orders to stabilize right ankle as advised by (Orthopedist) with daily skin checks. Continued review of Resident #1's progress notes revealed no mention of the splint and/or fracture to right foot until; - 12/23/18 at 3:33pm: Resident is alert and oriented to self. Staff anticipates all residents needs as she cannot voice them. Resident is tube fed. Tube is patent and intact. Incontinent of bladder and bowel. Staff provide assistance after each episode. Staff propels resident in her wheelchair. Resident has a brace on right foot. Limb is injured from previous fall Review of progress notes revealed no mention of the follow up appointment with orthopedist that was supposed to occur on 12/26/18. - 12/27/18 at 3:09pm: Alert and oriented to self. Complained of pain in her right leg and foot. Resident is non verbal . - 12/29/18 at 10:52am: Resident is alert and oriented to self. Denies pain at this time. No [MEDICAL CONDITION] noted. LCTA (lungs clear to auscultation) respirations are even and unlabored. BSX 4 abdomen soft and tender. Has Peg tube for feedings. No residual noted this am. Resident showed signs of pain this am and was anxious. Resident was given [MEDICATION NAME] and [MEDICATION NAME] with her morning medications. Incontinent of bladder and bowel. Staff provides assistance after each episode. Staff assist X2 for all her transfers. Has soft cast to right ankle due to ankle being fractured . Next note r/t right foot/leg; - 1/6/19 at 2:02pm: Noted scab on shin above splint to R foot. New order to cleanse w/NS, pat dry and apply small dressing daily. - 1/7/19 at 3:29pm: Notified by (Orthopedic doctor) office resident had wound noted to dorsal right foot under temporary splint. (Orthopedist) office sent resident to (local) wound care. Wound care sending to (Vascular Surgeon name) for evaluation today. Orders for Santyl to wound bed daily, wrap with gauze and secure in air cast given by wound clinic. Unknown at the time of this note what (Vascular Surgeon's) recommendations are. Will follow up when known. - 1/8/19 at 2:44pm: This nurse followed up with (Vascular Surgeon's) office. (Name) MA reported that (Surgeon) has spoken with the family. MA also reported that (Surgeon) is planning for AKA (Above Knee Amputation) this week but date has not been set at this time. - 1/9/19 at 8:19am: Pt resting quietly in bed, boot and dressing to RLE in place. Dressing c/d/I, removed old dressing, no drainage noted at this time. Wound to right dorsal side of foot aprox 5cm in width and 10 cm in length, thick white slough covers wound bed, some redness noted surrounding wound edges with granulation tissue to areas. Wound to right mid shin appeared to be healing well, no drainage noted, area on right mid calf has some redness without drainage. Cleansed area with NS, patted dry, applied non-stick [MEDICATION NAME] pads, wrapped with kerlix, reapplied boot without difficulties. - 1/9/19 at 3:01pm: Resident is day 1/10 antibiotics for [MEDICAL CONDITION] to RLE. No adverse reactions noted at this time. Medication initial dosed this shift. Will continue to monitor for changes. - 1/9/19 at 3:06pm: Per wound care they have diagnosed the 4 ulcers to right lower ex as arterial ulcers. - 1/9/19 at 3:14pm: On drsg change today (PA name) came to assess wound with this nurse and Corp Nurse (name) RN. He was able to find tibial pulse cap refill good and I noted the redness wound the dorsal foot wound was less than on the drssg change yesterday. Slough 100% to dorsal foot wound right shin wound right superior and inferior lateral arterial wounds. Faint odor noted on removal of dresg no odor after cleanse noted. Minimal purulent drainage. Warmth noted on palpation. Vascular did not order an ultrasound of Doppler (PA name) ordered doppler and ultrasound to right lower ex. Awaiting culture results at this time. - 1/9/19 at 3:30pm: clarification doppler will be performed today no ultrasound as they are duplicate study. - 1/10/19 at 9:22am: RLE Doppler impression indicates diminished distal circulation beginning below the knee; requires correlation with CT for it's accuracy and reproducibility. (PA name) notified. No new orders received. - 1/10/19 at 10:41am: Refer to (neighboring town) Wound Care and (town name) Vascular to evaluate and treat right lower extremity. - 1/10/19 at 4:14pm: This nurse attended resident's appointment with (doctors name) at (town name) Heart and Vascular. Vitals signs taken, and EKG was done. (Doctor's name) removed air cast and dressing too assess RLE. Measurements and pictures were taken. Wound redressed. Air cast inplace. (Doctor's name) plan of care is an angiogram to fully assess circulation and determine how much circulation can be reestablished to RLE. (Doctor's name) recommends continuing current wound treatments but proposing wound care referral until angiogram. Resident transferred back to facility and transferred to bed by staff with call light within reach Review of Provider Investigation Report dated 1/11/19 revealed that the facility reported the following allegation on 1/7/19 at 3:42pm; On (MONTH) 16, (YEAR), Resident had a fall. Resident did not complain of pain or show evidence of injury to the right foot on the date of the fall or the following day. On (MONTH) 18, (YEAR) bruising to her right foot was observed and an xray was ordered. The results of that xray indicated an acute comminuted spiral [MEDICAL CONDITION] fibula. Resident's attending physician was notified. On (MONTH) 19th, order was given to refer patient to orthopedic surgeon on that day. If appointment was unattainable on that day, order was given to send patient to ER. When calling orthopedic surgeon's office on 12/19/18, order was given to splint the foot with a posterior splint wrapped in ace wrap or in an immobilizer boot until the next appointment on 12/26/18. PA at facility was notified with these recommendations and new order was given to stabilize the right ankle as advised by orthopedic surgeon along with daily skin checks. This information was documented in the nurse's progress notes by Assistant Director of Nursing but was not transcribed over in the Electronic Medical Record as an order. Splint was applied to residents foot but the daily skin checks order was not put into the EMR for the Treatment Nurse to check resident's skin daily. The appointment scheduled for 12/26/18 with the orthopedic surgeon did not occur and appointment was changed to 1/7/19. At this appointment on 1/7/19, as foot was being evaluated, it was observed that resident had developed a wound to the dorsal right foot under the temporary splint. Review of Resident #1's Skin Assessment Forms during the period of 12/14/18 through 1/6/18 revealed no references to skin being assessed beneath the splint. Review of Resident #1's Orthopedic Clinic Visit Summary, dated 1/7/19, revealed the Orthopedist included the following; Impression: Right ankle lateral malleolus fracture, initial injury. Right dorsal foot ulcer. Right medial ankle ulcer. Plan: The patient cannot give me any helpful information at this time regarding her condition. She has a very serious problem that is potentially limb threatening, given her diabetes, the future of the ankle, and the foot ulcerations. I have immediately recommended evaluation by (Wound Doctor's name) with wound care to see if he feels any conservative treatment could be rendered. The foot ulcerations will clearly be the most complicated aspect of her treatment. The ankle fracture itself can be appropriately treated with boot immobilization and limited weight bearing. If this can be accomplished to allow for appropriate wound care, then certainly from my perspective she does not require casting or surgery for [REDACTED]. Depending on what (Wound Doctors name) thinks today, we may need to the consider this option.(sic) She is immediately placed into clean dressings and transferred to the wound care center today. Review of Resident #1's paperwork from her visit to a Wound Center, dated 1/7/19, revealed she is noted to have four wounds on her right foot. Wound #1 is described as a 7cm long by 4.7cm wide with purulent drainage, with signs and symptoms of an infection and tendon exposure. Wound #2 is described as 1cm long by 0.7 cm wide with a small amount of purulent drainage. Wound #3 is described as 1.5cm long by 1.1 cm wide with a small amount of purulent drainage. Wound #4 is described as 0.7cm long by 0.9 cm wide with a small amount of purulent drainage. The Wound Care Doctor noted Will begin Santyl to all ulcers. Sent directly to (Vascular Surgeon's name) for vascular consult. BK aircast. Attempting to contact family since she is non-communicative. Follow up 1 week depending on (Vascular Surgeon's name) eval. Review of Resident #1's paperwork of assessment from the Vascular Surgeon, undated but noted to be charted on 1/8/19 revealed the physical exam noted her, Right leg with hair loss below the knee, no palpable pulse on the right foot, 15 x 8 cm ulceration anterior right foot. The Surgeon's impression is noted to be, Gangrene of the right foot with right ankle fracture, non-ambulatory, nonverbal, multiple medical comorbidities. The surgeon documented the following plan; This patient is completely non-ambulatory and nonverbal and does not provide any assistance to her caregivers so I do not think it is reasonable to consider revascularization. She is really not a candidate for physical therapy if she were to get a [MEDICAL CONDITION] she is unlikely to ambulate. The safest and best option for her is right above the knee amputation to avoid wound complications because she is not going to ambulate in the future Review of Resident #1's Doppler Evaluation dated 1/9/18 revealed that the impression was, Diminished distal circulation beginning below the knee, obviously this requires correlation with CTA for it's better accuracy and reproducibility. Interview on 1/17/19 at 11:30am and on 1/18/19 at 11:00am with the facility DON revealed she confirmed there had been issues with the facility ADON not ensuring the order for the splint and the daily skin checks were entered into the electronic medical system. In addition, she stated the facility Wound Treatment Nurse should have been checking Resident #1's skin since she had a splint, but that was not done. The DON stated that once they were notified of the injury there was some concern regarding the recommendation of amputation by the Surgeon without vascular studies having been completed. She stated the Facility PA did an assessment and was able to detect a pulse on the right foot and the color and refill was good, and he did not feel like there was Gangrene. The PA ordered a vascular study prior to consideration of amputation. A second opinion was obtained by a Vascular Surgeon in Waco. That Surgeon placed stents and referred the resident back to the original surgeon for amputation. The DON stated there had been some improvement in the wound since that time so they were holding off on making the amputation appointment until the area could be reevaluated. Interview on 1/18/19 at 12:15pm with the facility ADON/LVN A revealed Resident #1 had multiple falls for which she was being monitored. One of the staff noticed some bruising, so we had x-rays done which came back positive for fracture. I called the facility PA; he told me to get her into see the Orthopedist, or if I couldn't get her in then to send her to the emergency room . I called the Orthopedist and he said the area fractured is not an emergency and that Resident #1 didn't need to go to the hospital. He said we could just splint it until an appointment on 12/26/18. The Orthopedist did say to do daily skin checks. I called the facility PA back to tell him what was said, and he gave me the order to go ahead with the splint and the daily skin checks. I charted the note and I thought I put the orders into Point Click Care (PCC). I remember typing in the order, but it wasn't there to be found after all this came to light. I'm not sure what happened but we were new to PCC. I went and told the floor nurse the orders and he wrapped up the ankle. I went and bought the splint then sent a picture of it to the facility PA to make sure it was the right one. It fit over the top of her foot and the wrap held it on. We talked about the fracture during the next morning meeting and at that time I assumed the wound care nurse would take over the daily skin checks. Interview on 1/17/19 at 1:40pm with LVN B revealed she had worked at the facility for 4 years. She reported that all the nurses knew Resident #1 had a fractured ankle and that there was a splint placed on her ankle. LVN B stated that she is a floor nurse and she does the daily skin assessments but she was not aware that there was an order to do so for Resident #1. She stated it is the wound nurse that does the weekly assessments for residents. LVN B stated she thought the splint was intended to stay on until the resident's next appointment with the doctor since there wasn't any orders saying otherwise. Interview on 1/18/19 at 10:32am with CNA C revealed she had worked with Resident #1 and was aware of the splint. She stated that the CNAs were aware she had a fracture, so they were careful to keep that leg straight. CNA C stated that the shower aides would cover the splint area with a bag and tape it prior to giving Resident #1 shower. She stated the CNAs do not ever remove splints unless they are given specific instructions to do so by the nurse. Interview on 1/18/19 at 9:44am with the Wound Treatment Nurse (WTN) revealed the facility does daily skin checks on people who wear braces. She stated this is documented in the treatment MAR and that nurses check too. On the weekends the nurse on the hall does skin checks. She understood that the Resident #1 fell and broke her ankle and they were told to put the splint on it. She stated she did not remove the splint because she did not think that it was removable and there were no orders to do so. The splint was placed on 12/18/18. She further stated, The shower aides do not remove splints; they placed a plastic bag over it. They received an in-service saying that splints are removable and that we can remove them. The other individuals that I listed have braces, not splints. They are not allowed to wear them in bed. I did receive disciplinary actions. I should have investigated it further b/c I am the wound care nurse. But at the time I thought there was no removal of splints. Interview on 1/18/19 at 11:40am with the facility Physician's Assistant (PA) - he stated Resident #1 was admitted after a [MEDICAL CONDITION]. She was uncomfortable for quite a while when she got here. Her [DEVICE] feedings were making her sick to her stomach. She is unable to talk so it is difficult to find out what is wrong. She was frequently pushing herself off her bed in what was probably discomfort related to her tube feedings. She ended up fracturing her fibula with a fall off the bed. Resident is not ambulatory. We called the orthopedist office and they said to put her in splint, non-weight bearing. We missed the first orthopedic appointment. The splint stayed on her foot and no one did skin assessments, so the splint was just there. The PA stated that the Orthopedist discovered Resident #1 had an ulcer under the splint on 1/7/19. He also referred her to a wound surgeon here in town who wanted to amputate her foot. A Surgeon in Waco was sought for a second opinion; he did a bunch of studies such as an angiogram. He was able to get a couple of stents in the veins of her foot but still did not feel that the foot was savable, so he referred her back to the first surgeon that wanted to do the amputation. The PA stated, I do not know whether the first order had daily skin checks. I believe that all the residents on skilled care should be receiving skin assessments. Some splints are not removable but the one she had on was easily removable so there was some type problem there that the facility had with not recognizing that. I'm not sure how it occurs that no one saw her skin for 2 weeks. He further stated this was just a very unusual case. Looking under the splint was overlooked. The surveyor re-entered the facility on 2/7/19. In a follow-up interview on 2/7/19 at 1:55pm with the facility DON she revealed that when the Surveyor was previously at the facility there was a possibility of Resident #1 needing an amputation. The DON reviewed the events that had occurred involving Resident #1. When Resident #1 went to appointment on 1/7/19 to see the Orthopedist, he immediately sent her to the Wound Care Center. On the same day the Wound Care Center sent Resident #1 to the Vascular Surgeon (VS#1). VS #1 was going on vacation but recommended amputation when he returned. Our PA felt this was a big decision and he wanted a second opinion. He also wanted a 2nd opinion because he felt the wound was improving. We ordered an ultrasound and sent Resident #1 to a Waco Vascular Surgeon (VS #2), who reviewed the ultrasound and said he'd go in and do an angiogram to have a closer look, that appointment was on the 10th. He couldn't determine the extent of her vascular disease, so Resident #1 came back to the facility on the 10th then she went for the angiogram on the 15th. After that, VS #2 referred Resident #1 back to VS #1 for the amputation. The leg was amputated on the 1/28/19. Review of VS#1 Clinic Visit Summary dated 1/21/19 revealed the following; Chief Complaint: Gangrene right foot. HPI: This is a [AGE] year-old woman who is essentially non responsive verbally was found to have a right ankle fracture and this was treated with a boot. The patient developed an ulcer on the anterior foot and was referred to podiatry and wound care and then subsequently to me for management. Due to the fact that she is completely non ambulatory and does not assist her caregivers in any way and has no motor function of that leg I recommended above knee amputation. I discussed this with the patient's son at the time and he was amendable. Because this leg was not used in any way I did not feel angiogram was indicated. She was subsequently referred by the nursing home to cardiology for urgent angiogram, and she underwent the procedure by (VS#2's name) in Waco last week. She has not been returned to me for above-the-knee amputation by (VS#2). Her family is here today to discuss the operation. Review of Resident #1's Hospital Records revealed she was hospitalized from [DATE] through 2/4/19. Resident #1 underwent an above the knee amputation of her right leg on 1/28/19. Interview on 2/7/19 at 10:15am with the Facility Medical Director A (MDA), who also participated in Resident #1's care while she was in the hospital after surgery revealed the following: MDA clarified that he was not Resident #1's doctor while she was at the facility but that he the Chief Medical Officer for the local hospital and provided her care after her surgery. He stated there clearly was some care that was not provided appropriately while the resident was at the facility as she wore a splint for a week or two without her skin being checked, but he did not see the wound, he only saw her after the amputation had occurred. Interview on 2/8/19 at 11:37 with the Facility Medical Director B (MDB) revealed he stated that the splint may have brought to light that the resident had severe arterial blood flow issues but he does not believe the ulcer was the cause for the amputation, but it was more so the arterial disease diagnosis. He stated the ulcer was not a pressure ulcer and that it was due to inadequate blood flow to the area. MDB stated that mistakes were made in that the resident wasn't sent to the ER for a fracture, an appointment wasn't kept, and someone wasn't looking under the boot. He stated he is sorry to have to say that mistakes were made. Interview on 2/7/19 at 10:04am with Resident #1's son revealed he is very concerned with the care his mother received while at the facility. He stated she entered the facility on the premise of receiving rehabilitation services and ended up falling within one week of being there and then having her leg amputated. He stated he is not understanding how something like this could happen. He was told it was from the cast she was wearing on her foot but it was a temporary wrap type thing and he wonders shouldn't someone have been looking under the wrap. He stated he only consented to the amputation after 2 different doctors stated that it was needed. Resident #1's son stated that he does not feel that his mother will recover at this point and has moved her to a different facility closer to him. It was determined the above failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 12/19/18 to 1/7/19. An IJ was identified at past non-compliance and the Administrator was notified on 2/8/19 at 2:45 p.m. Review of the facility provided list of actions to correct the non-compliance reflected: 1.On 1/7/19 nursing staff were given an in-service on Reporting procedures, positioning, skin integrity with splints and soft boots skin to be checked every shift. 2. On 1/10/19 Nursing Staff were given an in-service that states if any residents are diagnosed with [REDACTED]. 3. On 1/10/19 nursing staff were given an in-service/training on prevention of medical related devices pressure ulcers. 4. On 11/27/18- 11/30/18 Point Click Care training was provided. Interviews with nursing staff revealed refresher instructions were provided on 1/8/19 and 1/10/19, specifically on how to enter an order into the electronic record. 5. On 1/7/19 the administration provided a Transportation/Medical Appointment Inservice to the transportation drivers that every morning all appointments will be reviewed to make sure none are missed and that they are spaced out to accommodate flexibility in times. If there is a possibility of a medical appointment being missed the Administrator/DON is to be notified immediately so that other arrangements can be made. The in-service notes that failure to comply with the instructions could result in termination. The in-service is signed by the TD who worked on 12/26/18. 6. Confidential Employee Corrective Action Form dated 1/7/19 with the facility ADON revealed she was notified of her failure to enter the order for Resident #1's splint placement and daily skin checks to skin under the soft splint. The form notes that if the ADON's performance and/or conduct does not improve, further disciplinary action could occur up to termination. 7. Confidential Employee Corrective Action Form dated 1/7/19 with the facility WTN revealed she was notified of her failure to assess the skin under Resident #1's soft splint from 12/17/18 through 1/7/19. The form notes that if the WTN's performance and/or conduct does not improve, further disciplinary action could occur up to termination. 8. Review of Resident #1's Care Plan revealed that on 1/8/19 a new focus area was added noting the resident requires assistance with splint due to a fibular fracture. Interventions include for the next 90 days or until no longer needed, an air cast will be applied every morning at 6:00am and removed every night at 8:00pm. Resident #1's skin underneath the device is to be monitored for irritation or breakdown daily. 9. Review of Resident #1's (MONTH) MAR/TAR revealed an area designated for initials of Aircast being applied every morning and every evening since 1/7/19. 10. All residents in the facility were assessed for unidentified skin breakdown on 1/7/19. No new skin issues were identified. 11. As of 2/8/19 there have been no other residents with splints. Skin checks are occurring daily for residents that utilize braces. 12. The facility has implemented daily checks on the progress notes and physician orders [REDACTED]. This surveyor interviewed five CNAs, five LVNs and one RN on 1/17/19 - 2/8/19 and all were knowledgeable of abuse/neglect policies/procedures. The nurses were all aware and had received the in-services regarding daily skin checks for residents wearing splints or braces. The nurses were all aware of how to enter doctors' orders into Point Click Care.