Every finding on record at Legend Healthcare and Rehabilitation - Greenville

Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 3 residents (Resident #1) reviewed for pharmacy services. 1.The facility failed to ensure Resident #1 was administered his tacrolimus (also known by the brand name Prograf, it is a immunosuppressant [type of medicine that lowers or slows down the body's natural immune system] used to help prevent the body from rejecting a transplanted organ) on 5/5/26 and 5/6/26. MA B did not notify LVN A of Resident #1's refusals on 5/5/26 and 5/6/26 so the nurse could attempt administration. 2.The facility failed to ensure Resident #1 was administered his lacosamide (also known by the brand name Vimpat, it is an anticonvulsant [type of medication used to treat/prevent seizures]) on 5/5/26 at 7:30 a.m. The administration was not performed on 5/6/26 at 7:30 a.m. and 7:30 p.m. MA B did not notify LVN A of Resident #1's refusals on 5/5/26 and 5/6/26 at 7:30 a.m. so the nurse could attempt administration. RN F did not attempt to administer the medication on the evening of 5/6/26. 3.The facility failed to ensure Resident #1 was administered his levetiracetam (also known by the brand name Keppra, it is a anticonvulsant [type of medication used to treat/prevent seizures]) on 5/5/26 at 9:00 a.m. MA B did not notify LVN A of Resident #1's refusals on 5/5/26 so the nurse could attempt administration.These failures place residents at risk of preventable medical complications. Findings included: Record review of the Resident[BR2.1] #1's face sheet dated 8/11/26 indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses including liver transplant status, seizures, and Todd's paralysis (a temporary weakness or loss of movement in part or all of the body that happens after an epileptic seizure). Record review of Resident #1's baseline care plan dated 8/2/26 indicated Resident #1 had impaired coping. The care plan interventions included to encourage the use of PRN medication to alleviate symptoms and provide care in a calm and reassuring manner. Record review of Resident #1's care plan revision date 8/7/26 indicated Resident #1 was resistive to care at times including refusals of medications. The care plan interventions included to allow Resident #1 to make decisions about treatment regime, to provide a sense of control. Record review of Resident #1's physician's order summary dated 8/11/26 indicated Resident #1 had the following active physician's orders with a start date of 8/2/26; *Tacrolimus 0.5 mg, give 1 capsule by mouth once a day for immunosuppressant;*Lacosamide 100 mg, give 1 tablet two times a day for seizure disorder; and*Levetiracetam 750 mg, give 2 tablets two times a day for seizure disorder.Record review of Resident #1's physician's order with a start date of 8/3/26 indicated Resident #1 was to receive Reglan (also known by the generic name metoclopramide is a antiemetic [medicine or substance used to stop or prevent nausea and vomiting] 10mg, 1 tablet every 8 hours as needed for nausea and/or vomiting). Record review of the EMAR for Resident #1 for August 2026 revealed the following:*Tacrolimus 0.5 mg, give 1 capsule by mouth once a day for immunosuppressant was refused by Resident #1 on 8/5/26 and 8/6/26- these refusals were documented by MA B; *Tacrolimus 0.5 mg, give 1 capsule by mouth once a day for immunosuppressant was administered to Resident #1 on 8/2/26-8/4/26 as ordered;*Lacosamide 100 mg, give 1 tablet two times a day for seizure disorder was refused by Resident #1 on 8/5/26 and 8/6/26 at 7:30 a.m.- these refusals were documented by MA B;* Lacosamide 100 mg, give 1 tablet two times a day for seizure disorder was administered on 8/2/26-8/4/26 at 7:30a.m. and 7:30 p.m.; * Lacosamide 100 mg, give 1 tablet two times a day for seizure disorder was administered on 8/5/26 at 7:30 p.m.; *Levetiracetam 750 mg, give 2 tablets two times a day for seizure disorder was refused by Resident #1 on 8/5/26 at 9:00 a.m.-this refusal was documented by MA B; *Levetiracetam 750 mg, give 2 tablets two times a day for seizure disorder was initially refused by Resident #1 on 8/6/26 at 5:00 p.m., but subsequently administered-this refusal and administration was documented by MA C;*Reglan 10 mg 1 tablet every 8 hours as needed for nausea and/or vomiting was administered on 8/4/26 at 7:30 a.m. by LVN A. *No Reglan administration for 3:30 p.m. or 11:30 p.m. on 8/4/26; *No Reglan administration for 8/5/26; and *No Reglan administration on 8/6/26 before 9:41 p.m.Record review of Resident #1's nursing progress note dated 8/6/26 at 11:39 p.m., revealed Resident (#1's family member) just called stating 'We refused to give him his medication and he will die if he doesn't get his medication'. Nurse told (the family member) shift just changed. Nurse informed (family member) that he (Resident #1) refused his medications and once medications are refused, we waste the medications. Medications can not keep being refused and redispensed because we will run out of medication before it's time to reorder them. Also informed (family member) this is not the first time he refused his medication and moving forward he (Resident #1) needs to take hi medications at the scheduled time that they are being administered to avoid any issues/relapse in care. The note was written by RN F. Record review of Resident #1's nursing progress note for Resident #1 dated 8/6/26 at 11:56 p.m., revealed med aide just administered his seizure medication Keppra 1500 mg at this time. Resident informed he needs to take his medication when administered to him. The note was written by RN F. Record review of the nursing progress note dated 8/7/26 at 12:31 a.m., revealed EMS had arrived to the facility asking for Resident #1's room number. The note indicated the nurse had not called EMS and explained to EMS that Resident #1's night medications were administered on the previous shift but were refused. The note indicated the family was upset that the medications were not being administered now. The note was written by RN F. Record review of Resident #1's nursing progress note dated 8/7/26 at 12:45 a.m., revealed Resident #1's family had called EMS to transport him to the hospital for care. The not was written by RN F. Record review of Resident #1's nursing progress note dated 8/7/26 at 9:45 p.m., revealed Resident refused meds with multiple attempts. Physician aware. The nurse notified (Resident #1's family member), (Resident #'1s family member) would like current charge nurse to contact her. Charge nurse (RN F) notified. The note was written by ADON E. Record review of Resident #1's nursing progress notes from 8/5/26 through 8/8/26 revealed no additional documentation reflecting Resident #1 refusing medication or nursing administration attempts. During an interview on 8/12/26 at 11:07 Resident #1's family member stated she was on the phone with Resident #1 at approximately 10:30 pm on 8/6/26. He/she said Resident #1 explained to / him/her he ( Resident #1) was not refusing his medications. and was trying to handle it himself. Resident #1's family member said Resident #1 explained he was nauseated and just needed his nausea medication to take effect before he could take his medications. He/she said Resident #1 had been told the medications were going to have to be thrown away because the nurses shift was ending. He/she said while she was still on the phone with Resident #1 a nurse came in and told him he could not have his medications until in the morning. He/she said to Resident #1, Well, they have to find a way because those medications keep you alive. He/she said the nurse evidently could hear them and cut them off and said there was no way around it. He/she said the nurse continued and said Resident #1 would get the medications in the morning and if the medications could not be redispensed he would run out the medication early and could not be refilled because it would not be time for a refill. During an interview on 8/12/26 at 3:42 p.m., MA B said she took care of Resident #1 on 8/3/26 to 8/6/26 on the 6:00 a.m. to 2:00 p.m. shift. MA B said she only recalled Resident #1 refusing medications once and that LVN A was able to get Resident #1 to take the medications. MA B said if a Resident refused medications MAs were to report it immediately to the nurse so the nurse could assess and attempt to administer the medications themselves. MA B said if she charted Resident #1 refused medications she would notify the nurse (LVN A). MA B said she did not recall Resident #1's refusals on 8/5/26 and 8/6/26. During an interview on 8/12/26 at 3:50 p.m., LVN A said he only had Resident #1 refuse his medications once. LVN A said he was notified by the medication aide that Resident #1 was refusing his morning medications. LVN A said he believed that was on 8/4/26. LVN A said he went to talk to Resident #1 and found he was just really nauseated. LVN A said he obtained an order for Reglan and administered it to Resident #1 and Resident #1 later took his daily medications. LVN A said he was not made aware of any additional refusals because if he had been notified he would have done what he had done previously, assess the resident, administer Reglan and attempt the administration 30 minutes to hour later after the Reglan had time to take effect. LVN A said it was important for Resident #1 to receive his anti-rejection medication to reduce the risk of his body rejecting his transplanted organ. LVN A said it was important for Resident #1 to receive his anti-seizure medications to reduce his risk of seizures. During an interview on 8/12/26 at 4:35 p.m., RN F said she worked at the facility prn. RN F said she did take care of Resident #1 on 8/6/26 during the 10 p.m. to 6:00 a.m. shift. RN F said she was told by ADON E that Resident #1 had refused his evening medications. RN F said ADON E attempted administration of the medications right after she (RN F) had arrived to the facility and he had refused. RN F said the family was very upset and he/she was on the phone with Resident #1. RN F said Resident #1 said he needed his meds and RN F told him they tried to administer his medications and he refused. RN F said she did tell Resident #1 t medications could not be redispensed because the facility would run out of the medications before it was time to refill them. RN F said one of the medications Resident #1 refused was Keppra but was not sure what the other medications were. RN F said she did have the medication aide administer the Keppra before EMS showed up to the facility. RN F said she had not called EMS and that apparently the family had called EMS because they were upset about him missing medication. During an interview on 8/12/26 at 4:53 p.m., ADON E said she worked the floor on 8/6/26 on the 2:00 p.m. to 10:00 p.m. shift. ADON E said herself and LVN G were taking care of Resident #1. ADON E said she was notified by MA C that Resident #1 was refusing his evening medications. ADON E said Resident #1 was refusing because he was nauseated. ADON E said she asked LVN G to administer whatever Resident #1 had ordered for nausea. ADON E said LVN G administered the medication and she (ADON E) went to attempt the administration later before the end of her shift and Resident #1 still was refusing the medication. ADON E said Resident #1 was holding the med cup and said he would wait until the morning. ADON E said she explained that she could not leave the medications with him and since her shift was about to end she would have to dispose of the medications. ADON E said she notified the physician and Resident #1's family member of the refusal. During an interview on 8/12/26 at 5:20 p.m. the DON said she expected medication aides to immediately report medication refusals to the nurse so that the nurse could assess the resident and attempt to administer the medication themselves. The DON said it was important for Resident #1 to be administered his antirejection medication and anti-seizure medications to prevent seizures and reduce the risk of his body rejecting his transplanted if liver. The DON said it was inaccurate that medications would run out if they had to be redispensed. The DON said she would simply submit a cost approval and have them filled earlier and stated it was not a big deal to do so. During an interview on 8/12/26 at 5:30 p.m., the Administrator said she expected staff to follow facility policy and procedure regarding medication administration. Record review of the facility policy and procedure titled, Medication Administration, revised 8/31/2023, stated Policy: It is the policy of this facility that medications shall be administered as prescribed by the attending physician.(3) All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR).(11) Should a drug be withheld, refused or given other than at the scheduled time, the medication aide must report to charge nurse, charge nurse to document the missed dose and reason on the MAR.(13)Medications are reordered using the PCC [Electronic medical record system system used by the facility] Pharmacy integration, using the reorder supplies button in the Resident's MAR when supplies are needed or supply has been exhausted). A phone interview was attempted with Resident #1 on 8/12/26 at 11:08 am, via his personal cell phone. The interview was not completed due to message received call can not be completed as party is temporarily unavailable.A phone interview was attempted with Resident #1 on 8/12/26 at 11:18 a.m. via his hospital room and 8/12/26 at 12:21 p.m. The interview was not completed due to no answer with both attempts. A phone interview with LVN G was attempted but not completed on 8/12/26 at 5:09 p.m. a detailed message was left. No return call was received.

Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 3 (100 Hall Med Aide Cart, 100 Hall Nurses Cart, and 400 Hall Nurses Cart) of 4 carts and 1 resident (Resident #100) of 8 residents reviewed for pharmacy services. The facility failed to ensure:- LVN K responsible for100 Hall Med Aide Cart, counted controlled drugs every shift change.- RN B responsible for 100 Hall Nurses Cart, counted controlled drugs every shift change.- RN L responsible for 400 Hall Nurses Cart, counted controlled drugs every shift change. - ADON A, RN B, RN F, LVN C, LVN D and LVN E documented on Resident #100's MAR for administering prn hydrocodone-acetaminophen 10-325 mg tablets. - LVN C failed to document on 08/21/25 when she administered hydrocodone-acetaminophen 10-325 mg 2 tablets from emergency kit. These failures could place residents at risk of not having the medication available due to possible drug diversion and medications not administered according to physician orders. Findings Included:- Record review on 08/26/25 at 10:12 AM of 100 Hall Med Aide Cart, with MA J revealed missing signatures for Off duty for 08/26/2025 (10:00 PM to 6:00 AM shift) of the narcotic count sheet. - Record review on 08/26/25 at 10:21 AM of 100 Hall Nurses Cart, with LVN I revealed missing signatures for Off duty for 08/20/2025 (2:00 PM to 10:00 PM shift) of the narcotic count sheet. - Record review on 08/26/25 at 10:41 AM of 400 Hall Med Nurses Cart, with LVN K revealed missing signatures for On duty and Off duty for 08/21/2025 (2:00 PM to 10:00 PM shift) of the narcotic count sheet. Interview on 08/28/2025 at 11:54 AM, LVN K stated she should have signed the narcotic sheet after counting the narcotics, on 8/26/25 at the beginning and at the end of the shift 10 PM to 6 AM. She stated she got busy because she was called to go to the dining room, and she forgot to go back and sign the count sheet. She stated she knew that she supposed to sign immediately after the count was done. She stated the risk would be potential for drug diversion. Interview on 08/28/25 at 2:05 PM, RN L stated she should have signed the narcotic sheet after counting the narcotics on 8/21/25 at the beginning and at the end of the shift 2 PM to 10 PM. RN L stated, I counted the narcotics, but I don't remember what happened why I did not sign. RN L stated this failure could potentially cause a drug diversion. She stated she was trained and learned that she was supposed to sign the narcotic count sheet immediately after counting with the other nurse. On 08/28/25 at 2:14 PM attempted to call RN B, she did not answer. Interview on 08/28/25 at 12:15 PM, the DON stated she expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff was not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated the ADONs would daily check the cart on the weekdays and the weekend supervisor during the weekends for monitoring. 2. Review of Resident #100's face sheet undated reflected she was a [AGE] year-old female admitted to the facility on [DATE] for diagnoses of acute osteomyelitis of the left foot and ankle (infection of the bone), type 2 diabetes mellitus with diabetic neuropathy (chronic condition where the body does not produce enough insulin to regulate blood sugar levels and damage to nerves), chronic pain syndrome, peripheral vascular disease (condition that affect the blood vessels outside of the heart) and osteoarthritis (joint disease that causes pain, stiffness and swelling). Review of Resident #100's comprehensive care plan dated 08/24/25 reflected she had neuropathic pain and is prescribedanticonvulsant therapy. Intervention included Pain management as needed. See MD orders. Provide alternative comfortmeasures PRN. Review of Resident #100's physician order dated 08/20/25 of Hydrocodone-Acetaminophen Tablet 10-325 MG Give 2 tablet by mouth every 8 hours as needed for Pain. Review of Resident #100's Narcotic Record for Hydrocodone-Acetaminophen Tablet 10-325 MG reflected Resident #100 was administered the following:-2 tablets administered on 08/21/25 at 8:30 PM by LVN C-2 tablets administered on 08/22/25 at 5:30 AM by LVN D-2 tablets administered on 08/22/25 at 1:30 PM by ADON A-2 tablets administered on 08/22/25 at 9:30 PM by ADON A-2 tablets administered on 08/23/25 at 9:45 PM by LVN E-2 tablets administered on 08/25/25 at 5:15 AM by RN B-2 tablets administered on 08/25/25 at 3:45 PM by ADON A-2 tablets administered on 08/26/25 at 10:30 PM by RN F-2 tablets administered on 08/27/25 at 6:45 AM by LVN C-2 tablets administered on 08/27/25 at 3:30 PM by RN F Review of Resident #100's August 2025 MAR/TAR printed on 08/28/25 reflected no medication administration was documented for Resident #100 on 08/20/25, 08/21/25, 08/22/25 and 08/27/25 for Hydrocodone-Acetaminophen Tablet 10-325 MG - Give 2 tablet by mouth every 8 hours as needed for Pain. It did not reflect medication was administered on 08/23/25 at 9:45 PM by LVN E, 08/25/25 at 5:15 AM by RN B, 08/25/25 at 3:45 PM by ADON A, 08/26/25 at 10:30 PM by RN F, 08/27/25 at 6:45 AM by LVN C and 08/27/25 at 3:30 PM by RN F. Interview on 08/27/2025 at 3:25 PM with LVN C revealed on 08/21/25 Resident #100 complained of pain level of 7 or 8. LVN C stated she thought she called the pharmacy to get Resident #100's pain medication of Hydrocodone-Acetaminophen Tablet 10-325 MG out of the emergency e-kit since Resident #100 medication had not arrived yet from the pharmacy. She stated Resident #100 did have a current prn pain medication order and they had to contact the pharmacy to access narcotic medication out of the E-kit. She stated she was given an access code from pharmacy once the physician order was verified with the pharmacist. She stated she followed up with Resident #100 to ensure Resident #100's pain medication was effective. Interview on 08/27/2025 at 3:56 PM with the Pharmacist revealed on 08/21/25 at 2:41 PM LVN C contacted pharmacy to get pain medication for Resident #100 out of the emergency kit. The Pharmacist stated nurse from facility had to contact pharmacy to get a narcotic medication out of the emergency kit to get a code to access to put in the system so it will be dispensed. The Pharmacist stated this was the only time facility contacted pharmacy to get Resident #100 narcotic medication of Hydrocodone-Acetaminophen 10-325 mg 2 tablets out of emergency e-kit. She stated pharmacy was available 24 hours/365 days a year. She stated the nurse had to call the pharmacy to get a code to access the narcotic medication out of the emergency kit. Interview on 08/28/2025 at 10:00 AM with ADON A revealed prn pain medications should be documented on resident's MAR/TAR including the pain level. She stated she was pulled to work the floor as a charge nurse due to nurse having to lleave shift early. [SP1] She stated she should have documented on the MAR for Resident #100's prn pain medication including pain level. Interview on 08/28/2025 at 12:21 PM with LVN D revealed she should document on Resident #100's MAR for the prn pain medication. She stated she did review Resident #100's physician order but could not recall if she documented on the MAR she had given the prn pain medication when she worked on 08/22/25. Interview on 08/28/25 at 10:47 AM with LVN E revealed he typically documented on the resident's MAR when giving resident a prn pain medication. He stated Resident #100 had complained of pain level of 5 or 6 so he administered Resident #100's prn pain medication as ordered. He stated it was important to document the prn pain medication so it would show how often they are getting the pain medication, to document the pain levels at time of administration and follow up to ensure effectiveness of pain medication. Interview on 08/28/2025 at 11:01 AM with the DON revealed she expected the charge nurse to document Resident #100's pain level, administer medication as ordered, document it on the MAR along with the narcotic count sheet. She stated not documenting on the MAR when giving a prn pain narcotic medication could place residents at risk of medication given outside of physician orders and possible drug diversion if not documented accurately. She stated the charge nurse should document if getting the narcotic pain medication out of emergency kit in resident's chart. Surveyor attempted to contact RN F on 08/28/2025 at 12:08 PM, but was unable to reach RN F. Interview on 08/28/2025 at 12:09 PM with RN B revealed she could not recall what night she worked with Resident #100 but Resident #100 requested her prn pain medication for pain. She stated she did give the hydrocodone-acetaminophen 10-3325 2 tablets to her as ordered and documented on the narcotic count sheet. She stated she must have forgotten to document it on Resident #100's MAR to show the pain level and signing it was given. She stated she usually did document in the MAR when giving prn scheduling pain medication. Review of facility's policy Administration of Drugs revised May 2021 reflected .3. All current drugs and dosage schedules must be recorded on the resident's electronic administration record (eMAR).6. When PRN medications are administered, the nurse must record: A. Justification/reason the medication is given B. The date and time administered via eMAR C. Any results achieved from administering the drug and the time each results were observed.Right documentation - Document administration or refusal of the medication after the administration or attempt and note any concerns. Review of the facility's policy Controlled Medications - Storage and Reconciliation revised January 2022, reflected, . A reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record at each shift change.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 12 residents (Resident #95, and Resident #24) observed for infection control. 1. The facility failed to ensure Hospice Aide G used the required PPE and perform hygiene for Resident #95, who was on enhanced barrier precautions due to her Foley catheter and wound while providing the resident a bath and failed to place soiled linen in a plastic bag and not in the roommate's wheelchair on 08/27/25. 2. The facility failed to ensure CNA N changed gloves during incontinent care for Resident #24 on 08/27/2025. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #95's Face sheet dated 08/25/25 reflected an [AGE] year-old female with an admission date of 05/13/24 and a re-admission date of 08/14/25. Diagnosis included dementia. Record review of Resident #95's care plan with a revision date of 08/14/25 and 08/17/25 reflected, has indwelling catheter: Neurogenic bladder (injury or disease that interrupts the electrical signals between the nervous system and bladder function) .Has pressure ulcer development right sacrum (base of the spine) related to immobility.Interventions.Use Enhanced Barrier Precautions. In an observation on 08/27/25 at 09:35 a.m. Hospice Aide G was observed providing a bed bath to Resident #95. Hospice Aide G had on gloves but no gown. After completion of bed bath, Hospice aide removed the top sheet and blanket and placed them in the resident's roommate wheelchair. The Treatment Nurse entered Resident #95's room to perform a skin assessment. The Treatment Nurse washed her hands, donned gown and gloves and she and Hospice Aide G repositioned the Foley drainage bag and turned the resident to observe her skin. The Treatment Nurse uncovered the sacral wound to reveal it was about the size of pea with no drainage noted. The Treatment Nurse removed her PPE, washed her hand and left the room. Hospice Aide G then retrieved the top sheet and blanket from the wheelchair and placed them on top of the resident's night stand next to her bed. She then removed her gloves and without performing hand hygiene retrieved a clean top sheet and pillowcases and replaced the pillowcases on the 2 pillows. She then placed pillow under the resident's head and one under her feet to offload her heels and then covered her with a clean sheet. She then put the soiled top sheet in a plastic and bag and folded the blanket and laid it on top of the resident's nightstand. Hospice Aide G took the pan of bath water to the bathroom sink and discarded the water, rinsed out the bath basin and washed her hands. In an interview with Hospice Aide G on 08/27/2025 at 09:50 a.m. she stated Resident #95 was not in isolation and she did not have to wear a gown and mask when providing her care, only gloves. Hospice Aide G was not aware of what Enhanced Barrier Precautions meant and was not aware the resident was on Enhanced Barrier Precautions. She stated her company had reviewed isolation protocol with her for residents with COVID but was not familiar with what type of resident's required Enhanced Barrier Precautions. She stated she had not noticed the signage posted outside of the resident's door. She stated she realized when she placed the soiled linen on the wheelchair, that it was not the resident's wheelchair, which was why she moved it to the nightstand. She stated she knew she was not to place it on the floor, but stated she should have placed the sheet in a plastic bag. She stated she did not realize she needed to wash her hands after removing her gloves. In an interview with LVN I on 08/27/2025 at 10:20 a.m. she stated most of the residents she had on hospice had the same aide come every day. She stated when a new aide comes in she will make sure they know if a resident is on Enhanced Barrier Precautions. She stated she was not aware Resident #95's hospice aide was not familiar with Enhanced Barrier Precautions. She stated Resident #95 was on Enhanced Barrier Precautions due to her wound and her Foley catheter. She stated the risk of not wearing the proper PPE during care was the spread of drug-resistant germs to other residents. In an interview with the Hospice Patient Care Manger on 08/28/2025 at 09:23 a.m. she stated Hospice Aide G was new. She stated she had her going out with another aide to makes sure she was familiar with all the residents she sees but stated she was not sure if she had been out with her to this facility. She stated they do go over infection control and thinks it included Enhanced Barrier Precautions but was not certain. She stated she would make sure she received additional training. In an interview with the DON on 08/28/2025 at 11:05 a.m. she stated any resident with an implanted medical device and or open wound had to be on Enhanced Barrier Precautions to prevent the risk of spreading multi-drug-resistant infections. She stated dirty lines should always be bagged and not placed on the floor or furniture and especially not on other resident's wheelchairs. She stated all staff were to perform hand hygiene after glove removal. She stated failure to follow their infection protocol placed all residents at risk of cross contamination. She stated she expected the hospice companies to train their staff but stated she would also make sure any hospice staff providing care in their facility followed their infection control protocol while providing care to their residents. 2.Record review of Resident #24's Quarterly MDS assessment dated [DATE] reflected Resident #24 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage), diabetes mellitus, and elevated blood pressure. Resident #24 had a BIMS score of 07, which indicated Resident #24's cognition was severely impaired. The MDS assessment indicated Resident #24 was frequently incontinent of urine and required maximal assistance with toileting hygiene. Observation on 08/27/25 at 9:55 AM revealed CNA N was in Resident #24's room to provide incontinence care. CNA N had gloves on, she unfastened Resident #24's brief, she then provided peri-care to the resident, wiping across the resident's pubis bone and then down each groin. She rolled resident on his side. CNA N wiped the resident's buttock area with peri-wipes, front to back, she then removed the soiled brief and with soiled gloves, placed the clean brief under the resident. She rolled the resident on his back onto the clean brief. Once finished, she fastened the resident's brief. She removed and discarded her gloves and washed her hands In an interview on 08/27/25 at 10:25 AM, CNA N stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA N stated failing to provide proper care exposed the resident to infections. In an interview on 08/28/25 at 12:15 PM, the DON stated she expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. She stated CNAs were trained to change gloves and perform hand hygiene when going from dirty to clean. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated the ADONs would do random rounds for monitoring. Record review of the Facility's policy titled, Enhanced Barrier Precautions, revised August 2022, reflected, Enhanced Barrier Precautions (EBP's) are utilized to prevent the spread of multidrug-resistant organisms (MDROs).EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do no otherwise apply.Examples of high-contact resident care activities.Bathing/showering.changing linens.EBP's are indicated .for residents with wounds and/or indwelling devices regardless of MDRO colonization.Staff are trained prior to care for residents on EBP's. Record review of the facility's policy titled, Handwashing/ Hand Hygiene, revised August 2019, reflected, The facility considers hand hygiene the primary means to prevent the spread of infections.All personnel shall.Wash hands with soap.and water.when hands are visibly soiled.Use an alcohol-based hand rub.or.soap.and water for the following situations.Before and after direct contact with residents.before moving from a contaminated body site to a clean body site during resident care.After removing personal protective equipment PPE and before moving to another body part .After removing gloves. Hand hygiene is always the final step after removing and disposing of personal protective equipment.The use of gloves does not replace handwashing/hand hygiene. Record review of the facility's policy titled, Laundry and Bedding, Soiled, dated September 2022, reflected, Soiled laundry/bedding shall be handled, transported and process according to best practices for infection prevention and control.All used laundry is handled as potentially contaminated using standard precautions.Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used) .

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #10) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #10 had her fingernails cleaned and trimmed on 8/26/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Record review of Resident #10's Quarterly MDS assessment dated [DATE] reflected Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, cognitive communication deficit, and need for assistance with personal care. Resident #10 had a BIMS score of 0, which indicated Resident #10' cognition was severely impaired. The MDS assessment indicated Resident #10 required maximal assistance with personal hygiene. Record review of Resident #10's Care Plan revised 04/06/25, reflected the following: Focus: [Resident#10] has an ADL self-care performance deficit . Goal: will current level of function through the review date . Interventions: . Personal hygiene .Staff to assist with ADLs as needed.In an observation on 08/26/25 at 10:56 AM revealed Resident #10 was laying in her bed. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored tan and had brownish colored residue underside. Resident #10 was confused and the answer to question did not make sense.In an interview on 08/26/25 at 11:57 AM, CNA M stated CNAs and nurses were responsible to clean and cut the residents' nails. CNA A stated she did not notice Resident #10's nails. She stated she would do it right then. She stated the risk would be infection control and injury. In an Interview on 08/28/25 at 12:15 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated he expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADONs would do the routine rounds to monitor. The DON stated residents having long and dirty nails could be an infection control issue and skin break down if scratching. Record review of the facility's policy Nails Care revised January 2022, reflected the following: . Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on an as needed basis.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #55) of two residents reviewed for foley catheter (a thin, flexible tube inserted into the bladder to drain urine) care. The facility failed to ensure CNA N and CNA P maintained the foley catheter drainage bag below Resident #55's bladder during a mechanical lift transfer on 08/27/25. This failure placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter. Record review of Resident #55's Quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), overactive bladder (a chronic condition characterized by a sudden, uncontrollable urge to urinate), and need for assistance with personal care. She had a BIMS of 13 which indicted she was cognitively intact. She required extensive to total assistance with transfer, and she had a foley catheter. Record review of the Resident #55's care plan initiated on 01/31/25 reflected, Has an indwelling catheter related to overactive bladder. Interventions included .Monitor/record/report to Medical Doctor for signs and symptoms of urinary tract infection . Observation on 08/27/25 at 10:49 AM revealed CNA N and CNA P entered Resident #55's room to transfer Resident from wheelchair to bed. CNA P unhooked the catheter bag from the wheelchair side and hooked it to the top bar of the mechanical lift, above resident's bladder. The staff raised the resident from the wheelchair with the Foley catheter bag hanging above the resident's head. Urine was observed flowing back toward the resident's bladder. The staff then positioned her over her bed and lowered her into her bed and unhooked the catheter bag from the mechanical lift and onto the side of her bed. In an interview with CNA P on 08/27/25 at 11:10 AM, she stated she was trained to make sure the catheter bag was always in a privacy bag, make sure the tubing was not kinked and make sure they emptied the drainage bag each shift. The CNA was not sure where the catheter bag should have been positioned during the transfer. She stated having it above the bladder could possibility cause the urine to run backwards, which could cause an infection. In an interview with CNA N on 08/27/25 at 11:12 AM, she stated they should have held the drainage bag below the resident bladder level while they transferred her. She stated failing to do this could cause the urine to back up and might cause an infection. In an interview with the DON on 08/28/25 at 12:15 PM, she stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of a urinary tract infection and cross contamination. She stated she would provide training to nursing staff on positioning of the drainage bag during transfers. She stated she would do skills check on foley catheter care to monitor nursing staff. Review of the facility's policy titled, Indwelling Urinary Catheter Care, reflected, . Maintain the drainage tubing below the level of the bladder.

Based on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored properly in locked compartments for one of five medication carts (medication cart for hall 300) reviewed for storage of Drugs and Biologicals. The facility failed to ensure RN F locked his medication cart for hall 300 on 08/27/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications and not receiving the full benefit of the medication. Findings included: Observation on 08/27/2025 at 03:44 p.m. revealed a medication cart was parked against the wall with the drawers facing out toward the hallway. The cart was not locked because the centralized, metal, round lock, was protruding and the metal lock needed to be pushed in to lock the drawers of the cart. The cart was facing the hallway, and the drawers could easily be opened. The drawers of the cart contained various over-the-counter medications, blister packs of medications, and insulins. Several staff and residents were passing by the unlocked cart. Approximately 5 minutes passed when RN F walked out of a Resident #100's room and returned to the medication cart. In an interview with RN F on 08/27/25 at 03:50 p.m. he stated he forgot to push the button on the cart to lock it before he answered the Resident #100's call light. He stated the risk of leaving the cart unlocked was anyone could have accessed the medications in the cart. He said the cart should be locked every time it was left unattended because anybody, residents, staff, and visitors, could open it and could get anything from the cart. In an interview with the DON on 08/28/2025 at 11:10 a.m., she stated medication carts should be always locked to prevent unauthorized access to the medications. She stated the risk were to resident's obtaining medications that was not intended for them as well as diversion of medications. She stated RN F was an as needed employee, but stated she had never seen him leave the cart unlocked. She stated they would re-educate him on the importance of keeping the medication cart secured. Record review of facility policy Medication Storage , revised May 2021 reflected, It is the policy of this facility to ensure the proper and safe storage of drugs and biologicals.Drugs and/or biologicals should not be left unsecured/unattended.Medication and treatment carts will be kept locked when unattended.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 16 (Resident #1) residents reviewed for abuse. The facility failed to protect Resident #1 from verbal and physical abuse from Resident #2 on [DATE]. The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings Include: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was readmitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and cognitive communication deficit. Record review of the quarterly MDS dated [DATE] indicated Resident # 1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated during the 7-day look back period Resident #1 did not have any physical behaviors towards others. The MDS indicated during the 7-day look back period Resident #1 did not have any verbal behaviors directed towards others. Record review of the care plan last updated [DATE] indicated Resident #1 had actual impairment to skin integrity r/t bruise to left upper arm [DATE]. The care plan indicated Resident #1 had a skin tear to the left upper arm [DATE]. Record review of an incident report dated [DATE] indicated, [Resident #1 was] noted to have [a] skin tear and bruise to [the] left upper arm. Another resident was witnessed grabbing [Resident #1's] arm. MD and RP notified. Wound care provided per facility protocol. Resident were separated immediately. Record review of the progress note dated [DATE] at 8:54 p.m. indicated, CNA reported to this nurse that while she was charting, she overheard another resident aggressive with this resident and when she turned around other resident had grabbed this resident left arm causing bruising and skin tear. Area was assessed, skin tear was cleaned and covered with steri-strips. When interviewed resident states that he was not sure what happened that other resident had just grabbed him. Two residents were immediately separated . Record review of the progress note dated [DATE] at 1:13 a.m. indicated [Resident #1] in another room, sleeping well, no acute distress noted . Record review of the progress note dated [DATE] at 3:13 p.m. indicated Resident #1 expired in the facility with family at bedside. 2. Record review of the face sheet dated [DATE] indicated Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, psychotic disorder with delusions (mental disorder that causes abnormal thinking and perceptions), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and muscle weakness. Record review of the quarterly MDS dated [DATE] indicated Resident #2 understood other and was understood by others. The MDS indicated Resident #2 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated during the 7-day look back period Resident #2 did not have any physical behaviors towards others. The MDS indicated during the 7-day look back period Resident #2 did not have any verbal behaviors directed towards others. Record review of the care plan last updated on [DATE] indicated Resident #2 had demonstrated physical behaviors toward other residents related to anger and dementia. Record review of the incident report dated [DATE] indicated, [Resident #2] reportedly grabbed another resident's arm and left a bruise and skin tear. [Resident #2] was heard saying give me the fucking toilet paper before grabbing [the] other resident's arm. [Resident #2] was noted to have a UTI and is now being treated . Record review of the progress note dated [DATE] at 8:48 p.m. indicated CNA reported to this nurse that [Resident #2] had grabbed another resident's arm causing bruise and small skin tear. Interviewed [Resident #2] who is unable to tell what happened. CNA reported that she was charting and heard resident make a statement about toilet paper and she turned around to see resident grabbing [another resident's] left arm. CNA told this resident to let go and he did and then CNA separated [the] two residents .Resident to move rooms. Record review of the PIR dated [DATE] indicated Resident #2 was witnessed by CNA A saying give me that fucking toilet paper to Resident #1 and was witnessed by CNA A with his hand on Resident #1's left arm. The PIR indicated Resident #1 was noted with a skin tear and bruise to his left arm. The PIR indicated after Resident #2 was asked to let go of Resident #1 that he complied. The PIR indicated the residents were separated immediately. During an interview on [DATE] at 12:36 p.m., Resident #1 said he had not had issue with too many of the other residents. During an interview on [DATE] at 1:01 p.m., CNA A said she did not remember the specifics of the incident between Resident #1 and Resident #2 except that Resident #2 reached out and grabbed Resident #1. During an interview on [DATE] at 1:49 p.m., the DON said in the event of a resident-to-resident altercation she expected staff to separate the residents and notify the abuse coordinator. The DON said the importance of preventing resident-to-resident altercations was for safety. During an interview on [DATE] at 2:01 p.m., the Administrator said she was the abuse coordinator. The Administrator said she expected staff to report all allegations or witnessed abuse and neglect to her immediately. The Administrator said the importance of preventing all types of abuse including resident-to-resident altercations was for resident safety. Record review of the facility's Freedom from Abuse, Neglect, Exploitation policy last revised ,d+[DATE] indicated, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. It is the policy of this facility to recognize the resident right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations .The facility act to protect and prevent abuse and neglect from occurring in the facility by: .Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validating that the facility has deployed the correct number of competent staff on each shift to meet the needs of residents . The facility had corrected the noncompliance prior to surveyor entrance by the following: Separating Resident #1 and Resident #2 In-servicing staff regarding abuse and neglect and how to handle residents with dementia. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of Resident #1 and Resident #2's progress notes and census record to ensure the residents were separated and there was a room change for Resident #1 following the incident. Record review of an in-services dated [DATE] indicated staff were in-serviced regarding abuse and neglect and how to handle residents with dementia. Staff interviewed (NA B, CNA C, CNA D, Treatment Nurse, CNA A, CNA E, SW, LVN F, LVN G, and LVN H) on [DATE], [DATE], and [DATE] between 9:16 a.m. and 1:23 p.m. were able to name all types of abuse including physical, verbal, sexual, emotional, and misappropriation of property. Staff interviewed said if they witnessed abuse, they would intervene and then report it immediately. Staff interviewed said the Administrator was the Abuse Coordinator of the facility. Staff interviewed said when handling residents with dementia and de-escalating resident-to-resident altercations, they would stay calm, attempt to redirect the resident, not argue with the resident, use reassuring tones, sit with the resident, and stay positive.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident was provided adequate supervision to prevent injuries for 1 of 3 residents (Resident #3) reviewed for accident hazards. The facility failed to ensure Resident #3 did not fall during a mechanical lift transfer on 12/17/24 when NA B performed a mechanical lift transfer (uses a specialized device to safely move individuals with limited mobility from one place to another) by herself. The noncompliance was identified as PNC. The noncompliance began on 12/17/24 and ended on 12/23/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury during mechanical lift transfers. Findings include: 1. Record review of the face sheet dated 4/9/25 indicated Resident #3 was admitted to the facility on [DATE] with diagnoses including contracture (a permanent or temporary tightening of soft tissues, muscles, tendons, ligaments, or skin that restricts movements) of the left knee, contracture of the right knee, lack of coordination, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), muscle weakness, and need for assistance with personal care. Record review of the quarterly MDS dated [DATE] indicated Resident #3 understood others and was understood by others. The MDS indicated Resident #3 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #3 was dependent with transfers. Record review of the care plan last updated 1/14/25 indicated Resident #3 had an actual fall without injury related to poor balance and unsteady gait. The care plan indicated Resident #3 had an ADL self-care performance deficit related to generalized weakness with interventions including transfer: mechanical lift with 2 persons assists. Record review of the incident report dated 12/17/24 indicated the nurse was notified by a CNA that after transferring Resident #3 to her wheelchair with the mechanical lift Resident #3 was sliding out of the wheelchair. The incident report indicated the CNA assisted Resident #3 to the floor. The incident report indicated when the nurse entered the room Resident #3 was lying on her back in the floor, on top of the mechanical lift pad. The incident report indicated Resident #3 reported her chest hurt and she wanted to go to the hospital. The incident report indicated the nurse assessed Resident #3 for injuries and no injuries were noted. The incident report indicated Resident #3 complained of hurting all over her body. The incident report indicated Resident #3 was sent to the hospital for evaluation. The incident report indicated Resident #3 was lowered to the floor by the CNA while transferring due to Resident #3 slipping out of the mechanical lift pad/sling. During an interview on 4/2/25 at 1:09 p.m., Resident #3 said she remember falling back in December. Resident #3 said she fell out of the mechanical lift and went to the hospital. Resident #3 said when she went to the hospital she was diagnosed with a UTI. Resident #3 said NA B had been operating the mechanical lift when she fell . During an interview on 4/2/25 at 1:23 p.m., NA B said she was a nurse aide at the facility and had worked at the facility for 6-7 months. NA B said she had taken the CNA class but had not taken her state test. NA B said she remember the incident with Resident #3 on 12/17/24. NA B said there was no one in the facility available to assist her with a mechanical lift transfer and she did not realize it was a requirement to have more than one person for a mechanical lift transfer. NA B said she was transferring Resident #3 by herself via mechanical lift from the bed to the chair. NA B said after she had Resident #3 in the air over the floor, she realized Resident #3 was at an angle due to not having the mechanical lift pad positioned under her properly. NA B said Resident #3 was freaking out and she lowered Resident #3 to the floor. NA B said she immediately ran to get assistance. NA B said Resident #3 complained of pain (she could not remember to where) but Resident #3 said the pain had been there prior to the transfer. NA B said Resident #3 was sent to the ER for evaluation. During an interview on 4/9/25 at 1:49 p.m., the DON said she expected 2 staff members to be present when performing a mechanical lift transfer. The DON said the importance of ensuring 2 staff members were present was for the safety of the residents. The DON said an NA should not perform any transfer by themselves including a mechanical lift transfer. The DON said an NA should not perform a transfer by themselves because they are not certified, and mechanical lift transfer should always have two staff members present. Record review of the facility's Safe Transfers policy revised 9/2023 indicated, It is the policy of this facility to transfer a resident in a safe manner. A transfer is the safe movement of a resident from one surface to another. Safe and efficient transfers are combination of the resident's ability and perceptual capacity, proper equipment, appropriate techniques, and good planning. Residents may transfer independently or be assisted by one or more caregivers. Transfers may involve assisted devices and/or involve a mechanical lift .Mechanical lift transfers are usually used for residents who are total dependent .Safe and secure mechanical lift transfers may require the help of minimum two, caregivers depending on the resident's conditions. The following basic principles apply to performing all mechanical lift transfers safely and effectively .7. Ensure that the resident's body is in alignment. 8. Make sure the placement of the sling is low enough to fully support the resident's thighs and buttocks so that the resident will not slip out of the bottom of the sling during the transfer .10. Always reevaluate the resident's position, the location of the slings, and the security of the attachments before moving away from the bed or chair . The facility had corrected the noncompliance by the following: Retraining NA B in mechanical lift transfers In-servicing staff regarding fall prevention and mechanical lift transfer The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of NA B's employee file indicated she was hired at the facility on 9/13/24 for a Nursing Assistant. The employee file indicated NA B had completed a Nurse Aide Competency Course approved by Texas HHS on 9/13/24. The employee file indicated on 12/17/24 NA B had been checked of by the OT regarding safe use of mechanical lift with 2 people. The employee file indicated NA B was given a final written warning on 12/17/24 regarding failure to perform job duties directly related to or engaging in conduct that in anyway compromises the safety, health, and/or physical comfort and well-being of a resident. On 4/3/25 observed CNA A, CNA E, CNA C and CNA D perform mechanical lift transfers safely using 2 staff members to assist in the transfer, ensuring the mechanical lift sling was properly placed under the residents prior to transfer, and ensuring each residents' body was aligned properly prior to transfer. Record review of in-services dated 12/23/25 indicated staff had been in-serviced regarding fall prevention and safe transfers. Staff interviewed (NA B, CNA C, CNA D, CNA A, and CNA E) on 4/2/25 and 4/3/25 between 9:16 a.m. and 1:23 p.m. were able to answer all question regarding in-services including fall precautions including beds in low position, call light in reach, and fall mats at bedside. Staff interviewed said mechanical lift transfers always required 2 persons assist, ensure the mechanical lift sling was properly placed under the resident, and ensure each resident's body was properly aligned prior to transfer.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights for 1 of 5 (Resident #1) residents reviewed for care plans, The facility failed to ensure Resident #1's code status was properly care planned. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. 1. Record review of the face sheet dated 1/30/25 indicated Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, heart failure, and hypertension (elevated blood pressure). Record review of the physician orders dated 1/30/25 for physician orders active as of 1/3/25 indicated Resident #1 had an order for Code Status: DNR starting 6/4/24. Record review of an Out-Of-Hospital Do-Not-Resuscitate Order dated 6/4/24 indicated Resident #1 DNR was effective 6/4/24. Record review of the MDS dated [DATE] indicated Resident #1 Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS score of 05 and was severely cognitively impaired. Record review of the care plan last revised on 11/20/24 indicated Resident #1 wished to be a full code. During an interview on 1/30/25 at 1:12 p.m. the DON said the facility uses the RAI Manual for care plans. The DON said the facility did not have a care plan policy. During an interview on 1/30/25 at 2:29 p.m. LVN A said the way she would look up a resident's code status was to go into the EMR in the resident's profile and under the resident's picture code status can be seen. LVN A said she did not know if the physician orders or care plan prompted the code status in the EMR. During an interview on 1/30/25 at 2: 39 p.m. MDS Coordinator B said the MDS Coordinators handled the care plans and ensured they were correct. MDS Coordinator B said the MDS Coordinators were responsible for ensuring the care plan was correct and was checked 7 days after completing an MDS. MDS Coordinator B said the computer system populated a care plan review. MDS Coordinator B said the MDS, and care plan code status should be the same. MDS Coordinator B said the orders populate the code status on the resident's profile under their picture. MDS Coordinator B said the importance of the orders and care plan code status matching was because the care plan represented the kind of care the facility was giving. During an interview on 1/30/25 at 2:46 p.m. the DON said the MDS Coordinators were responsible for ensuring the care plans were accurate. The DON said she expected the orders and the care plan to match including a resident's code status. The DON said the importance of ensuring the code status on the care plan and orders matched was for accuracy.

Based on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months, on a full-time basis, unless that individual is competent to provide nursing and nursing related services; and that individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State for 4 of 4 Student Nurse Aide (NA) reviewed for training and competency ( NA B, NA C, NA D and NA E). The facility failed to ensure NA B, NA C, NA D and NA E were certified nurse aides and had the appropriate training/competency to provide care to residents within four months of hire. This failure could place residents at risk for injury or receiving improper care by unlicensed personnel. Findings included: Record review of employee roster dated 9/13/24 revealed NA B had a hired date of 3/21/24 and position: nurse aide; NA C had a hired date of 3/21/24 and position: nurse aide; NA D had a hired date of 12/15/23 and position: nurse aide; NA E had a hired date of 12/13/23 and position: nurse aide. Record review of NA B's Texas Nurse Aide Performance Record revealed a training begin date of 3/27/24 and an end date of 4/19/24. Record review of NA C's Texas Nurse Aide Performance Record revealed training a begin date of 3/27/24 and an end date of 4/19/24. Record review of NA D's Texas Nurse Aide Performance Record revealed a training begin date of 12/18/23 and an end date of 1/12/24. Record review of NA E's Texas Nurse Aide Performance Record revealed training a begin date of 3/27/24 and an end date of 4/19/24. During an interview on 9/15/24 at 10:21 a.m., NA E said she had worked at the facility full time since April or May 2024 and was not a certified NA. She said she worked the 100 Hall from 6am-2pm shift and sometimes double shifts if needed independently. NA E said she had not scheduled to retake the state certification at this time and planned on scheduling to take the test soon. She said she previously took the test but did not pass. NA E said when she first started, she did some training and she worked with another CNA for a few days to know how to care for the residents. She said she did a peri care check off with the DON. She said she now worked independently when providing care to a resident unless she needed another aide to assist her with a resident that required two people. During an interview on 9/15/24 at 10:47 a.m., NA D said she had worked at the facility full time since around December 2023 and was not a certified NA. She said she worked the 200 Hall from 6am-2pm shift independently. NA D said she had not scheduled to take the state certification at this time and planned on scheduling to take the test soon. During an interview on 9/15/24 at 2:09 p.m., NA B said she had worked at the facility full time since April 2024 and was not a certified NA. She said she worked the 400 Hall from2p -10p shift independently. During an interview on 9/15/24 at 2:43p.m., NA C said she had worked at the facility full time since April 2024 and was not a certified NA. She said she worked the 300 Hall from2p -10p shift independently. NA C said when she first started, she did some training and she worked with another CNA for a few days to know how to care for residents. She said she did a peri care check off with the DON. She said she now worked independently when providing care to a resident unless she needed another aide to assist her with a resident that required two people. During an interview on 9/15/24 at 4:39 p.m., the Operations Manager said NA B, NA C, NA D and NA E were considered full-time staff. During an interview on 9/15/24 at 4:57 p.m., the DON said she was aware NA B, NA C, NA D and NA E were not certified NAs and NA B, NA C, NA D and NA E were allowed to provided patient peri care independently because they had completed training prior to working independently. The DON said she was aware NAs had 120 days to become certified, but NA B, NA C, NA D and NA E all went through a refresher class in August 2024 and had 3 more months to schedule to test. The DON said she was not aware NAs were not allowed to keep doing refreshers to restart the four months time period of working as NAs . Record review of the facility's nursing assistant job description dated 12/17/21 revealed the following: Position Summary - The primary purpose of your job position as a full-time staff member is to acquire the knowledge, skills, and certification as a Certified Nursing Assistant by participation in the facility's planned educational program consisting of classroom instructions, clinical practice and on- the - job supervised training, and to perform certain services for which you have been trained and found to be competent during the training period Acknowledgement: This position consistently supports and promotes compliance with the Code of Conduct by maintaining the privacy and confidentiality of information, protecting the assets of the facility, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal, State, and local laws and regulations, accreditation and licensure requirements (if applicable), and all policies and procedures .

Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 medication carts (Nurses cart hall 300 and Med Aide Cart Hall 400) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure: 1- RN A, responsible for Nurses Cart hall 300, removed medications in unsecure containers from the Nurses Cart. 2- MA C, responsible for Med Aide Cart hall 400, removed medications in unsecure containers from the Med Aide Cart. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: 1- Record review and observation on 05/28/24 at 12:48 PM of Nurses Cart Hall 300, with RN A revealed the blister pack for Resident #45's Hydroco/APAP 5 - 325 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister and tapped over. Interview on 05/28/24 at 12:50 PM, RN A stated he was unaware when the blister pack seal was broken, and he was not aware of who might have damaged the blister. He stated the risk would be a potential for drug diversion. He stated the nurses and med aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. He stated the count was done at shift change and the count was correct. He stated he did not see the broken blister during the count. He stated when a broken seal was observed, he would report it to the DON and would discard the pill with another nurse. 2- Record review and observation on 05/28/24 at 1:09 PM of Med Aide Cart Hall 400, with MA C revealed the blister pack for Resident #63's Clonazepam 0.5 mg tablet (controlled medication used for anxiety) had 1 blister seal broken and the pill still inside the broken blister and tapped over. Interview on 05/28/24 at 1:18 PM, MA C stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She stated the risk would be a potential for drug diversion. She stated the nurses and med aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated she did the count at shift change with the previous shift staff. She stated she did not see the broken blister during the count. She stated if a broken seal was observed, she would report it to the charge nurse. Interview on 05/30/24 at 8:40 AM, the DON stated she expected if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be potential for drug diversion and infection control issue. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON, and the DON were supposed to check the carts weekly. Record review of the facility's policy Medication Access and Storage revised May 2007, reflected the following: . 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy if a current order exists .

Based on observation, interview and record review, the facility failed to ensure each resident received food that accommodated their preferences for four (Resident #66, Resident #250, Resident #73, Resident #1) of 24 residents reviewed for dietary services. The facility failed to honor Resident #250's preference for no pork. The facility failed to provide snacks for dialysis for Resident #66 and Resident #73. The facility failed to provide Resident #1 with food that accommodated his preferences. This failure could place residents at risk for not having their choices and food preferences accommodated, possible weight loss and a diminished quality of life. Findings include: 1- Resident #66 Record Review of Resident #66s face sheet revealed she was admitted to facility with initial admitted [DATE]. Her relevant diagnoses include Diabetes Mellitus (increased blood glucose), Hypothyroidism (low thyroid hormone levels), Hypertension (high blood pressure), Dependence on Renal Dialysis (involves relying on a dialysis machine to treat failure of the kidneys). Record Review of Quarterly MDS assessment dated [DATE] reflected Resident #66 had BIMS of 15 which indicated resident was cognitively intact. Record Review of Resident #66s care plan revised 8/24/2023 reflected, Focus: [Resident #66] needs dialysis related to Renal Failure . Goal: Will have immediate intervention should any signs and symptoms of complications from dialysis occur through the review date. Interventions: May take snack to dialysis. In an interview on 05/28/24 at 11:15 AM Resident#66 stated she underwent dialysis three times a week at an outside dialysis facility. She stated she left the nursing facility about 4:00 AM three days a week. She stated the facility did not send anything with her for snacks and did not hold her breakfast. She stated she had to wait for lunch when she returned to the facility. She stated she would like to get a snack from the facility, if available. 2- Resident #250 Record review of Resident #250 Face sheet dated 5/21/2024 revealed Resident#250s initial admitted to the facility was 5/21/2024. Her relevant diagnoses included: Anxiety disorder, Diabetes Mellitus (high blood glucose), Protein calorie Malnutrition (supply of protein, calories or both is inadequate) and hypertension (high blood pressure). Record Review of Resident #250 physician order dated 5/21/2024 reflected Low Concentrated Sweets diet, Regular texture, Thin liquids consistency, NO PORK. Record Review of Resident#250 s care plan dated 5/21/2024 reflected, Focus: Has potential nutritional problem. Goal: Will maintain adequate nutritional status as evidenced by maintaining weight with no signs and symptoms of malnutrition through review date. Intervention: Honor resident rights to make personal dietary choices and provide dietary education as needed. In an Observation and Interview on 05/28/24 at 12:36 PM revealed Resident #250's lunch meal consisted of pizza with pepperoni, bread and steamed green beans. Resident #250 stated she cannot eat pork since it did not agree with her system. She stated that she had told her preference for not being served pork for meals to the facility staff, however Resident #250 was not able to identify which staff she had told. Resident #250 stated that she will not eat the pizza and did not know what alternatives were available. In an interview on 5/29/24 at 10:53 AM with RN A stated that he was not aware that Resident #250 preferred not eating pork. He stated that Resident #250 was new to the facility, and he was not sure if Resident #250 dietary preference were noted by the Dietary Manager. He stated he will inform the kitchen regarding Resident #250 preferences. RN A stated that Resident preferences for food should be accommodated within a reasonable means and suitable alternatives should be provided. He stated that if Resident's preferences are not met it could lead to decrease quality of life and possible weight loss. 3-Resident #73 Record Review of Resident #73s face sheet revealed she was admitted to the facility with initial admitted [DATE]. Her Relevant diagnoses included: End Stage Renal Disease (permanent stage of chronic kidney disease that occurs when the kidneys can no longer function on their own), Dysphagia (difficulty with swallowing), Diabetes Mellitus (high blood glucose), Essential Hypertension (high blood pressure), Dependence on renal Dialysis (involves relying on a dialysis machine to treat failure of the kidneys). Record Review of Quarterly MDS assessment dated [DATE] reflected Resident #73 had BIMS of 13 which indicated resident was cognitively intact. Record Review of Resident#73's care plan revised 1/8/2024 reflected, Focus : [Resident#73 ] needs hemodialysis related to Renal failure. Goal: Will have no signs and symptoms of complications from dialysis through the review date. Intervention: May send snack with resident to dialysis. In an interview on 05/28/24 at 1:45 PM with Resident # 73 stated she underwent dialysis three times a week and at an outside dialysis facility. She stated she left the nursing facility about 10:00 a.m. She stated the facility does not provides her snacks for her trips to dialysis. She stated she takes her own snacks that her family brings to her. She stated she would take snacks from the facility if nursing facility provided them. In an interview with LVN H on 5/29/24 at 1:46 PM revealed that both Resident #66 and Resident #73 did not get snacks from the facility before going to dialysis since November 2023. She stated that she had seen Resident #66 and Resident #73 prepare their own snacks or the family provided them with snacks. She stated that Facility provided nighttime snacks, however no snacks were provided specifically for the residents who went to dialysis. LVN H stated that facility should attempt to provide snack choices to dialysis resident and failure to do so may result in decreased quality of life and possible weight loss. In an interview on 5/29/24 at 12:29 PM with Dietary Manager stated she had been the Dietary manager for about a week at the facility. She was not familiar with Kitchen policies. She stated that previous Dietary Manager had stopped the practice of providing alternate menus to the residents since she worked as a [NAME] in the same facility prior to being promoted as a Dietary manager She stated that all residents are provided with snacks, however she did not know if the dialysis resident received a packed snack from the facility before they went to dialysis. She stated that when Residents were gone for a long time , they should be provided with snacks and their food choices should be honored. She also stated that Resident #250 was newer to the facility and the dietary manager was not aware that Resident #250 could not eat pork. She stated she was educated regarding the process of obtaining Resident food preferences on the day of this interview. The Dietary manager stated Residents food preferences and choices should be met by the facility and not doing so can lead to decreased quality of life. In an interview on 5/29/24 at 12:50 PM the Dietitian stated that it was her expectation that Resident food choice, preferences and allergies were met by the facility within reasonable means. The Dietitian stated she thought Resident #66 and Resident #73 were provided a snack for dialysis since it was outlined in their care plan but stated she had not checked whether the facility was providing one. She stated [NAME] resident #250s preference for not having pork should have been honored and a substitute protein alternative should have been offered. The dietitian stated the facility had learned on the day of this interview that the previous dietary manager was not providing residents with preference sheets. She stated failure to honor Resident food choices and preferences can lead to decreased quality of life and possible weight loss. In phone Interview on 5/30/24 at 11:31 AM the Dietitian stated the facility did not have a Resident Dining and food preference policy available for review. 4- Resident #1 Review of Resident #1 Face Sheet dated 03/30/24 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnosis included Cerebral Infarction due to unspecified occlusion (also known as a stroke), Hemiplegia and Hemiparesis following cerebral infarction (which occurs after a stroke), and Aphasia following cerebral infarction (a language disorder that can occur after a stroke). Interview with Resident #1 on 05/28/24 at 2:15pm, revealed the food is ok but the portion sizes of the food could be larger. He stated the kitchen does not give 2nd servings when requested. An interview with the Dietary Manager on 05/29/24 at 10:55am, revealed the portion sizes are listed on menu tickets. The Dietary Manager stated a resident can change the portion sizes. The Dietary Manager stated monthly menus, without alternatives, are posted at the end of each hall and daily menus are posted in the dining room (with alternatives). The Dietary Manager stated the breakfast daily menu is not listed in the dining room. The Dietary Manager stated CNAs inform residents, who do not come to the dining room for meals, of the menu options. The Dietary Manager stated those residents relay their choice, changes, and request for 2nd servings to the CNAs who inform the kitchen staff. An interview with CNA F on 05/29/24 at 11:20am, revealed residents who eat in their rooms are only informed of the menu if asked. The CNA stated if the resident requested an alternative or 2nd helping, the kitchen was informed right away. The CNA stated 2nd helpings are provided after every resident has been served. An interview with the DON on 05/29/24 at 12:30pm, revealed CNAs received meal tickets from the Dietary Manager and then provided meal tickets to residents who circle their choices. The DON stated the choices contained substitutions as well. Interview with Resident #1 on 05/29/24 at 12:40pm, revealed he has never received a meal ticket outlining meal options and alternatives. Resident #1 stated the only alternative he was aware of is a grilled cheese sandwich. 49640

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 the facility's only kitchen 1. The facility failed to ensure food items in the facility refrigerator, freezer and dry storage were dated or labeled. 2. The facility failed to ensure dented cans were stored away from the main dry storage area. 3. The facility failed to ensure Dietary manager checked food temperature before serving during lunch meal service on 5/29/24. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings included: Observation in the facility's kitchen on 5/28/24 at 10:54 AM revealed one-gallon Ziplock bag of orange mashed food. Observation in Facility's dry storage on 5/28/2 at 10:44 AM of kitchen dry storage area revealed 3 cans of canned butterbeans and 1 can Chicken Broth were dented and stored within the storage area with other canned goods. Observation of lunch meal service on 5/29/24 at 12:06 PM revealed that Dietary manager went to the dry storage to obtain a big can of chicken noodle soup. She opened the can and poured it in a container. She then placed the soup container on the gas stove to heat it for about 2 minutes. Later, she poured the soup from the container into small bowls, covered it up and placed them on the food cart to be delivered to the residents. The Dietary manager did not check the temperature of the soup before serving it to the residents. In an interview with Dietary Manager on 5/29/24 at 12:29 PM revealed she was not sure what exactly was in the bag stored in the refrigerator and she threw it away on 5/28/24 due to it being unlabeled. She stated that she knew all food items in the kitchen should be labeled and dated . She stated that cooks, Dietary aides, and herself were responsible for dating and labeling all food items. She stated it was important to label and date all food items in the kitchen; so that food can be identified properly, and older items can be used first to decrease the risk of any food borne illness. The Dietary manager stated she saw the dented cans in the dry storage on 5/27/24 and meant to remove them and put them in her office but had not yet gotten around to it yet. The Dietary manager stated dented cans should not be used because they could result in contamination such as metal shavings or rust or have a broken seal that could make residents sick. The Dietary manager also stated that she forgot to measure temperature of the chicken noodle soup before serving it to the residents because they were in the process of serving lunch and she didn't want the residents to wait on it . She stated that she knew that the soup temperature should have been checked before serving it to residents to prevent any food borne illness. In an interview with the Dietitian on 5/29/24 at 12:50 PM she stated that it was her expectation that dented cans cannot be stored with regular canned goods because it may cause food borne illness if used inadvertently. She stated there was a place in the Dietary manager's office to secure dented cans. She stated it was her expectation that all foods in the kitchen should be labeled and dated and not doing so can increase risk of food borne illness for residents. The Dietitian stated that she expected the food service manager to heat canned goods including soup adequately and measure temperature of all foods before serving them to residents. The risk of not obtaining food temperatures before serving it to the residents can lead to food borne illness. In an interview with [NAME] G on 5/29/24 at 1:02 PM revealed that she was aware all foods in the kitchen should be dated and labeled. She stated that she was not aware who left the un-labeled item in the facility refrigerator. She stated that everyone in the kitchen including cooks, aides and dietary manager were responsible for dating and labeling food items. She stated that dented cans needed to be stored separately and was not sure why they were not stored in the Dietary manager's office. She stated that it might have been overlooked and can cause the resident to get sick if served. She stated that cooks usually obtain food temperatures before serving it to the residents. She stated that not obtaining food temperature, or not dating and labeling food items can lead to risk of food borne illness to the resident. In another phone Interview with the Dietitian on 5/30/24 at 11:31 AM stated the facility did not have a Food storage policy that included dating or labeling food items, storage of dented cans; Food temperature safety, however referred to Texas Food Establishment rules (TFER) for guidance. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Review of Food and Drug Administrative Food Code, dated 2022, reflected, .Chapter 3. Food Condition 3-101.11 Safe, Unadulterated, and Honestly Presented The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Review of Food and Drug Administrative Food Code, dated 2022, reflected .5. Develop and Implement Standard Operating Procedures (SOPs) Following standardized, written procedures for performing various tasks ensures that quality, efficiency, and safety criteria are met each time the task is performed Procedures are implemented for measuring temperatures at a given frequency and for taking appropriate corrective actions to prevent hazards associated inadequate cooking.

Based on observation, interview, and record review, the facility failed to ensure that based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 21 residents (Resident #44) reviewed for quality of care. The facility staff failed to ensure Resident #44's splint was placed on his right arm and hand on 06/04/24 and 06/05/24 per physician orders. These failures could place residents at risk of not receiving the care and treatment needed to meet their needs and could result in decreased Range of Motion and worsening of contractures. Findings included: Record review of Resident #44's face sheet dated 06/06/24 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of aphasia (loss of ability to understand or express speech caused by brain damage), hemiplegia right side (paralysis), and cerebral vascular accident (stroke). Record review of Resident #44's quarterly MDS assessment dated [DATE] reflected a staff assessment for mental status determined the resident was moderately cognitively impaired, he was dependent for his ADL needs and had one side functional limitations in range of motion on both upper and lower limbs. Record review of Resident #44's care plan initiated 11/28/22 reflected, [Resident #44] have right hand that requires splinting related to Cerebral Vascular Accident and contractures .Goal .Maintain current function and prevention of further contractures .Interventions .Right hand splint to be worn daily at 08:00 a.m. and remove splint at 2 p.m. Nursing to apply Right hand splint with wearing schedule daily as tolerated. Record review of Resident #44's Physician order Summary Report dated 06/05/24 reflected, Right hand splint to be worn daily at 8 am and removed splint at 2 pm two times a day with a start date of 01/03/23. Record review of Resident #44's MAR and TAR for June 2024 at 09:45 a.m. reflected RN C had signed the TAR on 06/04/24 which indicated the splint had been placed on at 8 a.m. and off at 2 p.m. and on 06/05/24 it was signed off which indicated the splint had been placed on at 8 a.m. In an observation on 06/04/24 at 10:20 a.m., Resident #44 was observed lying in bed. Resident indicated he was doing okay. Right hand noted to be clenched in a tight fist. No splint in use. Resident was unable to open his right hand. In an observation on 06/04/24 at 12:15 p.m. resident #44 was observed up in a Geri-chair in the dining room. Family members present. No splint on right hand. In an observation on 06/05/24 at 09:30 a.m. Resident #44 was observed in bed. No splint or hand rolls observed on right hand. In an observation on 06/05/24 at 11:10 a.m. Resident #44 remained in bed. No splint in place on resident's right hand. In an observation and interview on 06/05/24 at 11:30 a.m. CNA H entered Resident #44's room to get him up for the day. CNA H stated the CNAs and sometimes therapy are responsible for putting the resident's splint on. She stated she had not put the splint on this morning (06/05/24) because she had just now got his clothes changed. In an interview on 06/05/24 at 11:35 a.m. with RN C, she stated the nurses were responsible for monitoring to ensure the splints were in place for any resident who had orders for splint placement. She stated she thought Resident #44's splint had been placed on the resident. She stated she was not sure why his splint was not on 06/04/24, and again on 06/05/24. She stated she does not check off on the TAR if the splint was not in place and stated the CNAs should be informing her if they had taken it off since he had specific order for it to be in place from 8 am to 2 p.m. In an interview on 06/05/24 at 11:40 a.m. with CNA I, she stated she was assigned to Resident # 44 on 06/04/24. She stated she does not normally work that hall and was not familiar with the resident. She stated she did not put a splint on the resident stating she was not aware he had a splint. She stated an unknown Nurse had told her to put a washcloth in his hand but did not say anything about a splint. She stated she thought the Nurses were responsible for putting on splints. In an interview on 06/05/24 at 11:45 a.m. with ADON A, she stated the nurses were responsible for ensuring splints were in place if they had an order for splint placement. She stated the nurse, or the CNA could put the splints on the resident. She stated the nurse needed to assess the skin at the time of the removal of the splint to ensure no skin issues. She stated failure to ensure placement of splints could result in a decline of mobility and worsening of contractures. On 06/05/24 at 12:50 p.m. Resident # 44 was observed sitting up in Geri-chair in the dining room with family present. Right hand splint was now in place. Interview with resident's Family member, stated the resident did not have his splint on yesterday (06/04/24) when they came at noon. She stated he usually had it on. In an interview on 06/05/24 at 02:10 p.m. with the DON, he stated the nurses were responsible for ensuring the splints were in place and should not sign off on the TAR indicating it was in place when it was not. He stated the CNAs had all been trained on splint placement and could put the splints on and take them off, but the nurse needed to ensure the resident was wearing the splint the prescribed amount of time, and if not the reason why. He stated the nurse should also check the skin when the splint is removed. He stated failure to follow the prescribed amount of time or failure to place the splints on a resident could lead to worsening of the contractures and loss of mobility. Review of the facility's undated policy titled, Resident Mobility and Range of Motion, reflected, Resident's will not experience an avoidable reduction in range of motion .Resident with limited range of motion will receive treatment and services to increase and/ or prevent a further decrease in ROM .Residents with limited mobility will receive interventions per the plan of care, which include appropriate services, equipment such as splints and other devices and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for three of five residents (Resident #52, Resident #70, and Resident #85) reviewed for catheter care. 1. The facility failed to ensure CNA D and CNA E maintained the foley catheter drainage bag below Resident #52's bladder during a mechanical lift transfer. 2. The facility failed to ensure RN P maintained Resident #70's foley catheter drainage bag below the bladder level during wound care on 06/03/24. 3. The facility failed to ensure Resident #85's catheter bag did not had contact with the floor. This failure placed residents at risk for not receiving care appropriate to address their incontinence. Findings included: 1. Record review of Resident #52's face sheet dated 06//06/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), diabetes and obesity. Record review of Resident #52's quarterly MDS assessment dated [DATE] reflected he had a BIMS of 15 which indicted he was cognitively intact, required substantial/maximum assist with toileting and transfers and was frequently incontinent of urine and always incontinent of bowel. Record review of Resident #52's care plan initiated on 04/23/24 reflected, Risk for infection related to foley catheter .Goal .Resident will remain free from signs and symptoms of infection due to catheter .Interventions .Staff will provide catheter care every shift as ordered/indicated . Review of Resident #52's Order Summary report dated 06/06/24, reflected, .Foley catheter care q shift and PRN, Clean with soap and water Keep bag off floor and below bladder level every shift for infection control with a start date of 01/29/24. Observation on 06/06/24 at 09:50 a.m. revealed CNA D and CNA E entered Resident #52's room to get the resident up for the day. CNA D emptied the catheter drainage bag and placed it on the bed while preparing to place the mechanical lift sling under the resident. Both staff positioned the resident on the sling. CNA E picked up the catheter drainage bag and handed it CNA D, who then handed it to Resident #52, and he placed it top of his abdomen. The staff raised the resident from the bed with the catheter drainage bag remaining on the resident's abdomen, above the resident's bladder. Urine was observed flowing back toward the resident's bladder. The staff then positioned him over his wheelchair and lowered him into his chair and then placed the catheter bag onto the side of his wheelchair. In an interview with CNA D on 06/06/24 at 09:55 a.m., he stated she was trained to always keep the catheter drainage bag below the bladder. He stated having it above the bladder could possibility cause the urine to run backwards, which could cause an infection. He stated placing the bag on the bed could cause a risk of cross contamination. In an interview with CNA E on 06/06/24 at 09:58 a.m. she stated they should not have placed the catheter bag in Resident #52's lap. She stated when the resident held out his hand for the bag, they just handed it to him without thinking. She stated she knew the catheter bag and tubing were supposed to be kept below the bladder. She stated failing to do this could cause the urine to back up and might cause an infection. In an interview with the DON on 06/06/24 at 11:30 a.m., he stated any resident with a foley catheter should always have the bag and tubing below the bladder. He stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of a urinary tract infection and cross contamination. He stated to ensure staff were knowledgeable in the care of indwelling catheter the facility does skills competency checks and he stated the ADONs, and Charge Nurses made daily rounds and watched care. He said when staff needed to be re-trained her provided the in-service training. Record review of CNA D's competency check off for catheter care revealed he was proficient in care as of 02/16/24. Record review of CNA E's competency check off for catheter care revealed she was proficient in care as of 02/16/24. 2. A record review of Resident #70's Comprehensive MDS assessment dated [DATE] reflected Resident #70 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included morbid (severe) obesity due to excess calories, chronic heart failure, and metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood due to an illness or organ dysfunction). Resident #70 had a BIMS of 15 which indicated Resident #70's cognition was intact. She had a stage 4 pressure ulcer to the sacrum. She required extensive assistance of two-person physical assistance with personal hygiene and toileting. Record review of Resident #70's care plan initiated on 05/02/24 reflected, [Resident #70] has indwelling foley catheter (a catheter that's inserted into the bladder through the urethra and left in place to drain urine) related to stage 4 wound .Goal . No injury related to catheter and [Resident #70] will remain free from signs and symptoms of infection due to catheter . Review of Resident #70's Order Summary report dated 06/06/24, reflected, Foley catheter care every shift and PRN (as needed), clean with soap and water keep bag off floor and below bladder level with a start date of 04/17/24. Observation on 06/06/24 at 10:33 AM revealed RN P entered Resident #70's room to do wound treatment. RN P unhooked the catheter bag from the bed rail and put it flat on the foot of bed, above the resident's bladder. RN P provided wound care to sacral wound. During the procedure urine was observed flowing back toward the resident's bladder. The staff finished the treatment and then hooked the catheter bag onto the bed rail. In an interview with RN P on 06/06/24 at 10:53 AM she stated she should not have placed the catheter bag on the bed. She stated she knew the catheter bag and tubing were supposed to be kept below the bladder. She stated failing to do this could cause the urine to back up and might cause an infection. 3. Record review of Resident #85's Annual MDS assessment, dated 03/22/2024, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #85 had diagnoses which included: hypertension (high blood pressure), Gastroesophageal Reflux Disease (condition in which stomach acid repeatedly flows back up into the food tube), Anxiety, and Depression (common mental disorder). He was always incontinent of urine and bowel and had a Foley catheter. Resident had BIMS of 9 suggesting Resident #85 had moderate cognitive impairment. Record review of Resident #85's active Physician order dated 7/20/2023 reflected Foley catheter Care every shift and as needed, Clean with soap and water; Keep bag off floor and below bladder level every shift for Infection Control. Record review of Resident #85's comprehensive care plan, dated 04/05/2024, reflected Focus [Resident #85] has indwelling foley catheter. Goals: No injury related to catheter over next 90 days. Interventions: Ensure that catheter is secured to leg and drainage bag is covered. In an Observation and Interview on 06/04/24 at 11:28 AM revealed Resident #85 was in his wheelchair and the catheter bag was in contact with the floor. Resident #85 stated that he had often seen the catheter bag touching the floor many times. Resident #85 then proceeded to pick up the catheter bag tubing and placed it back on the side of his wheelchair. Interview with CNA Q on 06/04/24 at 11:34 AM revealed the catheter bag should not be touching the floor. She stated the CNA or nurses were responsible for emptying the bag. She did not see the catheter bag tubing on the floor until the time of this interview. She stated if the catheter bag was on the floor it could lead to increased risk of infections. In an interview with RN J on 06/5/24 at 2:52 PM revealed the catheter bag tubing should never touch the floor because of increased risk of infection. She stated that she was assigned to the resident and did not see the catheter bag on the floor until the time of this interview. She stated that Resident #85 was not compliant with keeping the catheter tubing off the floor. She stated that Resident #85 had several urine infections in the past and the risk of not keeping the catheter tubing off the floor can lead to increased risk of infection. In an interview with the DON on 6/5/24 at 2:56 PM revealed his expectation was the catheter bag should always be off the ground and below the resident's bladder, per nursing standards. He stated the risk for having a catheter bag in contact with the floor was increased risk for infections. Review of the facility's undated policy titled, Catheter Care, Urinary, reflected, The purpose of this procedure is to prevent catheter-associated urinary tract infections .The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Infection control .Use standard precautions when handling or manipulating the drainage system .Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (300 hall nurses' medication cart) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure the 300 Hall medication cart had: 1- 1 insulin pens with no label and with an expired opened date. 2- 1 insulin pen for Resident #250 with no opened date. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: 1- Observation on [DATE] at 12:48 PM revealed the 300-hall nurse's medication cart had a pen of Novolin R insulin pen 100 unit/ml, had no label an opened date of [DATE]. The label revealed discard after 28 days. 2- Record review of Resident #250's Comprehensive MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus and elevated blood pressure. She had a BIMS score of 15 indicating her cognition was intact. Record review of Resident #250's physician's orders dated [DATE] revealed an order for Humulin N subcutaneous suspension 100 unit/ml. Inject 30 unit subcutaneously (insertion of medications beneath the skin) at bedtime. Observation on [DATE] at 12:48 PM revealed the 300-hall nurse's medication cart had a vial of Humulin N- 100 unit/ml, for Resident #250, that did not have an opened date. Interview on [DATE] at 12:50 PM, RN A stated the insulin pen or vial was supposed to be labeled and have the name of the resident. He stated he did not give any one of the two insulins. He stated the Humulin N insulin belonging to Resident #250 did not have an open date. He stated the purpose of open dates was for expiration purposes because the insulin was only good for 28 days. He stated expired insulin would be ineffective and the insulin with no resident name was supposed to be discarded. Interview on [DATE] at 8:40 AM, the DON stated the insulin flex pens or vial, once opened, needed to be dated because each insulin pen or vial had a 28 or 30 days shelf life and if not thrown out before that time the insulin could lose its effectiveness. The DON stated the Assistant DON and the DON were supposed to do random check of the medication carts for monitoring. Record review of the facility's policy Medication Access and Storage revised [DATE], reflected the following: . 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy if a current order exists .

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of sixteen residents (Resident #78, Resident #13 and Resident #51) observed for infection control. 1. The facility failed to ensure that CNA D performed hand hygiene while providing incontinence care to Resident #78 on 06/04/24. 2. The facility failed to ensure that CNA F changed his gloves and performed hand hygiene while providing incontinence care to Resident #13 on 06/04/24. 3. The facility failed to ensure that CNA L changed her gloves and performed hand hygiene while providing incontinence care to Resident #51 on 06/04/24. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #78's Face sheet dated 06/06/24 reflected a [AGE] year-old male with an admitted [DATE]. Diagnoses included cerebral infarction (disrupted blood flow to the brain), hemiplegia affecting right side (paralysis) and chronic kidney disease. Record review of Resident #78's quarterly MDS assessment dated [DATE] reflected resident had a BIMS of 2 which indicated he was severely cognitively impaired. He was dependent for ADL care and was frequently incontinent of bladder and bowel. An observation on 06/04/24 at 11:30 a.m. revealed CNA D and CNA E entered Resident #78's room to provide incontinence care. Both staff washed their hands and put on gloves. CNA D unfastened the resident's brief and cleaned down each groin, across the pubic area and retracted the foreskin and cleaned the tip of the penis, wiped down the shaft and changed the wipes with each pass. Both staff assisted the resident onto his side revealing he had a moderate bowel movement. CNA D cleaned the resident from front to back, removed his gloves and put on clean gloves without performing hand hygiene. CNA D placed a clean brief under the resident and both staff repositioned the resident back onto his back and fastened the brief. Both staff then removed their gloves and washed their hands. In an interview with CNA D on 06/04/24 at11:20 a.m. he stated he was supposed to do hand hygiene before, after cleaning the resident, and when he changed his gloves and after completion. He stated he forgot to do hand hygiene when he changed his gloves after cleaning the resident. He stated the risk for failing to do hand hygiene was infection and cross contamination. Record review of CNA D's competency check off for hand hygiene revealed he was proficient in care as of 02/16/24. 2. Record review of Resident #13's Face sheet dated 06/06/24 reflected a [AGE] year-old female with an admitted [DATE]. Diagnoses included multiple sclerosis (chronic disease of the central nervous system), and overactive bladder. Record review of Resident #13's quarterly MDS assessment, dated 05/07/24, reflected she had a BIMS of 9 which indicated she was moderately cognitively impaired. She was dependent of care for all ADL. She was frequently incontinent of urine and always incontinent of bowel. In an observation on 06/04/24 at 03:20 p.m. CNA F and CNA G were observed entering Resident #13's room to transfer resident with a mechanical lift from her Geri-chair to the bed. Both staff washed their hands and put on gloves. The resident was transferred without incident. CNA F removed his gloves and left the room without performing hand hygiene to retrieve supplies for incontinences care. CNA F returned to the room and put on gloves without performing hand hygiene. CNA F opened the resident's brief and wiped down each groin, across the pubic area and down the middle using a different wipe each time. Both staff rolled the resident onto her side and CNA F removed the soiled brief and placed a clean brief under the resident before cleaning her peri anal area and buttocks. CNA F proceeded to wipe the resident's anal area revealing small bowel movement which fell on to the clean brief. CAN F picked up the bowel movement with a wipe, leaving a smear on the upper portion of the brief, and threw it into the trash can. CNA F continued with peri care and rolled the resident back onto the soiled brief and fastened the brief. Wearing the same gloves, CNA F adjusted the bed, and both staff removed the resident's gown and put a clean gown, covered her up and repositioned her in the bed. Both staff removed their gloves and washed their hands. In an interview on 06/06/24 at 03:40 p.m. with CNA F he stated he was supposed to wash his hands before and after care. He stated he was not aware he had to change his gloves after he finished cleaning the resident and before touching the clean brief or the resident's clean gown. He then stated he could see the risk of infections. He stated he should have washed his hands when he came back into the room with the supplies. In an interview on 06/04/24 at 03:50 p.m. with ADON A she stated staff were supposed to wash hands and change gloves before, after completion of cleaning a resident, and after completion of care. She stated she did the skills checks on her CNAs and any additional training they might need. She stated they were all taught to change their gloves when going from dirty to clean. She stated the risk of failing to perform hand hygiene is increased infections and cross contamination. 3. Record review of Resident #51's Face sheet dated 06/06/24 reflected Resident #51 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included paraplegia (paralysis that affects legs, but not arms) and chronic respiratory failure Record review of Resident #51's Comprehensive MDS assessment, dated 04/05/24, reflected Resident #51's cognition was severely impaired. The MDS assessment indicated Resident #51 was dependent of care for all ADLs. He requires 2 persons assist with rolling left and right. He was always incontinent of urine and bowel. Observation on 06/04/24 at 10:13 AM revealed CNA L entered Resident #51's room to provide incontinence care. CNA L had gloves in her hands. She unfastened Resident #51's brief and cleaned down each groin, across the pubic area and retracted the foreskin and cleaned the tip of the penis and wiped down the shaft. She removed her gloves and put on clean gloves without performing hand hygiene. She wiped the resident's buttock area with peri-wipes, front to back. She then removed the soiled brief and with soiled gloves, placed the clean brief under the resident. LVN N entered the room, and she helped CNA L to roll Resident #51 on his back onto the clean brief. LVN N left the room to bring clean linen. CNA L fastened the resident's brief. LVN N entered the room with clean linens, and CNA L covered Resident #51 with the blanket. Both staff removed their gloves and washed their hands. In an interview on 06/04/24 at 10:45 AM, CNA L stated she was supposed to do hand hygiene before, after, and in the middle of the procedure of incontinent care. She stated she should change her gloves and perform hand hygiene when she went from dirty to clean. She stated she was nervous and forgot to change gloves and perform hand hygiene. CNA L stated failing to provide proper care exposed the resident to infections. Record review of CNA L's competency check off for hand hygiene revealed she was proficient in care as of 08/28/23. In an interview on 06/06/24 at 11:11 a.m. with the DON he stated hand Hygiene was to be done before incontinence care, staff were to change gloves and perform hand hygiene after cleaning the resident and before putting on a clean brief and clean clothing. He stated the ADONs did skill checks on the staff, and he expected the ADON's and Charge nurses to make rounds and observe care provided by the staff. He stated if the ADON's or Charge nurses determine additional training was needed then he provided the training through in-services. He stated the failure to follow the procedure was risk of infection and cross contamination. Record review of CNA F's skill checks reflected both staff were skills checked on 06/04/24 and were competent in hand hygiene and perineal care. In a follow up interview with ADON A on 06/06/24 at 02:00 p.m. she stated she had been unable to locate CNA's F and G previous skills checks. She stated she knew the previous DON had performed those skills checks because they had a clinic where all the staff were skills checked with a mannequin, but stated she could not locate the documents. She stated she re-educated both staff and checked their competency on 06/04/24. Record review of the facility's undated policy titled, Handwashing/Hand Hygiene, reflected, The Facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection .Wash hands with soap and water .when hands are visibly soiled .Use an alcohol-based hand rub .Before and after direct contact with residents .Before moving from a contaminated body site to a clean body site during resident care .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace hand washing/hand hygiene .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that established a system of records of receipt and disposition of all controlled drugs in sufficient detail to ensure an accurate reconciliation for 4 of 5 carts (Carts 1, 2, 3, and 4) reviewed for securing controlled drugs. The facility failed to ensure all controlled drugs were received and counted according to facility procedure when nursing staff failed to document the count of controlled drugs on the medication carts. MA A failed to secure controlled drugs on cart #3. This failure could place residents at risk for misappropriation of their medications or not receiving the therapeutic benefits from medications because there are not available. Findings included: Cart 1: Review of a narcotic count sheet dated September 2023 for the nursing medication cart for the 100-hall showed: On 09/01/23 at the end of the 6:00 a.m. to 2:00 p.m. shift there were a total of 16 cards which indicated the number of controlled drugs in the cart. On 09/01/23 during the 2:00 p.m. to 10:00 p.m. shift there were 18 cards. There was no documentation as to why there were two additional cards on the cart. On 09/01/23 the count for the 10:00 p.m. to 6:00 a.m. shift there were 16 cards. There was no documentation of what happened to the 2-missing cared shown on the 2:00 pm to 10:00 pm shift. On 09/02/23 during the 6:00 a.m. to 2:00 p.m. shift there were 16 cards. On the 2:00 p.m. to 10:00 p.m. the number of cards was left blank. On the 10:00 p.m. to 6:00 a.m. shift there was 18-2. (18 minus 2). There was no documentation as to why this entry was made. On 09/03/23 during the 6:00 a.m. to 2:00 p.m. shift there were 16 cards. On the 2:00 p.m. to 10:00 p.m. shift the number of cards was left blank. An observation and record review on 09/03/23 at 10:21 a.m. of the nursing medication cart for the 100-hall showed an entry for 09/03/23 for the 10:00 p.m. to 6:00 a.m. showing 16 cards. (The entry had been made for a future shift). Observation of the number of cards in the cart on 09/03/23 at 10:25 a.m. showed 16 cards in the cart. During an interview on 09/03/23 at 10:21 a.m. LVN C said she works the 100-hall. LVN C said she completed a narcotic count this morning with the 10:00 a.m. to 6:00 a.m. Nurse. LVN-C said she not only counts the sheets but counts each pill on each card. LVN C said the count this morning showed 16 cards and all pills were accounted for in the cart. LVN C said there were two cards that went from the nurse's cart to the medication cart because the medication was changed to a routine medication and not a PRN (As needed) medication. LVN C said when the medication was changed to the medication aide cart, whomever moved the medication wrote a minus 2 on the narcotic count sheet showing the two cards had been removed. During an interview on 09/03/23 at 10:47 a.m. LVN/ADON said she did not remove the narcotics from the nursing cart on 100-hall to the medication cart on 100-hall. LVN/ADON said more in-service was needed on facility procedures for handling narcotics including transferring narcotics from one cart to the other. LVN/ADON the training needed to include discontinued medication and documentation of narcotics. LVN/ADON said each pill is counted during the narcotic count at the end of each shift or when the keys to the cart are given to another nurse or medication aide. LVN/ADON said the count sheet is used to document the count had been completed before the keys were passed as well as the number of count sheets on the cart at the time of the count. LVN/ADON said there had been a problem with missing count sheets and that is why the number of count sheets are also counted during the narcotic count. LVN/ADON said the nurses/medication aides are to count each pill on each card and count the number of count sheets on the cart to ensure none of the narcotic are missing. LVN/DON said staff failed to accurately document the count had been performed. Cart 2: Review of a narcotic count sheet dated September 2023 for the Medication Aide cart for the 100-hall showed: On 09/01/23 at the end of the 6:00 a.m. to 2:00 p.m. shift there were a total of 21 cards which indicated the number of controlled drugs in the cart. On 09/01/23 during the 2:00 p.m. to 10:00 p.m. shift there were 21 cards. On 09/01/23 the count for the 10:00 p.m. to 6:00 a.m. shift there were 24 cards. (The 24 had been written over what appeared to be 22) There was no documentation of why the increase from 21 cards to 24 cards. On 09/02/23 during the 6:00 a.m. to 2:00 p.m. the number of cards was left blank. On the 2:00 p.m. to 10:00 p.m. the number of cards showed 20. There was no documentation as to why the number of cards changed from 24 to 20. On the 10:00 p.m. to 6:00 a.m. shift there was 19. There was no documentation as to why the number of cards changed from 20 to 19. On 09/03/23 during the 6:00 a.m. to 2:00 p.m. shift the number of cards was blank. An observation and record review on 09/03/23 at 10:26 a.m. of the medication aide cart for the 100-hall showed an entry for 09/03/23 for the 10:00 p.m. to 6:00 a.m. showing 19 cards. (The entry had been made for a future shift). Observation of the number of cards in the card on 09/03/23 at 10:28 a.m. showed 19 cards in the cart. During an interview on 09/03/23 at 10:21 a.m. LVN C said during med count she would count all the pills and the cards. LVN C said she was to also count the number of sheets to ensure none of the count sheets are missing and record the number of sheets on the count sheet when she completes the count. LVN C only the DON or the ADON are to remove narcotics or count sheets from the cart. Cart #3: Observation on 09/03/23 at 10:35 a.m. showed the cart was on the 300-hall in front of room [ROOM NUMBER]. The door to room [ROOM NUMBER] was closed. The outside lock to the cart was unlocked. MA A was observed exiting the room. During an interview on 09/03/23 at 10:35 a.m. MA A said she was the medication aide for the 300-hall. MA A said she was in room [ROOM NUMBER] taking the blood pressure of the resident before administering his medication. MA A said she left the cart unlocked and should have locked the cart before going into the resident's room to take his blood pressure. MA said she conducted a count with LVN A at the 6:00 a.m. when she started her shift. MA A said she did not sign the count sheet showing the count had been completed. MA A said there is only one card of narcotics in the 310-317 cart. During an interview on 09/03/23 at 10:35 a.m. LVN A said he is the charge nurse for the 300-hall. LVN A said he counted the cart with MA A this morning at the start of her shift. LVN A said he failed to document the count was completed. LVN said all narcotics should be counted before the keys are given to another staff. LVN said there is only one card of narcotics in the 310-317 cart. Review of a narcotic count sheet dated September 2023 for the Medication Aide cart for the 310-317 hall showed: On 09/01/23 at the end of the 6:00 a.m. to 2:00 p.m. shift there was a total of 1 card which indicated the number of controlled drugs in the cart. On 09/01/23 during the 2:00 p.m. to 10:00 p.m. shift there was 1 card. On 09/01/23 the count for the 10:00 p.m. to 6:00 a.m. shift there was 1 card. On 09/02/23 during the 6:00 a.m. to 2:00 p.m. there was 1 card. On the 2:00 p.m. to 10:00 p.m. the number of cards showed 1. On the 10:00 p.m. to 6:00 a.m. shift the number of cards was left blank. On 09/03/23 during the 6:00 a.m. to 2:00 p.m. shift the number of cards was blank. Cart #4: Review of a narcotic count sheet dated September 2023 for the Medication Aide cart for the 200-hall showed: On 09/01/23 at the end of the 6:00 a.m. to 2:00 p.m. shift there were a total of 33 cards which indicated the number of controlled drugs in the cart. On 09/01/23 during the 2:00 p.m. to 10:00 p.m. shift the signatures were left blank and the count was 33. On 09/01/23 the count for the 10:00 p.m. to 6:00 a.m. shift there were 33 cards. On 09/02/23 during the 6:00 a.m. to 2:00 p.m. the number of cards was 33. On the 2:00 p.m. to 10:00 p.m. the number of cards showed 33. On the 10:00 p.m. to 6:00 a.m. shift there were 33. On 09/03/23 during the 6:00 a.m. to 2:00 p.m. shift the number of cards was blank. There was an entry of 33 cards for the 10:00 p.m. to 6:00 a.m. shift. (The entry had been made for a future shift). An Observation of the number of cards in the cart on 09/03/23 at 12:20 p.m. showed 33 cards in the cart. During an interview on 09/03/23 at 12:20 p.m., LVN B said she was the charge nurse for the 200-hall. LVN B said she did the narcotics count with the nurse going off shift when she started this morning at 6:00 a.m. LVN B said she failed to enter the number of cards on the count sheet after completing the count. LVN B said she was not sure why the nurse signed showing the count was 33 on the upcoming night shift, but more than likely it was done in error. During an interview on 09/08/23 at 9:10 a.m., the DON said she just started as the DON this week. The DON said she is concerned with the security of the narcotics and had updated the narcotics log and provided training to all nursing staff on conducting a narcotic count, documentation of when narcotics are received, administered, or discontinued. The DON said she also provided training to nurses on what to do when residents are discharged home or go out on leave. The DON sad she and the ADON are responsible for monitoring the carts to ensure nursing staff are accounting for all narcotics each shift. The DON said two nurses are required to sign when a narcotic is delivered, when the narcotic is placed on the medication cart, and when the narcotic is removed. The DON said this information will be recorded and reconciled with the count sheet during the narcotic count each shift and any variation in the count will immediately reported to the DON or the ADON. During an interview on 09/08/23 at 11:00 a.m. the Administrator said the concerns of the narcotic count was identified at the beginning of August 2023 when some medications were found to be missing. ADM said it was addressed in the QAPI meeting on July 31, 2023. ADM said the new DON had implanted a new count sheet that required two nurses to sign any time a narcotic was delivered or removed from the medication carts. ADM said the DON and/or the ADON will monitor to ensure narcotics are accounted for and kept secure. Review of in-service records dated 09/03/23 showed nursing staff received training on Discharging a resident with medication, Residents discharging to the hospital, Discrepancies in narcotic count, and Narcotic count. Review of in-service records dated 06/30/23 showed Discharging Home and Narcotics .Narcotic count sheet signed by 2 nurses the total medication sent with resident upon discharge. Resident/family must sign to verify medications released to them. Review of Quality Assurance and Performance Improvement (QAPI) dated 07/31/23 showed the issue of narcotics count and security was addressed at the meeting. The Medical Director was not present at the meeting. Review of the facility policy for Controlled Medication-Storage and reconciliation dated 01/2022 showed It is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments .This facility will maintain a process for monitoring, administration, documentation, reconciliation and destruction of controlled substances. 8. A reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record at each shift change. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit. ? The reconciliation at shift change includes controlled medications stored under refrigeration and those stored in emergency kits .

47006 Based on interviews and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 4 of 20 residents (Resident's #7, #23, #27, and #129) reviewed for comprehensive assessments and timing. 1. The facility failed to ensure Resident #129's cognitive status was assessed. 2. The facility failed to ensure Resident #7, #23, and #27's cognitive and mood statuses were assessed. This failure could place residents at risk of not having their needs identified and met. The findings included: 1. Record review of Resident #129's face sheet dated 3/20/23 revealed he was a [AGE] year-old, male, and admitted to the facility on [DATE] with diagnoses of cerebral infarction (disruption of blood flow to the brain which can parts of the brain to die off, also known as a stroke), hemiplegia and hemiparesis of right dominant side (weakness or inability to move the right side of the body), aphasia (loss of ability to understand or express speech caused from brain damage), dysphagia (difficulty swallowing), diabetes (disease of too much sugar in the blood), hypertension (high blood pressure), and anxiety (feeling of worry, unease, or nervousness). Record review of Resident #129's admission MDS dated [DATE] revealed Resident #129's BIMS interview was dashed, which indicated the BIMS interview was not completed. During an interview on 3/22/23 at 3:00 PM with MDS Coordinator G revealed Resident #129 should have had a BIMS, but the BIMS was not completed during the seven-day look back period. She said the Social Worker was responsible for completing the BIMS, but there was a time frame when they did not have a steady social worker. MDS Coordinator G said she identified there was a problem with the BIMS not being completed timely and had corrected the problem by having the social worker or the speech therapist responsible for completing the BIMS. 2. Record review of Resident #7's face sheet, dated 03/22/2023, revealed Resident #7 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and pulmonary fibrosis (disease in which the lungs become scarred (fibrosed) and damaged causing difficulty in breathing). Record review of the MDS assessment, dated 03/07/2023, revealed Resident #7 had clear speech and was understood by staff. The MDS revealed Resident #7 was able to understand others. The MDS revealed Resident #7's BIMS interview, which assessed cognitive function, should have been completed. The MDS revealed Resident #7's BIMS interview was dashed, which indicated the BIMS interview was not completed. The MDS revealed Resident #7's PHQ-9 interview, which assessed mood, should have been completed. The MDS revealed Resident #7's PHQ-9 interview was dashed, which indicated the PHQ-9 interview was not completed. 3. Record review of Resident #23's face sheet, dated 03/22/2023, revealed Resident #23 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of moderate intellectual disabilities (level of cognitive development and adaptive behavior that is moderately below age expectations), schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and borderline personality disorder (mental disorder characterized by the instability in mood, behavior, and functioning). Record review of the MDS assessment, dated 03/08/2023, revealed Resident #23 had clear speech and was understood by staff. The MDS revealed Resident #23 was able to understand others. The MDS revealed Resident #23's BIMS interview, which assessed cognitive function, should have been completed. The MDS revealed Resident #23's BIMS interview was dashed, which indicated the BIMS interview was not completed. The MDS revealed Resident #23's PHQ-9 interview, which assessed mood, should have been completed. The MDS revealed Resident #23's PHQ-9 interview was dashed, which indicated the PHQ-9 interview was not completed. 4. Record review of Resident #27's face sheet, dated 03/22/2023, revealed Resident #27 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the MDS assessment, dated 03/06/2023, revealed Resident #27 had clear speech and was understood by staff. The MDS revealed Resident #27 was able to understand others. The MDS revealed Resident #27's BIMS interview, which assessed cognitive function, should have been completed. The MDS revealed Resident #27's BIMS interview was dashed, which indicated the BIMS interview was not completed. The MDS revealed Resident #27's PHQ-9 interview, which assessed mood, should have been completed. The MDS revealed Resident #27's PHQ-9 interview was dashed, which indicated the PHQ-9 interview was not completed. During an interview on 03/22/2023 at 5:44 PM, MDS Coordinator G stated the social worker was responsible for completing the BIMS and the PHQ-9. MDS Coordinator G stated she was ultimately responsible for ensuring the BIMS and PHQ-9 interviews were completed prior to the ARD date. MDS Coordinator G stated the social worker started at the end of January 2023 and started completing the BIMS and PHQ-9 interviews timely. MDS Coordinator G stated the BIMS and PHQ-9 interviews were not completed for Residents #7, #23, and #27 because the ARD date was set late, and the interviews were not completed during the look-back period. MDS Coordinator G stated during the weekly Medicaid meeting it was determined by the IDT that an MDS assessment needed to be completed to capture current residents' statuses. MDS Coordinator G stated it was important to accurately assess Resident #7, #23, and #27's cognitive and mood statuses to ensure the MDS assessment accurately reflected the residents' status. MDS Coordinator G stated completing the BIMS and PHQ-9 was important for monitoring the resident's status, care planning, and to ensure the resident had no decline. During an interview on 03/22/2023 at 7:32 PM, the Administrator stated the IDT was responsible for ensuring the BIMS and PHQ-9 interviews were completed by the ARD date. The Administrator stated the IDT member's responsible could have been the social worker, therapist, or therapy assistant. The Administrator stated the IDT met multiple times a week to review the ARD dates and to ensure all parts were completed. The Administrator stated he expected the BIMS and PHQ-9 interview to be completed during the look-back period. The Administrator stated the MDS assessment should have accurately reflected the resident's status. The Administrator stated ensuring the MDS assessment had a completed BIMS and PHQ-9 interview was important because the facility used an MDS assessment to update the plan of care and services being provided. The MDS policy was requested. The Administrator stated the facility did not have a MDS policy, they referred to the RAI manual. Review of the CMS RAI Version 3.0 Manual, dated October 2019, revealed, in Chapter 3, Section C, page C-2 Coding Tips: Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) . The RAI Manual further revealed, in Chapter 3, Section D, page D-2 Coding Tips and Special Populations: Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) .

46062 Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 8 of 20 residents reviewed for palatable food. (Resident #239, Resident #240, and 6 residents in a confidential group). The facility failed to provide palatable food served at an appetizing temperature for Resident #239, Resident #240, and 6 residents in a confidential group. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: 1. Record review of Resident #239's face sheet dated 3/21/23 revealed she was an [AGE] year-old, female, and admitted to the facility on [DATE] with diagnoses of fracture of right ischium (broken right pelvis), history of falls, diabetes (disease of too much sugar in the blood), pain, and history of lung cancer. Record review of Resident #239's MDS revealed it had not been completed. Record review of Resident #239's BIMS assessment dated [DATE] revealed a BIMS of 15, which indicated she was cognitively intact. Record review of Resident #239's initial care plan dated 3/18/23 revealed she had a potential nutritional problem related to a disease process. Record review of the Resident #239's order summary report dated 3/21/23 revealed an order for a regular diet. During an interview on 3/20/23 at 4:34 PM, Resident #239 revealed the food was served cold and had no taste, especially the breakfast. She said breakfast was served with a top cover over a regular plate and did not have the bottom cover . During an observation and interview on 3/21/23 at 8:20 AM revealed a staff member delivered Resident #239's breakfast with just the top insulator covering a regular plate and sat the tray on the resident's bedside table and removed the top cover. Resident #239 said her food was cold again this morning and there was no salt or pepper for the egg. She said the whole plate was cold and asked the surveyor to touch the bottom of the plate, which reflected it was cool to touch. Resident #239 was served a hard fried egg, a biscuit, and 2 sausage patties and there were no condiments on the resident's tray to season the food. During an interview on 3/22/23 at 11:43 AM Resident #239 said her breakfast was cold again that morning, but there was an insulated cover on both the top and bottom of the plate. She said her pancakes were cold and would not melt her butter and her oatmeal was barely warm. She said lunch and dinner were usually warm, but nothing had any flavor, and they did not put salt or pepper on her trays. 2. Record review of Resident #240's face sheet dated 3/22/23 revealed she was a [AGE] year-old, female, and admitted to the facility on [DATE] with diagnoses of aortic valve stenosis (narrowing of the valve in the large blood vessel branching off the heart), aortic valve replacement (surgical replacement of the valve in the large blood vessel branching off the heart), diabetes (disease of too much sugar in the blood), hypertension (high blood pressure), paroxysmal atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), and chronic kidney disease (long term disease of the kidneys that effects the kidney's ability to filter waste and excess fluid from the blood). Record review of Resident #240's MDS revealed it had not been completed. Record review of Resident #240's BIMS assessment dated [DATE] revealed a BIMS of 14, which indicated she was cognitively intact. Record review of Resident #240's initial care plan dated 3/20/23 revealed the resident had a potential nutritional problem related to malnutrition. Record review of Resident #240's order summary report dated 3/22/23 revealed an order for a regular low concentrated sweets and no added sodium diet. During an interview on 3/22/23 at 11:52 AM Resident #240 revealed her breakfast was cold that morning, the eggs were overcooked, and there were no seasonings on the eggs or on her plate. She said the lunch pot roast yesterday was good, but the potatoes had no flavor, and the spinach was awful and tasted like it was just poured out of a can. She said she loved spinach and potatoes, but was unable to eat them, because they had no flavor. 3. During a confidential resident group meeting six out of six residents stated the food was not good at all. They stated most of the meals were cold and needed more seasoning. They stated the issue had been reported to staff but could not recall their names. They stated an alternative or substitution was usually requested. 4. During an observation and interview on 03/21/2023 at 12:36 p.m. a lunch tray was sampled by the Dietary Manager and five surveyors. The sample tray consisted of roast beef, potatoes & onions, spinach, a roll, and a brownie. The potatoes & onions were bland. The spinach was bland. The Dietary Manager stated the spinach and potatoes & onions were bland. There were no issues with the temperature of the food items tested . During an interview on 3/21/23 at 12:43 PM, the Dietary Manager revealed all meal trays for the residents on the hallways should have both top and bottom insulators to keep the plates warm during transport. She said if the resident's plate did not have the top and bottom insulators, the plate and food would cool down quicker. She said she was not in the facility during the breakfast service and was not aware the breakfast trays were served without the bottom insulator, but they should have had both a top and bottom insulator to keep the plates warm. Record review of the grievance resolution form dated 11/29/2022 indicated a resident complained about her meals being cold. The resolution stated the ADON informed the social worker a new scheduling system was set to be in place to reduce wait times for trays at mealtime. The Interim Administrator was working to correct issue. During an interview on 03/22/2023 at 1:47 p.m., CNA L stated residents complained to her about food not being seasoned. CNA L stated she offered the residents an alternative. CNA L stated all food complaints were reported to the charge nurse. CNA L stated resident's not eating their food could potentially cause weight loss. During an interview on 03/22/2023 at 1:55 p.m., LVN A stated residents complained to him about the food being bland. LVN A stated they could tell by the intake amount that some residents did not like the meal that day. LVN A stated he had reported the complaints to the dietician. LVN A stated he offered the residents an alternative. LVN A stated resident's not eating their food could potentially cause weight loss. During an interview on 03/22/2023 at 3:00 p.m., the Dietary Manager stated she had not received any food complaints from staff or residents. The Dietary Manager stated she visited with residents randomly to see if there were any complaints about the food. The Dietary Manager stated she monitors by tasting each meal selection daily through a regular and pureed diet. The Dietary Manager stated previously a test tray was done with the dietician that raised concerns or palatability seasoning. The Dietary Manager stated a verbal in-service was done with the cook that prepared the meal. The Dietary Manager stated there was an ongoing issue with a certain cook. The Dietary Manager stated if she was not supervised by a manager or team lead, she did not follow the menu directions on how to properly season the food. The Dietary Manager stated the test tray that was given to the surveyors was prepared by the cook that was already being monitored for ensuring the food was aligned with the policy and procedures. The Dietary Manager stated this failure could potentially cause weight loss and decrease in residents' independence. During an interview on 03/22/2023 at 6:51 p.m., the Administrator stated he expected all food to be palatable. The Administrator stated he had not received any food complaints from residents or staff. The Administrator stated a test tray was done randomly and he did not notice any issues with flavor. The Administrator stated this failure would result in residents not eating their vegetables which then could result in decreased nutritional values. Record review of the Dietary Services policy, last revised on 10/2022, indicated .1. Director of food service responsibilities . J. Assure food that was served palatable .

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 3 of 4 residents reviewed for accidents. (Residents #5, 58 and 63) The facility failed to ensure CNA AA transferred Resident #5 with two-person assistance. CNA AA transferred Resident #5 from bed to wheelchair without using two-person assistance. Resident #5 lost her balance during the transfer and was lowered to the floor. An x-ray indicated Resident #5 had an acute fracture in the distal right femur (area of the leg just above the knee joint). The facility failed to ensure CNA H locked the mechanical lift properly when transferring Resident #63. The facility failed to ensure CNA J and NA K did not lift Resident #58 from under the arm below the shoulder when performing a 2-person gait belt transfer. These failures could place residents who required the use of a gait belt or mechanical lift for transfers at risk of injury and hospitalization . Findings included: 1. Record review of a face sheet dated 02/09/22 indicated Resident #5 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of lower end of right femur, orthopedic aftercare, [CONDITION(S)] disease (stroke caused by insufficient blood flow or bleeding in the brain), abnormal posture, lower back pain, arthritis, muscle weakness, difficulty in walking, lack of coordination, unsteadiness on feet, anxiety disorder, muscle wasting and atrophy, [CONDITION(S)] disease (stroke caused by insufficient blood flow or bleeding in the brain), cognitive communication deficit and [CONDITION(S)] (decrease in the heart's pumping action to deliver oxygen to the body). Record review of the MDS dated [DATE] indicated Resident #5 required extensive two-person assistance with transfers and had no impairments to her upper and lower extremities. Resident #5 used a wheelchair for mobility. The MDS did not address Resident #5's cognition. Record review of the care plan revised on 04/29/19 indicated Resident #5 had an ADL self-care performance deficit related to a history of [CONDITION(S)] accident (stroke), pain, arthritis, abnormal gait, and abnormal posture. Interventions included Resident #5 required physical assistance with transferring. The care plan interventions did not address the type of transfer or staff assistance required with transfers. Record review of the Kardex on 02/08/22 indicated Resident #5 required physical assistance during transfers. The Kardex did not address the type of transfer needed to transfer Resident #5. Record review of an incident report dated 01/15/19 at 2:02 a.m., indicated LVN Z was called to Resident #5's room and noted Resident #5 was on her buttocks to left side of her bed. CNA X reported Resident #5 lost her footing during the transfer and Resident #5's right leg got twisted under her when he lowered her to the ground. Resident #5 said she got weak. Resident #5 was assessed, complained of pain to her right knee tried to straighten her leg and was sent to the hospital. Record review of a hospital x-ray dated 01/15/22 at 2:42 a.m., indicated Resident #5 had an acute fracture in the distal right femur at the metadiaphysis extending to the femoral stem component of the knee prothesis is identified with mild displacement. No dislocation is present. Record review of a provider investigation report signed and submitted to the state office on 01/21/22 by the Administrator indicated a staff member (unknown) transferred Resident #5 from her wheelchair to her bed and lost her balance. Resident #5 was assisted to the floor by the staff member and pinned her leg underneath herself and the wheelchair. The staff member notified the nurse. Resident #5 complained of pain to her leg when the nurse attempted to straighten the resident's leg. Resident #5 was discharged to the hospital and diagnosed with a leg fracture. Resident #5 had surgery to repair her fractured leg. The investigation summary indicated facility protocols and best practices were followed and the fracture sustained was not a result of any negligence or wrongdoing on part of the facility and its staff. The investigation finding indicated the allegation was unfounded. The investigation report did not have witness statements. During an observation and interview on 02/08/22 at 2:09 p.m., Resident #5 was in her room sitting in a wheelchair with her right leg propped up and straight. Resident #5 had several staples to her right knee. Resident #5 said she was in bed and pushed her call light button to call for assistance because she needed to use the bathroom. Resident #5 said she was in bed and CNA AA answered her call light. Resident #5 said CNA AA transferred her by himself to her wheelchair and lowered her to the floor after her legs became weak during the transfer. Resident #5 said she had pain in her right leg and was sent to the hospital. Resident #5 said since she broke her leg, she was transferred with a Hoyer lift. During a phone interview on 02/09/22 at 6:00 AM, CNA AA said he was responsible for providing care to Resident #5 and worked the 10 p.m. to 6 a.m. shift. CNA AA said Resident #5 could stand with assistance and required a gait belt with one-person assistance when transferred. CNA AA said he answered Resident #5's call light. CNA AA said Resident #5 was in her bed and he placed a gait belt on her. CNA AA said he transferred Resident #5 from her bed to her wheelchair by himself and when she stood up her legs gave out. CNA AA said he assisted Resident #5 to the floor and her right leg was bent back underneath her and the wheelchair. CNA AA said he notified the charge nurse and Resident #5 complained of pain when the nurse assessed her. CNA AA said Resident #5 was sent to the hospital and diagnosed with a right leg fracture. CNA AA said he used the computerized charting system and looked in the Kardex section under the resident's name to find what level of assistance is needed. CNA AA said Resident #5's Kardex showed she was a one-person assistance when he transferred her. CNA AA said he did not know Resident #5 needed two-person assistance when he transferred or why it was not updated. CNA AA said Resident #5 would not have been injured if her Kardex was updated with the correct level of assistance needed for transfers. CNA AA said he was not interviewed or asked to write a witness statement about Resident #5's fall. During an interview on 02/09/22 at 1:20 p.m., the administrator said he was the abuse coordinator. The administrator said Resident #5 had a fall during the night shift and fractured her right leg. The administrator said he investigated Resident #5's fall and submitted the final investigation report to the state. The administrator he reviewed Resident #5's incident report and concluded CNA AA transferred Resident #5 appropriately and was not at fault. The administrator said there was enough information in Resident #5's incident report for him to make his conclusion. The administrator said he did not interview or get a written witness statement from CNA AA and LVN CC during his investigation and was unaware he needed to do so. The administrator said he was unaware Resident #5 was an extensive two-person assistance with transfers when she fell . The administrator said he did not know who was responsible for updating a resident's care plan. The administrator said he had access to Resident #5's care plan and MDS and should have looked at it during his investigation. During an interview on 02/09/22 at 1:55 p.m., RN BB said she was the MDS nurse and was responsible for completing a residents MDS and updating their care plan. RN BB said she updated a care plan if a resident has a change in condition, change in assistance and MDS changes. RN BB said a care plan was used to promote safety when providing care to a resident. RN BB said she completed and signed Resident #5's MDS on 11/07/21. RN BB said she believed she documented the resident required extensive one-person assistance with transfers but was not sure and would look. RN BB said, after she reviewed Resident #5's MDS dated [DATE] and care plan, the MDS indicated she was an extensive two-person assistance with transfers and her care plan indicated she required physical assistance with transfers which means one-person. RN BB said she did not update Resident #5's care plan and should have when her level of assistance changed. RN BB said Resident #5's Kardex said she required physical assistance with transfers which means that one-person needed to assist her. RN BB said it was overwhelming when there were weeks she had 70 or more care plans to update, and it was an oversight by her Resident #5's care was not updated. RN BB said the CNA's used the Kardex section in the computer charting system to find what level of assistance is required. RN BB said the Kardex updates immediately after the care plan has been updated. RN BB said Resident #5 would not have been injured if she updated her care plan. Record review of a Safe Transfer policy revised on 05/2007 indicated, It is the policy of this facility to transfer a resident in a safe manner .2. Know the resident's abilities and limitations. Transfer status can be found in the Kardex in PCC and also POC .3. Two-person transfers using a gait belt .F. Provide the necessary help for the resident to stand up. The caregivers should stand on both sides of the resident and hold the gait belt .Mechanical lift transfers are usually used for residents who are very large or extremely dependent .1. Always be aware of and follow the manufacturer's recommendations for the particular lift being used .10. Always reevaluate the resident's position, the location of the slings, and the security of the attachments before moving away from the bed or chair. 2. Record review of the consolidated physician orders dated 02/09/22 indicated Resident #58 was 93-years-old, admitted to the facility on [DATE] with diagnoses including dementia, history of falling, bilateral [CONDITION(S)] of knee, muscle weakness, muscle wasting and atrophy (wasting away of body tissues as a result of degeneration of calls), and need for assistance with personal care. Record review of the MDS dated [DATE] indicated Resident #58 usually understood others and was understood by others. The MDS indicated Resident #58 was severely cognitively impaired with a BIMS score of 04. The MDS indicated Resident #58 required extensive assistance with bed mobility, transferring, dressing, personal hygiene, and toileting. The MDS indicated Resident #58 required limited supervision with eating. Record review of the care plan updated on 01/17/22 indicated Resident #58 has an activities of daily living self-care performance deficit related to limited mobility, pain, and limited range of motion. During an observation on 02/08/22 at 1:55 p.m. CNA J and NA K were performing a 2-person gait belt (a device put on a patient/resident who has mobility issues to aid in safe movement of the patient/resident) transfer from wheelchair to bed on Resident #58. CNA J placed the gait belt around Resident #58's torso. CNA J and NA K each placed an arm under Resident #58's arm directly below the shoulder, then grabbed the gait belt from the back, and transferred Resident #58 from the wheelchair to the bed. During an interview on 02/08/22 at 02:00 p.m. PTA Q said staff should never place their arms under a resident's arm when performing a 2-person gait belt transfer. PTA Q said transferring a resident in that manner could cause injury to the resident being transferred. During an interview on 02/08/22 at 02:10 p.m. CNA J said she always performed 2-person gait belt transfers by putting an arm under the resident's arm below the shoulder to lift. CNA J said staff should not transfer a resident by lifting under the arm below the shoulder. CNA J said staff should only use the gait belt to aid with lifting a resident during that type of transfer. CNA J said the importance of not lifting under the arm below the shoulder was to prevent injury or breaking a resident's bone. CNA [NAME] said she received training on resident transfers twice a year. During an interview on 02/08/22 at 2:41 p.m. CNA M said when performing a gait belt transfer staff should only lift with the gait belt. CNA M said when residents were lifted under the arm below the shoulder it put the resident at risk for injury including shoulder dislocation, skin tear, or other injury. During an interview on 02/08/22 at 3:35 p.m. LVN N said staff should never lift a resident from under the arm below the shoulder. LVN N said transferring a resident under the arm below the shoulder put the resident at risk for getting off balance or shoulder dislocation. During an interview on 02/09/22 at 09:58 a.m. LVN P said during a gait belt transfer a resident should never be lifted from under the arm below the shoulder. LVN P said the importance of not lifting from under the arm below the shoulder was to prevent injury. During an interview on 02/09/22 at 11:25 a.m. ADON F said staff should not lift a resident from under the arm below the shoulder during a gait belt transfer. ADON F said transferring a resident under the arm below the shoulder could cause injury to the resident. ADON F said the ADON's perform CNA skills checkoffs annually and as needed for training and efficiency of skills including proper transfer techniques. During an interview on 02/09/22 at 02:31 p.m. the Administrator said when staff were transferring residents with gait belt staff should not lift with their arm under the resident's arm at the shoulder. The Administrator said the importance of not transferring in this manner was to prevent injury. Record review of Gait Belt/Transfer Belt policy dated 05/2007 indicated, It is the policy of this facility to: Provide safety for the unsteady and/or confused resident. Aid in the transfer of the dependent resident. Prevent injuries to employees and residents .Two-person transfer .Place gait belt around resident's waist; snug but not tight. Avoid ribs, hip bone, or breasts. Grasp the gait belt on either side. Staying close to the resident, the assistance should rock back and forth, synchronizing movements and shifting weight from one leg to the other while maintaining a backward pelvic tilt. With hips and knees bent, and on the count of three, lift the resident .

Based on observation, interview, and record review the facility failed to ensure each resident was free from abuse neglect, misappropriation of resident property, and exploitation for one of (Resident #5) of seven residents review for abuse and neglect. LVN F failed to assess Resident #5 on the significance of the resident's pain and having the resident wait over an hour for pain medication. LVN F was loud, and shook her head in Resident #5's face told the resident, the doctor should order pain medication differently and she would have to wait for the medication. LVN F also told the Resident she was working two halls. These failures placed Resident # 5 at increased risk for unrelieved pain and suffering, and the 46 residents on pain management at risk for unmanaged pain control and 51 residents on hall 100 and 300 where LVN F worked for abuse and unmet needs. Findings included: Resident #5's Electronic Face Sheet reflected she was a [AGE] year-old female who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS dated [DATE] reflected the resident was cognitively alert and oriented and able to make decisions and relate her needs without difficulty. The pain Assessment Scale dated 04/23/17 reflected the resident was a high risk for pain at a level 12. Level greater than 10 was a high risk for pain. Resident #5's care plan, dated 04/23/17, reflected she was a risk for pain. The goal was to be able to verbalize pain. The interventions were to monitor for signs/symptoms of pain, follow the pain scale, monitor and record pain, observe for non-verbal pain, moaning .allow resident to verbalize feeling of pain or discomfort .pain assessment completed per policy and notify MD if medication is ineffective. On 05/01/17 at 10:23 a.m. during an observation and interview with Resident # 5 the resident had her call light on and stated she had it on for a while and she needed to go to the bathroom. Resident # 5 revealed she had a problem getting her pain medication on the night shift. Resident # 5 revealed on one night 04/23/14 she was suffering with her leg and she could not get her pain pill. The nurse came in asked what she wanted and when the resident asked for her pain medication The nurse said she would have to wait. When the resident inquired further the nurse got in her face and said she would have to wait, was loud, shook her head at the resident and said you are not the only one who gets medicine at 11:00 p.m. and the doctor should have ordered it different. She further reveled the doctor told her to take the medicine when the pain first started and not to let it get bad because it would take longer for the medication to work, when the resident tried to tell the nurse that information, the nurse told the resident she was working two halls. I had wait over an hour for my medication. It took the pain medication much longer to work and did not completely alleviate my pain. When asked if the resident had reported it to any one she said no but then said she told her daughter and she told the front office she believed the head nurse. The Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED] recieve medication for pain at 11:00 p.m but did not have any medication signed as administered. Review of the Medication Administration Record [REDACTED]. Nurses Notes dated 04/23/17 at 4:29 a.m. the pain medication was effective. There was no mention if the resident was resting, asleep or what her pain scale was. Review of the Grievance Interview Record from family member dated 04/25/17 which mentioned the resident did not get her pain medication for over an hour and the nurse was being rude to her and talking loudly to the resident. The DON talked with LVN F working that night and the LVN F revealed she was with another resident and said the resident asked her why she was talking so loud. The LVN F said she did not think the Resident #5 heard her. The DON informed the family of the her results, and moved the nurse to another hall. According to the form the LVN F was not to go back into Resident #5's room. Review of the Grievance Interview Record from a family member dated 04/27/17, the family was concered with pain medication being administered timely, assistance to the restroom and how long resident was going to require therapy. A Concern that the daughter has to call and remind resident to call the nurse for pain medication and it is taking a long time for the nurses to bring the medication sometimes over an hour, and revealed it takes a long time to answer the call light. The form revealed the ADON reassured the family they would take care of the family concerns. On 05/01/17 at 2:13 p. m. during an interview with the Director of Nurses she was asked about pain medication delivery and she reflected medication was given according to the physician's orders [REDACTED]. She mentioned the incident with Resident #5 and she revealed she was aware of the situation and spoke with the daughter and the family was satisfied with what had been done. When asked what she did? The DON revealed she wrote up a grievance form, talked with the resident, the nurse, and moved the nurse to another hall. The DON was asked if a counseling form was done for the nurse and she revealed no she did not do one. She also revealed she interviewed other residents on the hall and they had no problems. The DON was asked to see the interviews and she revealed she did not write them up. On 05/01/17 at 2:30 p.m. and 5:30 p.m. the DON was asked for the phone number of LVN F and she attempted to reach the LVN F who administered the medication, however there was no answer on her telephone or a return phone call. On 05/11/17 at 1:30 p.m. attempted to reach LVN F by telephone, left a message for her to return the call, by 5:00 p.m. there was no return phone call. On 05/01/17 at 2:13 p.m. an interview with the DON regarding the incident with Resident #5 and she revealed she did not know about it until 04/25/17 when the family member came in and filed a grievance. The grievance said it took too long to get pain medication, and when the nure did finally bring it to Resident #5, LVN F was rude and very loud to the resident. The DON revealed she listened to her concerns and told her she would get back to her. The family was satisfied with her actions. However there was another concern addressed on 04/27/17. The staff reassured the family they would take care of their concerns. When asked if she thought the nurse being loud and rude to the resident was verbal abuse she stated no not based on what the LVN had told her. When asked if delaying the pain medication for an hour according to the resident and family member and causing the resident to suffer was neglect she did not think so at the time. On 05/01/17 at 6:27 p.m. the surveyor interviewed the Operation Manager and asked him his expectation was to report the incident to the DON. Obviously she was getting different stories. Today was the first time I heard of the incident that occurred with Resident #5 on 04/23/17 and the reports on 04/25/17 and 04/27/17. What would you have done with this incident knowing what you know now? I would have reported it as abuse and neglect. The Administrator on 05/01/17 at 5:35 p.m. was not made aware of the the abuse and negect issues until 05/01/17 and would have reported them had he know about them. The facility's Policy/Procedure for Abuse Prevention, dated 11/28/16, reflected: All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. When an incident or allegation of resident abuse or injury of an unknown source is identified, the Administrator/ Designee will initiate an investigation. A license nurse shall immediately examine the resident upon receiving reports of alleged physical or sexual abuse. They finding of the examination shall be recorded in the resident's medical record. The investigation shall consist of: 1. An interview with the person(s) reporting the incident; 2. An interview with the resident(s); 3. Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; 4. A review of the resident's medical record; 5. An interview with staff members (on all shifts) having contact with the resident (s) during the period of the alleged incident; 6. Interviews with other residents to whom the accused employee provides care or service; 7. An interview with staff members (on all shifts) having contact with the accused employee; and 8. A review of all circumstances surrounding the incident . 2. If the suspected perpetrator is an employee: a. Remove employee immediately form the care of any resident; b. Suspend employee during the investigation All alleged violations will reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days. (See separate Elder Justice Act reporting requirements on separate policy) . The facility's Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the MDS Coordinator on 04/29/17, The Census Sheet dated 04/28/17 provided by the Operations manager reflected 46 residents were on a pain management program. There were 51 residents who resided on 100 and 300 Halls combined.

Based on observation, interview, and record review the facility failed to ensure each resident was free from abuse neglect, misappropriation of resident property, and exploitation for one of (Resident #5) of seven residents review for abuse and neglect. LVN F failed to assess Resident #5 on the significance of the resident's pain and having the resident wait over an hour for pain medication. LVN F was loud, and shook her head in Resident #5's face told the resident, the doctor should order pain medication differently and she would have to wait for the medication. LVN F also told the Resident she was working two halls. These failures placed Resident # 5 at increased risk for unrelieved pain and suffering, and the 46 residents on pain management at risk for unmanaged pain control and 51 residents on hall 100 and 300 where LVN F worked for abuse and unmet needs. Findings included: Resident #5's Electronic Face Sheet reflected she was a [AGE] year-old female who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS dated [DATE] reflected the resident was cognitively alert and oriented and able to make decisions and relate her needs without difficulty. The pain Assessment Scale dated 04/23/17 reflected the resident was a high risk for pain at a level 12. Level greater than 10 was a high risk for pain. Resident #5's care plan, dated 04/23/17, reflected she was a risk for pain. The goal was to be able to verbalize pain. The interventions were to monitor for signs/symptoms of pain, follow the pain scale, monitor and record pain, observe for non-verbal pain, moaning .allow resident to verbalize feeling of pain or discomfort .pain assessment completed per policy and notify MD if medication is ineffective. On 05/01/17 at 10:23 a.m. during an observation and interview with Resident # 5 the resident had her call light on and stated she had it on for a while and she needed to go to the bathroom. Resident # 5 revealed she had a problem getting her pain medication on the night shift. Resident # 5 revealed on one night 04/23/14 she was suffering with her leg and she could not get her pain pill. The nurse came in asked what she wanted and when the resident asked for her pain medication The nurse said she would have to wait. When the resident inquired further the nurse got in her face and said she would have to wait, was loud, shook her head at the resident and said you are not the only one who gets medicine at 11:00 p.m. and the doctor should have ordered it different. She further reveled the doctor told her to take the medicine when the pain first started and not to let it get bad because it would take longer for the medication to work, when the resident tried to tell the nurse that information, the nurse told the resident she was working two halls. I had wait over an hour for my medication. It took the pain medication much longer to work and did not completely alleviate my pain. When asked if the resident had reported it to any one she said no but then said she told her daughter and she told the front office she believed the head nurse. The Physician order [REDACTED]. Review of the medicationAdministration Record for April 2017 reflected Resident #5 was able to recieve medication for pain at 11:00 p.m. but there was no medication doumented as being administered. Review of the Medication Administration Record [REDACTED]. Nurses Notes dated 04/23/17 at 4:29 a.m. the pain medication was effective. There was no mention if the resident was resting, asleep or what her pain scale was. Reviewe of the Grievance Interview Record from family member dated 04/25/17 which mentioned the resident did not get her pain medication for over an hour and the nurse was being rude to her and talking loudly tothe resident. The DON talked with LVN F working that night and the LVN F revealed she was with another resident and said the resident asked her why she was talking so loud. The LVN F said she did not think the Resident #5 heard her. The DON informed the family of the of her results, and moved the nurse to another hall. According to the form the LVN F was not to go back into Resident #5's room. Reviewe of the Grievance Interview Record from a family member dated 04/27/17 the family was concered with pain medication, being administered timely, assistance to the restroom and how long resident was going to require therapy. Concern the daughter has to call and remind resident to call the nurse for pain medication and it is taking a long time for the nurses to bring the medication sometimes over an hour, and revealed it takes a long time to answer the call light. The form revealed the ADON reassured the family they would take care of the family concerns. On 05/01/17 at 2:13 p. m. during an interview with the Director of Nurses she was asked about pain medication delivery and she reflected medication was given according to the physician's orders [REDACTED]. She mentioned the incident with Resident #5 and she revealed she was aware of the situation and spoke with the daughter and the family was satisfied with what had been done. When asked what she did? The DON revealed she wrote up a grievance form, talked with the resident, the nurse, and moved the nurse to another hall. The DON was asked if a counseling form was done for the nurse and she revealed no she did not do one. She also revealed she interviewed other residents on the hall and they had no problems. The DON was asked to see the interviews and she revealed she did not write them up. On 05/01/17 at 2:30 p.m. and 5:30 p.m. the DON was asked for the phone number of LVN F and she attempted to reach the LVN F who administered the medication, however there was no answer on her telephone or a return phone call. On 05/11/17 at 1:30 p.m. attempted to reach LVN F by telephone, left a message for her to return the call, by 5:00 p.m. there was no return phone call. On 05/01/17 at 2:13 p.m. an interview with the DON regarding the incident with Resident #5 and she revealed she did not know about it until 04/25/17 when the family member came in and filed a grievance. The grievance said it took too long to get pain medication, and when the nure did finally bring it to Resident #5, LVN F was rude and very loud to the resident. The DON revealed she listened to her concerns and told her she would get back to her. The family was satisfied with her actions. However there was another concern addressed on 04/27/17. The staff reassured the family they would take care of their concerns. When asked if she thought the nurse being loud and rude to the resident was verbal abuse she stated no not based on what the LVN had told her. When asked if delaying the pain medication for an hour according to the resident and family member and causing the resident to suffer was neglect she did not think so at the time. On 05/01/17 at 6:27 p.m. interviewed the Operation Manager and asked him his expectation was to report the incident to the DON. Obviously she was getting different stories. Today was the first time I heard of the incident that occurred with Resident #5 on 04/23/17 and the reports on 04/25/17 and 04/27/17. What would you have done with this incident knowing what you know now? I would have reported it as abuse and neglect. The Administrator on 05/01/17 at 5:35 p.m. was not made aware of the the abuse and negect issues until 05/01/17 and would have reported them had he know about them. The Facility's Policy/Procedure for Abuse Prevention, dated 11/28/16, reflected: All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. When an incident or allegation of resident abuse or injury of an unknown source is identified, the Administrator/ Designee will initiate an investigation. A license nurse shall immediately examine the resident upon receiving reports of alleged physical or sexual abuse. They finding of the examination shall be recorded in the resident's medical record. The investigation shall consist of: 1. An interview with the person(s) reporting the incident; 2. An interview with the resident(s); 3. Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; 4. A review of the resident's medical record; 5. An interview with staff members (on all shifts) having contact with the resident (s) during the period of the alleged incident; 6. Interviews with other residents to whom the accused employee provides care or service; 7. An interview with staff members (on all shifts) having contact with the accused employee; and 8. A review of all circumstances surrounding the incident . 2. If the suspected perpetrator is an employee: a. Remove employee immediately form the care of any resident; b. Suspend employee during the investigation All alleged violations will reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days. (See separate Elder Justice Act reporting requirements on separate policy) . The facility's Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the MDS Coordinator on 04/29/17, The Census Sheet dated 04/28/17 provided by the Operations manager reflected 46 residents were on a pain management program. There were 51 residents who resided on 100 and 300 Halls combined.

Based on observation, interview, and record review, the facility failed ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures to implement a written policy which ensured that each resident was free of abuse and neglect, for one of (Residents #5) of seven residents reviewed for abuse and neglect. and report the incident within 24 hours of determining an incident had occurred and possibly involved abuse and neglect. The facility failed to implement the written policy and procedure for abuese and neglect. The DON failed to appropriately investigate, keep residents safe, and report the an alleged incident of abuse to the State Survey Agency. appropriate agency. LVN F failed to assess Resident #5 on the significance on of the residents' pain and having the resident wait over an hour for pain medication. LVN F was loud, and shook her head in the Resident #5's face, told the resident, the doctor should order pain medication differently and she would have to wait for the medication. LVN F also told the Resident she was working two halls. These failures placed 99 residents at risk for abuse and neglect and Resident # 5 at increased risk for unrelieved pain and suffering, and the 46 resident's on pain management at risk for unmanaged pain control and 51 residents on hall 100 and 300 where LVN F worked for abuse and unmet needs. Findings included: The facility's Policy/Procedure for Abuse Prevention, dated 11/28/16, reflected: All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. When an incident or allegation of resident abuse or injury of an unknown source is identified, the Administrator/ Designee will initiate an investigation. A license nurse shall immediately examine the resident upon receiving reports of alleged physical or sexual abuse. They finding of the examination shall be recorded in the resident's medical record. The investigation shall consist of: 1. An interview with the person(s) reporting the incident; 2. An interview with the resident(s); 3. Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; 4. A review of the resident's medical record; 5. An interview with staff members (on all shifts) having contact with the resident (s) during the period of the alleged incident; 6. Interviews with other residents to whom the accused employee provides care or service; 7. An interview with staff members (on all shifts) having contact with the accused employee; and 8. A review of all circumstances surrounding the incident . 2. If the suspected perpetrator is an employee: a. Remove employee immediately form the care of any resident; b. Suspend employee during the investigation All alleged violations will reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days. (See separate Elder Justice Act reporting requirements on separate policy) . Resident #5's Electronic Face Sheet reflected she was a [AGE] year-old female who admitted to the facility on [DATE] e following Diagnoses: [REDACTED]. Resident #5's Electronic Face Sheet reflected she was a [AGE] year-old female who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS dated [DATE] reflected the resident was cognitively alert and oriented and able to make decisions and relate her needs without difficulty. The pain Assessment Scale dated 04/23/17 reflected the resident was a high risk for pain at a level 12. Level greater than 10 was a high risk for pain. Resident #5's care plan, dated 04/23/17, reflected she was a risk for pain. The goal was to be able to verbalize pain. The interventions were to monitor for signs/symptoms of pain, follow the pain scale, monitor and record pain, observe for non-verbal pain, moaning .allow resident to verbalize feeling of pain or discomfort .pain assessment completed per policy and notify MD if medication is ineffective. On 05/01/17 at 10:23 a.m. during an observation and interview with Resident # 5 the resident had her call light on and stated she had it on for a while and she needed to go to the bathroom. Resident # 5 revealed she had a problem getting her pain medication on the night shift. Resident # 5 revealed on one night 04/23/14 she was suffering with her leg and she could not get her pain pill. The nurse came in asked what she wanted and when the resident asked for her pain medication The nurse said she would have to wait. When the resident inquired further the nurse got in her face and said she would have to wait, was loud, shook her head at the resident and said you are not the only one who gets medicine at 11:00 p.m. and the doctor should have ordered it different. She further reveled the doctor told her to take the medicine when the pain first started and not to let it get bad because it would take longer for the medication to work, when the resident tried to tell the nurse that information, the nurse told the resident she was working two halls. I had wait over an hour for my medication. It took the pain medication much longer to work and did not completely alleviate my pain. When asked if the resident had reported it to any one she said no but then said she told her daughter and she told the front office she believed the head nurse. The Physician order [REDACTED]. Review of the MedicationAdministration Record for April 2017 reflected Resident #5 was able to recieve medication for pain at 11:00 p.m. Review of the Medication Administration Record [REDACTED]. Nurses Notes dated 04/23/17 at 4:29 a.m. the pain medication was effective. There was no mention if the resident was resting, asleep or what her pain scale was. Reviewe of Grievance Interview Record from family member dated 04/25/17 which mentioned the resident did not get her pain medication for over an hour and the nurse was being rude to her and talking loudly tothe resident. The DON talked with LVN F working that night and the LVN F revealed she was with another resident and said the resident asked her why she was talking so loud. The LVN F said she did not think the Resident #5 heard her. The DON informed the family of the of her results, and moved the nurse to another hall. According to the form the LVN F was not to go back into Resident # #5's room. The concern of the familiy member was the need to call and remind resident to call the nurse for pain medication and it taking a long time for the nurses to bring the medication sometimes over an hour, and revealed it takes a long time to answer the call light. The form revealed the ADON reassured the family they would take care of the family concerns. On 05/01/17 at 2:13 p. m. during an interview with the Director of Nurses she was asked about pain medication delivery and she reflected medication was given according to the physician's orders [REDACTED]. She mentioned the incident with Resident #5 and she revealed she was aware of the situation and spoke with the daughter and the family was satisfied with what had been done. When asked what she did? The DON revealed she wrote up a grievance form, talked with the resident, the nurse, and moved the nurse to another hall. The DON was asked if a counseling form was done for the nurse and she revealed no she did not do one. She also revealed she interviewed other residents on the hall and they had no problems. The DON was asked to see the interviews and she revealed she did not write them up. When asked if she wrote up the residents statement she replied no. The DON was asked if she reported the incident to the administrator or the state she again replied no as she did not think it was abuse. When asked about delaying the medication for an hour and the resident suffering with pain as the resident and family member said did she see it as neglect? The DON replied not at the time. On 05/01/17 at 2:30 p.m. and 5:30 p.m. the DON was asked for the phone number of LVN F and she attempted to reach the LVN F who administered the medication, however there was no answer on her telephone or a return phone call. On 05/11/17 at 1:30 p.m. attempted to reach LVN F by telephone, left a message for her to return the call, by 5:00 p.m. there was no return phone call. The Administrator on 05/01/17 at 5:35 p.m. was not mate aware of the the abuse and negect issues untile 05/01/17 and would have reported themm had he know about them. On 05/01/17 at 6:27 p.m. interviewed the Operation Manager and asked him his expectation was to report the incident to the DON. Obviously she was getting different stories. Today was the first time I heard of the incident that occurred with Resident #5 on 04/23/17 and the reports on 04/25/17 and 04/27/17. The Administrator on 05/01/17 at 5:35 p.m. was not made aware of the the abuse and negect issues until 05/01/17 and would have reported themm had he know about them. The facility's Policy/Procedure for Abuse Prevention, dated 11/28/16, reflected: All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. When an incident or allegation of resident abuse or injury of an unknown source is identified, the Administrator/ Designee will initiate an investigation. A license nurse shall immediately examine the resident upon receiving reports of alleged physical or sexual abuse. They finding of the examination shall be recorded in the resident's medical record. The investigation shall consist of: 1. An interview with the person(s) reporting the incident; 2. An interview with the resident(s); 3. Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; 4. A review of the resident's medical record; 5. An interview with staff members (on all shifts) having contact with the resident (s) during the period of the alleged incident; 6. Interviews with other residents to whom the accused employee provides care or service; 7. An interview with staff members (on all shifts) having contact with the accused employee; and 8. A review of all circumstances surrounding the incident . 2. If the suspected perpetrator is an employee: a. Remove employee immediately form the care of any resident; b. Suspend employee during the investigation All alleged violations will reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days. (See separate Elder Justice Act reporting requirements on separate policy) . The facility's Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the MDS Coordinator on 04/29/17, The Census Sheet dated 04/28/17 provided by the Operations manager reflected the census was 99 residents including

Based on interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident # 5) of four residents reviewed for pain management. The facility failed to administer Resident #5's physician ordered [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg (a narcotic [MEDICATION NAME] used to treat pain) as needed. This failure placed 46 residents on a pain management program at risk for unrelieved pain and a decreased quality of life and care. Findings included: Resident #5's Electronic Face Sheet reflected she was a [AGE] year-old female who admitted to the facility on [DATE] she had the following Diagnoses: [REDACTED]. On 05/01/17 at 10:23 a.m. during an observation and interview with Resident # 5 the resident had her call light on and stated she had it on for a while and she needed to go to the bathroom. The resident had a long leg splint on her left leg and revealed she had fallen at home and fractured her leg. She said she did the splits and at 75 she should not be doing that. Resident # 5 revealed she had a problem getting her pain medication on the night shift. Resident # 5 revealed on one night she was suffering with her leg and she could not get her pain pill. The nurse came in asked what she wanted and when the resident asked for her pain medication The nurse said she would have to wait. When the resident inquired further the nurse got in her face and said she would have to wait, was loud, shook her head at the resident and said you are not the only one who gets medicine at 11:00 p.m. and the doctor should have ordered it different.' She further reveled the doctor told her to take the medicine when the pain first started and not to let it get bad because it would take longer for the medication to work, when the resident tried to tell the nurse that information, the nurse told the resident she was working two halls. I had to wait over an hour for my medication. It took the pain medication much longer to work and did not completely alleviate my pain. When asked if the resident had reported it to any one she said no but then said she told her daughter and she told the front office she believed the head nurse. The MDS dated [DATE] reflected the resident was cognitively alert and oriented and able to make decisions and relate her needs without difficulty. The pain Assessment Scale dated 04/23/17 reflected the resident was a high risk for pain at a level 12. Resident #5's care plan, dated 04/23/17, reflected she was a risk for pain. The goal was to be able to verbalize pain. The interventions were to monitor for signs/symptoms of , follow the pain scale, monitor and record pain, observe for non-verbal pain, moaning .allow resident to verbalize feeling of pain or discomfort .pain assessment completed per policy and notify MD if medication is ineffective. The Medication Administration Record [REDACTED]. Nurses Notes dated 04/23/17 at 4:29 a.m. the pain medication was effective. There is no mention of the resident resting, asleep or what her pain level was. Grievance Interview Record from Resident #5's family member dated 04/25/17 which mentioned the resident not getting her pain medication for over an hour and the nurse being rude, and talking loudly. The DON talked with the LVN F working that night and LVN F stated she was with another resident, and said the resident asked her why she was talking so loud. The DON informed the family of the results, and moved the nurse to another hall. According to the form the LVN F was not to go back into Resident #5's room. Grievance Interview Record from family member dated 04/27/17 with concerns addressing pain medication, being administered timely, assistance to the restroom and how long resident was going to require therapy. The family concerned she had to call and remind the resident to call and sk the nurse for pain medication, and it was taking a long time for the nurses to bring the medication. It was taking over an hour. The form revealed the ADON reassured the family they would take care of the family concerns. On 05/01/17 at 2:13 p. m. during an interview with the Director of Nurses asked her about pain medication delivery and she revealed medication was given according to the physician's orders [REDACTED]. Specifically mentioned the incident with Resident #5 and she revealed she was aware of the situation and she spoke with the daughter and the family was satisfied with what she had done. When asked what she did? The DON revealed she wrote up a grievance form, talked with the resident and the nurse, and moved the nurse to another hall. The DON was asked if a counseling form was done for the nurse and she revealed no she did not do one. The DON also revealed she interviewed other residents on the hall and they had no problems. I asked to see the interviews and she revealed she did not write them up. On 05/01/17 at 2:30 p.m. the DON attempted to reach the LVN F who administered the medication however there was no answer on her telephone. On 05/01/17 at 5:30 p.m. The DON again attempted to reach LVN F who administer medication on the night shift on 04/23/17 The facility's Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the MDS Coordinator on 04/29/17, reflected 46 residents were on a pain management program

Based on observation, interview, and record review the facility failed to ensure that one (1) of three (3) residents (Resident # 1) reviewed for special needs received proper [MEDICAL CONDITION] care and suctioning and failed to protect (Resident # 1) from recurrent nosocomial infections when: A. The facility failed to practice standard precautions when LVN D did not use adequate hand hygiene or change gloves appropriately during invasive suctioning and [MEDICAL CONDITION] care for Resident #1 whom had recurrent nosocomial infections. B. The facility failed to provide and maintain aseptic and clean techniques when LVN D broke sterility by dumping sterile equipment on a non-sterile towel and contaminating her sterile gloves and failed to follow procedure during invasive suctioning and [MEDICAL CONDITION] care for Resident #1 whom had recurrent nosocomial infections. C. The facility failed to ensure that each nurse was adequately trained and competent in the skills of [MEDICAL CONDITION] care and suctioning. The DON delegated Respiratory therapy training to three LVN ' s that have not been trained on how to train others. Respiratory Therapy skills check offs audits did not include observing individual nurse techniques or monitoring the nurses proficiency in performing procedures and providing direct Resident care of Resident # 1 ' s [MEDICAL CONDITION]. This failure to ensure staff were proficient in providing [MEDICAL CONDITION] care and suctioning resulted in Resident # 1 receiving unsanitary treatments and procedures which had the potential to cause harm from recurrent infections and lead to impairment, and/or death for Resident # 1 and could affect two (2) residents dependent on staff for [MEDICAL CONDITION] care. An Immediate Jeopardy (IJ) was identified on 11/20/14. While the IJ was removed on 11/21/14, the facility remained out of compliance at a severity level of "Potential for more than minimal Harm that is not immediate jeopardy," and scope of "Pattern," because the facility had yet to provide retraining with return demonstration for all nursing staff. Findings include: Resident # 1 ' s face sheet dated 6/4/14 reflected he was admitted to the facility on [DATE] with a [MEDICAL CONDITION]. Resident # 1 ' s most current MDS assessment dated [DATE] reflected he was a [AGE] year old male with the following Diagnoses: [REDACTED]. This assessment reflected his cognition was intact. The MDS assessment included the following special treatments and procedures: Under the section reflecting Respiratory Treatments; [MEDICAL CONDITION] Care and Suctioning were both checked indicating that Resident #1 received these services. Resident # 1 ' s most recent Care Plan with a readmission date of [DATE] reflected: Focus-Resident has [MEDICAL CONDITION] related to late effects of [MEDICAL CONDITION]. Goals- 1.?Resident will have clear and equal breath sounds bilaterally through the next review date 2.?Resident will have no signs and symptoms of infection related to [MEDICAL CONDITION] through the next review date 3.?Resident will have no abnormal drainage around [MEDICAL CONDITION] site through the next review date Interventions- Check Oxygen saturations every shift and as needed, Provide Oxygen as ordered, Oxygen via [MEDICAL CONDITION] mask at 28% as needed for low oxygen saturations of less than 90% or when Resident requests for shortness of breath, Monitor for and document restlessness, agitation, confusion, increased heart rate or decreased heart rate and notify physician as needed, and monitor, document and report to the physician as needed signs/symptoms of respiratory distress, increased heart rate, restlessness, sweating, lethargy, confusion, blood in sputum, cough, pain, and accessary muscle usage. Review of the Physicians Order summary report for Resident # 1 dated September 2014 reflected: 1. Oxygen via [MEDICAL CONDITION] mask at 3 lpm as needed for low oxygen sats below 90% or as patient requests as needed for shortness of breath related to [MEDICAL CONDITION] status and keep saturation settings at 28%. 2. Oxygen saturation checks every shift to maintain sats greater than 90%. 3. Replace Shiley 6DIC (type of [MEDICAL CONDITION]) once a month on the 9th and as needed if [MEDICAL CONDITION] comes out of stoma. Use sterile technique related to [MEDICAL CONDITION] Status. 4. Suction [MEDICAL CONDITION] as needed for increased mucus every shift as needed. 5. [MEDICAL CONDITION] care twice a day and as needed. Sponge should not be moist or soiled. Observation on 11/18/14 at 2:45 PM revealed a heavily bearded Resident #1 sitting up in bed. Resident #1's [MEDICAL CONDITION] sponge dressing was intact under the flange (face plate) of his [MEDICAL CONDITION]. A humidifier was located on a table to the left of the Resident #1 and a suction machine was located on a table to the right of the Resident #1. During an interview on 11/18/14 at 2:50 PM ADON B stated that Resident # 1 was alert and oriented to person, place, and time. ADON B said Resident # 1 made his needs known and communicated using his Dynabox (computerized communicator). ADON B stated that facility staff provided all of the [MEDICAL CONDITION] care for Resident # 1 and that he did not provide any of his own [MEDICAL CONDITION] care. ADON B stated that Resident # 1 gets frequent infections at least 1-2 a month. ADON B stated " I'm not sure why Resident #1 gets so many infections because Resident # 1 is usually good about not messing with his [MEDICAL CONDITION]". Record review of the monthly Resident Infection Analysis form used by the facility to track and trend infections reflected: A nosocomial infection is one that was not present or incubating at the time of admission to the facility. If the incubation period is unknown and the infection developed more than 72 hours after admission, it is called nosocomial. Review of an infection control log, lab cultures, and physician's order [REDACTED]. 1.?On 9/2/14 Resident # 1 was started on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. 2.?On 9/28/14 Resident #1 was started on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. 3.?On 10/1/14 Resident # 1 was started on the Corticosteroid [MEDICATION NAME] and treated for [REDACTED]. 4.?On 11/2/14 Resident # 1 was started on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. A sputum culture was ordered. 5.?On 11/7/14 Resident # 1 was continued on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. Review of the sputum culture dated 11/6/14 reflected: 1.?Heavy growth of Pseudomonas Aeruginosa (Isolate 1) 2.?Moderate growth of Proteus Mirabilis (Isolate 2) Review of the Centers for Disease Control and Prevention (CDC) website at www.cdc.gov <http://www.cdc.gov> in regards to Diseases and Organisms in Healthcare Settings reflected: 1.?Pseudomonas infection is caused by strains of bacteria found widely in the environment; the most common type causing infections in humans is called Pseudomonas aeruginosa. Pseudomonas can be spread on the hands of healthcare workers or by equipment that gets contaminated and is not properly cleaned. In the healthcare setting, careful attention to routine infection control practices, especially hand hygiene and environmental cleaning, can substantially lower the risk of infection. 2.?Proteus mirabilis is A common inhabitant of animal fecal material found particularly in soil and water and is a common cause infection of the eye, skin, urinary, and respiratory tract. Review of Resident # 1 ' s Physician provider visit note dated 9/29/14 at 5:27 PM reflected: Subjective: Pt seen in the nursing home today for f/u for cough congestion and fever. He was started on [MEDICATION NAME] yesterday. Pt has a [MEDICAL CONDITION] and wears 02 at all time. Increased sputum production with yellow and brown sputum. Review of the Physician provider visit note dated 10/06/14 at 4:05 PM reflected: Subjective: Pt seen in the nursing home today to f/u on [MEDICAL CONDITION], HTN, [MEDICAL CONDITION], Depression, and Upper Respiratory Infection. He has completed all [MEDICATION NAME] and [MEDICATION NAME] Pt has a [MEDICAL CONDITION] and wears 02 at all time. Increased sputum production. White and frothy. In an interview on 11/21/14 at 12:35 PM. DON stated that Resident has had frequent infections since admission to the facility. DON stated that the ADON ' s were in charge of analysis and reports and that ADON B was responsible for tracking the infections for Resident #1. DON stated that once a month she and the Medical Director would discuss and respond to problems or concerns identified by the infection control analysis and reports. DON said that they have discussed with Resident #1 the importance about not touching the [MEDICAL CONDITION] with his hands in the past after his admission. In an interview with the DON and ADM on 11/19/14 at 9:08 A.M. the DON stated nurses were trained and checked off on [MEDICAL CONDITION] care prior to admission of a resident with a [MEDICAL CONDITION]. Observation on 11/19/14 at 9:40 AM revealed Resident #1 was sitting up in bed. A clean intact dressing was observed under the flange (face plate) of his [MEDICAL CONDITION]. In an interview on 11/19/14 at 9:40 AM LVN D stated that she had just finished performing [MEDICAL CONDITION] Care and suctioning for Resident # 1. LVN D stated that all of Resident #1' s supplies for [MEDICAL CONDITION] care are kept in some drawers at his bedside. LVN D opened a chest of drawers to the right of Resident # 1 ' s bed and showed investigator Resident # 1 ' s extra [MEDICAL CONDITIONS] care kits, sterile gauze sponges, and inner cannulas. Observation of [MEDICAL CONDITION] suctioning and care on 11/20/14 at 9:00 AM revealed LVN D not performing procedures according to the facility ' s outlined method as indicated by acceptable professional practice, not maintaining aseptic and clean techniques, not following standard precautions in regards to hand hygiene and glove changing, and LVN D cross contaminating Resident #1 and Resident #1s supplies and equipment during both [MEDICAL CONDITION] suctioning and [MEDICAL CONDITION] care when: 1. LVN D did not properly assemble and handle Resident #1 [MEDICAL CONDITION] supplies using aseptic technique when she dumped the sterile [MEDICAL CONDITION] kit supplies directly onto a towel that she took from a clean linen closet shelf which in turn compromised the sterility of the supplies. 2. LVN D applied one sterile glove to her un-sanitized left hand and did not apply a glove to her right hand. LVN D then used both hands to move Resident # 1 ' s beard off of the outer face plate of the [MEDICAL CONDITION], open an individually wrapped suction catheter that was laying on the edge of Resident # 1 ' s bedside table, and connect the suction catheter to Resident #1 ' s suction machine. 3. LVN D then went to the clean field of supplies and removed and applied the 2nd sterile glove. LVN D then set up and assembled the suctioning and [MEDICAL CONDITION] care containers and other supplies that were on the towel. LVN D then proceeded by suctioning Resident #1 using these same gloves. 4. After suctioning of the [MEDICAL CONDITION] was complete, LVN D removed her gloves and threw them in the trash. LVN D did not wash her hands, but did apply a new pair of non-sterile clean gloves prior to removing the inner cannula and old dressing from around Resident # 1 ' s [MEDICAL CONDITION]. LVN D did not change the gloves or wash her hands. The contaminated non-sterile gloves were then used to provide stoma care and to insert the new disposable cannula for Resident #1. Resident # 1 was coughing up a moderate amount of opaque, green, and yellow colored sputum from his [MEDICAL CONDITION] site during care. 5. LVN D failed to restrain or cover Resident # 1 ' s beard. LVN D did not successfully prevent Resident # 1 ' s beard from coming in direct contact with the [MEDICAL CONDITION] site during care causing further cross contamination. During an interview on 11/20/14 at 9:40 AM LVN D stated that Resident #1 had just completed an antibiotic for a Respiratory infection and he had not yet received his medication that helps to dry up his secretions and that was the reason for the moderate amount of [MEDICAL CONDITION] drainage from the [MEDICAL CONDITION] site. LVN D stated that she normally performed [MEDICAL CONDITION] care the same way she did today with the exception of being watched by someone. LVN D stated she had training in the earlier part of the year which consisted of watching videos the DON provided and being coached through the procedural steps of [MEDICAL CONDITION] care and suctioning. LVN D stated that the only time she was ever watched performing [MEDICAL CONDITION] care was when the DON assisted her in changing out the outer [MEDICAL CONDITION] cannula for Resident #1 one time, because she had never done it before. LVN D stated she had never been observed performing [MEDICAL CONDITION] suctioning or site care for Resident # 1. In an interview on 11/20/14 at 11:30 A.M. LVN D stated Resident #1 is the only resident with a [MEDICAL CONDITION] she has cared for in the facility. LVN D said she trained before Resident #1 was admitted to the facility approximately a year and a half ago and has been taking care of Resident #1 ' s [MEDICAL CONDITION] since that time. LVN D said she does primary care on Resident #1 ' s [MEDICAL CONDITION] once per day and suctioning as needed. LVN D said she checks on Resident #1 approximately every 30 minutes. In an interview on 11/20/14 at 1:40 PM DON stated that she expected nurses to provide [MEDICAL CONDITION] care using aseptic technique and expected nurses to keep the dominant hand used for Resident suctioning sterile. DON stated that she expected nurses to keep hands sanitized and gloves changed appropriately. DON stated that Resident # 1 's beard should have been concealed with a cover or mask prior to the procedures. DON stated that she didn't know why LVN D missed the last training session for [MEDICAL CONDITION] care a few weeks ago. DON stated that all nurses are not individually checked off by return demonstration for [MEDICAL CONDITION] care and suctioning. DON stated that they are done in groups and simulate by verbalizing steps in the process. DON stated that there are too many to do at one time and the facility does not have mannequin to enable a physical return demonstration simulation by each nurse. DON stated that she was trained by the Respiratory Therapist for [MEDICAL CONDITION] care and suctioning. DON stated that she has LVN ' s such as LVN C and the ADON ' s whom are also LVN ' s train other LVN ' s for [MEDICAL CONDITION] care and suctioning, because it is within a LVN ' s scope of practice to train other LVN ' s for [MEDICAL CONDITION] care and suctioning. (Respiratory Therapy). Record review of The MDS Mentor dated March 2011 VOLUME 4, ISSUE 1, an article in regards to LVN ' s conducting Respiratory Training written by BSN, RN, RAC-CT MDS Clinical Coordinator and MDS Automation Coordinator reflected: Can a LVN Conduct Respiratory Training? When the title question was asked, CMS wrote " It is a facility responsibility to ensure that staff that conduct respiratory therapy follow their state practice act. " A challenge has been that many facility staff are not familiar with the requirements of their state practice act, including the Nursing Practice Act , available on the Texas Board of Nursing (BON) website at <http://www.bon.state.tx.us/index.html>. However, to assist in clarifying this question and to avoid 1245 facilities in Texas contacting the BON all at once, DADS staff met with BON staff and developed the following clarification, congruent with both agencies ' guidelines. The BON does not maintain a comprehensive list of tasks that LVNs may perform. Each nurse has a different back-ground, knowledge and level of competence and must use their judgment in deciding to accept an assignment. A LVN who has demonstrated competency in providing respiratory therapy services may train other LVNs to provide respiratory therapy, using the following guidelines: The curriculum used to train other LVNs must be developed and approved by a certified respiratory therapist, registered nurse, or physician trained to provide respiratory therapy services. A LVN may participate in developing the training curriculum to train other LVNs, but cannot develop the curriculum and training materials independently. The LVN must demonstrate competency in training other LVNs. This includes having a system in place to document the competency of the LVN to both provide respiratory therapy services and train other LVNs in respiratory therapy services. There must be a system in place to periodically establish continued nursing competence - at least annually or at some other specified interval. Record review of the facility Proficiency audits for LVN ' s did not include that LVN ' s doing training for Respiratory Therapy demonstrated competency in training other LVNs. There was a system in place to document the competency of the LVN to provide respiratory therapy services, but not to train other LVNs in respiratory therapy services. Record review of the facility Proficiency audits for the three LVN ' s delegated by the DON to train other LVN's for Respiratory Therapy revealed ADON A, ADON B and LVN C had signed off on training other LVNs but reflected no training on how to train which is not part of the scope of practice for an LVN. In an interview on 11/20/14 at 3:30 PM the Administrator stated that she felt like part of the problem with the [MEDICAL CONDITION] care was that LVN D missed the most recent [MEDICAL CONDITION] Care training by the Respiratory Therapist a few weeks ago, because LVN D was out with a health related condition. Review of the facility ' s infection control policy for Hand Hygiene with a revised date of September 2010 reflected: Policy: Hand hygiene is the most important component for preventing the spread of infection. Proper handwashing technique is to be accomplished at all times that handwashing is indicated. When to wash hands: Hand washing must be done in all of the following instances ? ?When hands are visibly soiled: Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practices); ? ?Before and after performing invasive procedures ? ?Before and after assisting a resident with personal care ? ?Upon and after coming in contact with a resident ' s intact skin ? ?After contact with a resident ' s mucous membranes and body fluids or secretions ? ?After handling soiled or used dressings ? ?After handling soiled equipment ? ?After removing gloves Review of the facility 's [MEDICAL CONDITION] Care competency check off dated July 17, 2008 reflected: Purpose: To provide a standard procedure to ensure that qualified personnel giving [MEDICAL CONDITION] care provide the maximum respiratory support with minimal incidence of infection ? ?If the inner cannula is disposable, don gloves and remove the old inner cannula and soiled [MEDICAL CONDITION] dressing. Discard gloves and dressing in the trash, wash hands, don sterile gloves and proceed with stoma care. After stoma is cleaned insert new disposable inner cannula. Record review of Policy/Procedure for [MEDICAL CONDITION] Cleaning dated September 2007 received from the DON on 11/20/14 reflected Policy: [MEDICAL CONDITION] will be cleaned regularly to decrease the possibility of infection and to maintain a patent airway. Procedure: The following steps are followed when a [MEDICAL CONDITION] is cleaned. 1.?Gather equipment. 4.?Wash hands. 5.?Place the patient in a comfortable position with neck hyperextended. 6.?Put on sterile gloves. 7.?Open sterile catheter using aseptic techniques and pour solution into bowl. 8.?Remove dressing and discard into plastic bag. 9.?Remove gloves, wash hands and put on sterile gloves. 10.?Suction entire length of inner cannula according to procedure. 11.?With non-dominant hand, unlock inner cannula by turning lock 90 degrees counter-clockwise. Remove inner cannula. 15.?Inspect cannula for encrustations and repeat cleaning as needed. 17.?Suction outer cannula 18.?Insert the inner cannula in the direction of curvature by grasping outer flange of inner cannula and lock in place. 19.?Clean [MEDICAL CONDITION] site and apply new dressing. 20.?Clean area and dispose of equipment in appropriate areas. 21.?Wash hands. 22.?Check patient comfort. Record review of Policy/Procedure for [MEDICAL CONDITION] Suctioning dated September 2007 received from the DON on 11/20/14 reflected Policy: [MEDICAL CONDITION] will be suctioned regularly to decrease the possibility of infection and to maintain a patent airway. Procedure: The table below explains the procedure for [MEDICAL CONDITION] suctioning. 2.?Gather equipment. 5.?Wash hands. 6.?Place the patient in a comfortable position with neck hyperextended. 7.?Put on sterile gloves. 8.?Connect suction catheter to tubing and machine maintaining dominant hand as sterile. Hold sterile catheter in dominant sterile hand and connect tube in other sterile hand and connect to section. 9.?Test catheter with saline or water; also serves to lubricate the end of the tube. 10.?Insert the catheter 10-12.5 cm or until the patient coughs. 11.?Apply suction for 5-10 seconds. 12.?Rotate the catheter as you slowly withdraw it. Suction saline or water through catheter to clear tubing. 13.?Encourage the patient to breathe deeply and cough. 14.?Repeat steps 9-12 until airway is clear. 15.?Turn off suction and disconnect the catheter from suction tubing. 16.?Hold catheter in gloved hand, grasp the cuff of glove with other hand, and peel the glove off so that it turns inside out over the catheter. Remove other glove by grasping cuff and peeling off so it turns wrong side out. 17.?Discard disposable equipment appropriately. 18.?Check patient for comfort. 19.?Observe secretions suctioned for amount, color, odor, thickness, etc. 20.?Clean appropriate equipment. An Immediate Jeopardy was identified and the facility Administrator was notified on 11/20/14 at 1:45 PM. The Plan of Removal was accepted on 11/21/14 at 4:05 PM and included: All nurses currently on duty and caring for [MEDICAL CONDITION] patients on 6 a.m. - 2 or 2-10 shifts will be in-serviced on proper [MEDICAL CONDITION] care within one hour of IJ by DON. Clinical check offs will be completed using return demonstration on each nurse providing [MEDICAL CONDITION] care on 6-2 and 2-10 shift prior to them giving [MEDICAL CONDITION] care to their patients. Checks offs will be done by D.O.N. Prior to 10-6 shift taking the floor, D.O.N. will in-service those nurses providing [MEDICAL CONDITION] care, and clinical competency check-offs will be completed using return demonstration for them as well. An observation of Resident #1 on 11/21/14 at 9:05 a.m. revealed the DON and LVN D were in his room with [MEDICAL CONDITION] equipment. The DON stated that they were doing practice demonstrations for [MEDICAL CONDITION] care. The DON said LVN D had to do it several times and they would come to get investigators when they were ready for LVN D to be observed performing [MEDICAL CONDITION] care on Resident #1. Observation on 11/21/14 at 9:11 A.M. of [MEDICAL CONDITION] care and suctioning for Resident # 2 revealed that LVN C maintained aseptic and clean techniques during invasive suctioning and care of Resident #2 ' s [MEDICAL CONDITION] and provided care appropriately according to facility policy and procedure and professional standards of practice. Observation on 11/21/14 at 10:00 A.M. of [MEDICAL CONDITION] care and suctioning for Resident # 1 revealed that LVN D maintained aseptic and clean techniques during invasive suctioning and care of Resident #1 ' s [MEDICAL CONDITION] and provided care appropriately according to facility policy and procedure and professional standards of practice. The facility Assistant Director of Nurses ADON B stated that the facility had two Residents with Tracheostomies on 11/18/14.

Based on observation, interview and record review the facility failed to be administered in a manner that enabled it to use its resources effectively to ensure that one (1) of three (3) residents (Resident # 1) was provided care in a manner to prevent recurrent nosocomial infections when: A. The DON failed to ensure that each nurse was adequately trained and competent in the skills of Tracheostomy care and suctioning by not monitoring the nurses performing procedures and providing direct Resident care of Resident # 1 ' s Tracheostomy. B. The charge nurse, LVN D, failed to implement infection control practices by not using adequate hand hygiene, not changing gloves appropriately, not maintaining aseptic and clean techniques, and not following procedure during invasive suctioning and Tracheostomy care for Resident #1 whom had recurrent nosocomial infections. C. ADON B and the DON identified Resident # 1 as having recurrent nosocomial infections but failed to investigate the potential causative factors contributing to the infections. This failure to ensure staff were proficient in providing tracheostomy care and suctioning resulted in Resident # 1 receiving unsanitary treatments and procedures which had the potential to cause harm from recurrent infections and lead to impairment, and/or death for Resident # 1 and could affect two (2) residents dependent on staff for tracheostomy care. An Immediate Jeopardy (IJ) was identified on 11/20/14. While the IJ was removed on 11/21/14, the facility remained out of compliance at a severity level of "Potential for more than minimal Harm that is not immediate jeopardy," and scope of "Pattern," because the facility had yet to provide retraining with return demonstration for all nursing staff. Findings include: Resident # 1 ' s face sheet dated 6/4/14 reflected he was admitted to the facility on [DATE] with a Tracheostomy. Resident # 1 ' s most current MDS assessment dated [DATE] reflected he was a [AGE] year old male with the following Diagnoses: [REDACTED]. This assessment reflected his cognition was intact. The MDS assessment included the following special treatments and procedures: Under the section reflecting Respiratory Treatments; Tracheostomy Care and Suctioning were both checked indicating that Resident #1 received these services. Resident # 1 ' s most recent Care Plan with a readmission date of [DATE] reflected: Focus-Resident has Tracheostomy related to late effects of CVA. Goals- 1.?Resident will have clear and equal breath sounds bilaterally through the next review date 2.?Resident will have no signs and symptoms of infection related to Tracheostomy through the next review date 3.?Resident will have no abnormal drainage around tracheostomy site through the next review date Interventions- Check Oxygen saturations every shift and as needed, Provide Oxygen as ordered, Oxygen via tracheostomy mask at 28% as needed for low oxygen saturations of less than 90% or when Resident requests for shortness of breath, Monitor for and document restlessness, agitation, confusion, increased heart rate or decreased heart rate and notify physician as needed, and monitor, document and report to the physician as needed signs/symptoms of respiratory distress, increased heart rate, restlessness, sweating, lethargy, confusion, blood in sputum, cough, pain, and accessary muscle usage. Review of the Physicians Order summary report for Resident # 1 dated September 2014 reflected: 1. Oxygen via tracheostomy mask at 3 lpm as needed for low oxygen sats below 90% or as patient requests as needed for shortness of breath related to Tracheostomy status and keep saturation settings at 28%. 2. Oxygen saturation checks every shift to maintain sats greater than 90%. 3. Replace Shiley 6DIC (type of tracheostomy) once a month on the 9th and as needed if tracheostomy comes out of stoma. Use sterile technique related to Tracheostomy Status. 4. Suction Tracheostomy as needed for increased mucus every shift as needed. 5. Tracheostomy care twice a day and as needed. Sponge should not be moist or soiled. Observation on 11/18/14 at 2:45 PM revealed a heavily bearded Resident #1 sitting up in bed. Resident #1's tracheostomy sponge dressing was intact under the flange (face plate) of his Tracheostomy Tube. A humidifier was located on a table to the left of the Resident #1 and a suction machine was located on a table to the right of the Resident #1. During an interview on 11/18/14 at 2:50 PM ADON B stated that Resident # 1 was alert and oriented to person, place, and time. ADON B said Resident # 1 made his needs known and communicated using his Dynabox (computerized communicator). ADON B stated that facility staff provided all of the tracheostomy care for Resident # 1 and that he did not provide any of his own Tracheostomy care. ADON B stated that Resident # 1 gets frequent infections at least 1-2 a month. ADON B stated " I'm not sure why Resident #1 gets so many infections because Resident # 1 is usually good about not messing with his tracheostomy". Record review of the monthly Resident Infection Analysis form used by the facility to track and trend infections reflected: A nosocomial infection is one that was not present or incubating at the time of admission to the facility. If the incubation period is unknown and the infection developed more than 72 hours after admission, it is called nosocomial. Review of an infection control log, lab cultures, and physician's order [REDACTED]. 1.?On 9/2/14 Resident # 1 was started on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. 2.?On 9/28/14 Resident #1 was started on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. 3.?On 10/1/14 Resident # 1 was started on the Corticosteroid [MEDICATION NAME] and treated for [REDACTED]. 4.?On 11/2/14 Resident # 1 was started on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. A sputum culture was ordered. 5.?On 11/7/14 Resident # 1 was continued on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. Review of the sputum culture dated 11/6/14 reflected: 1.?Heavy growth of Pseudomonas Aeruginosa (Isolate 1) 2.?Moderate growth of Proteus Mirabilis (Isolate 2) Review of the Centers for Disease Control and Prevention (CDC) website at www.cdc.gov <http://www.cdc.gov> in regards to Diseases and Organisms in Healthcare Settings reflected: 1.?Pseudomonas infection is caused by strains of bacteria found widely in the environment; the most common type causing infections in humans is called Pseudomonas aeruginosa. Pseudomonas can be spread on the hands of healthcare workers or by equipment that gets contaminated and is not properly cleaned. In the healthcare setting, careful attention to routine infection control practices, especially hand hygiene and environmental cleaning, can substantially lower the risk of infection. 2.?Proteus mirabilis is A common inhabitant of animal fecal material found particularly in soil and water and is a common cause infection of the eye, skin, urinary, and respiratory tract. Review of Resident # 1 ' s Physician provider visit note dated 9/29/14 at 5:27 PM reflected: Subjective: Pt seen in the nursing home today for f/u for cough congestion and fever. He was started on [MEDICATION NAME] yesterday. Pt has a tracheostomy and wears 02 at all time. Increased sputum production with yellow and brown sputum. Review of the Physician provider visit note dated 10/06/14 at 4:05 PM reflected: Subjective: Pt seen in the nursing home today to f/u on Respiratory Failure, HTN, CVA, Depression, and Upper Respiratory Infection. He has completed all [MEDICATION NAME] and [MEDICATION NAME] Pt has a tracheostomy and wears 02 at all time. Increased sputum production. White and frothy. In an interview on 11/21/14 at 12:35 PM. DON stated that Resident has had frequent infections since admission to the facility. DON stated that the ADON ' s were in charge of analysis and reports and that ADON B was responsible for tracking the infections for Resident #1. DON stated that once a month she and the Medical Director would discuss and respond to problems or concerns identified by the infection control analysis and reports. DON said that they have discussed with Resident #1 the importance about not touching the tracheostomy with his hands in the past after his admission. In an interview with the DON and ADM on 11/19/14 at 9:08 A.M. the DON stated nurses were trained and checked off on tracheostomy care prior to admission of a resident with a tracheostomy. Observation on 11/19/14 at 9:40 AM revealed Resident #1 was sitting up in bed. A clean intact dressing was observed under the flange (face plate) of his Tracheostomy Tube. In an interview on 11/19/14 at 9:40 AM LVN D stated that she had just finished performing Tracheostomy Care and suctioning for Resident # 1. LVN D stated that all of Resident #1' s supplies for Tracheostomy care are kept in some drawers at his bedside. LVN D opened a chest of drawers to the right of Resident # 1 ' s bed and showed investigator Resident # 1 ' s extra Tracheostomy, tracheostomy care kits, sterile gauze sponges, and inner cannulas. Observation of Tracheostomy suctioning and care on 11/20/14 at 9:00 AM revealed LVN D not performing procedures according to the facility ' s outlined method as indicated by acceptable professional practice, not maintaining aseptic and clean techniques, not following standard precautions in regards to hand hygiene and glove changing, and LVN D cross contaminating Resident #1 and Resident #1s supplies and equipment during both tracheostomy suctioning and tracheostomy care when: 1. LVN D did not properly assemble and handle Resident #1 Tracheostomy supplies using aseptic technique when she dumped the sterile tracheostomy kit supplies directly onto a towel that she took from a clean linen closet shelf which in turn compromised the sterility of the supplies. 2. LVN D applied one sterile glove to her un-sanitized left hand and did not apply a glove to her right hand. LVN D then used both hands to move Resident # 1 ' s beard off of the outer face plate of the tracheostomy, open an individually wrapped suction catheter that was laying on the edge of Resident # 1 ' s bedside table, and connect the suction catheter to Resident #1 ' s suction machine. 3. LVN D then went to the clean field of supplies and removed and applied the 2nd sterile glove. LVN D then set up and assembled the suctioning and tracheostomy care containers and other supplies that were on the towel. LVN D then proceeded by suctioning Resident #1 using these same gloves. 4. After suctioning of the tracheostomy was complete, LVN D removed her gloves and threw them in the trash. LVN D did not wash her hands, but did apply a new pair of non-sterile clean gloves prior to removing the inner cannula and old dressing from around Resident # 1 ' s tracheostomy. LVN D did not change the gloves or wash her hands. The contaminated non-sterile gloves were then used to provide stoma care and to insert the new disposable cannula for Resident #1. Resident # 1 was coughing up a moderate amount of opaque, green, and yellow colored sputum from his tracheostomy site during care. 5. LVN D failed to restrain or cover Resident # 1 ' s beard. LVN D did not successfully prevent Resident # 1 ' s beard from coming in direct contact with the tracheostomy site during care causing further cross contamination. During an interview on 11/20/14 at 9:40 AM LVN D stated that Resident #1 had just completed an antibiotic for a Respiratory infection and he had not yet received his medication that helps to dry up his secretions and that was the reason for the moderate amount of tracheostomy drainage from the tracheostomy site. LVN D stated that she normally performed tracheostomy care the same way she did today with the exception of being watched by someone. LVN D stated she had training in the earlier part of the year which consisted of watching videos the DON provided and being coached through the procedural steps of tracheostomy care and suctioning. LVN D stated that the only time she was ever watched performing tracheostomy care was when the DON assisted her in changing out the outer tracheostomycannula for Resident #1 one time, because she had never done it before. LVN D stated she had never been observed performing tracheostomy suctioning or site care for Resident # 1. In an interview on 11/20/14 at 11:30 A.M. LVN D stated Resident #1 is the only resident with a tracheostomy she has cared for in the facility. LVN D said she trained before Resident #1 was admitted to the facility approximately a year and a half ago and has been taking care of Resident #1 ' s tracheostomy since that time. LVN D said she does primary care on Resident #1 ' s tracheostomy once per day and suctioning as needed. LVN D said she checks on Resident #1 approximately every 30 minutes. In an interview on 11/20/14 at 1:40 PM DON stated that she expected nurses to provide tracheostomy care using aseptic technique and expected nurses to keep the dominant hand used for Resident suctioning sterile. DON stated that she expected nurses to keep hands sanitized and gloves changed appropriately. DON stated that Resident # 1 's beard should have been concealed with a cover or mask prior to the procedures. DON stated that she didn't know why LVN D missed the last training session for tracheostomy care a few weeks ago. DON stated that all nurses are not individually checked off by return demonstration for tracheostomy care and suctioning. DON stated that they are done in groups and simulate by verbalizing steps in the process. DON stated that there are too many to do at one time and the facility does not have mannequin to enable a physical return demonstration simulation by each nurse. DON stated that she was trained by the Respiratory Therapist for tracheostomy care and suctioning. DON stated that she has LVN ' s such as LVN C and the ADON ' s whom are also LVN ' s train other LVN ' s for tracheostomy care and suctioning, because it is within a LVN ' s scope of practice to train other LVN ' s for tracheostomy care and suctioning. (Respiratory Therapy). Record review of The MDS Mentor dated March 2011 VOLUME 4, ISSUE 1, an article in regards to LVN ' s conducting Respiratory Training written by BSN, RN, RAC-CT MDS Clinical Coordinator and MDS Automation Coordinator reflected: Can a LVN Conduct Respiratory Training? When the title question was asked, CMS wrote " It is a facility responsibility to ensure that staff that conduct respiratory therapy follow their state practice act. " A challenge has been that many facility staff are not familiar with the requirements of their state practice act, including the Nursing Practice Act , available on the Texas Board of Nursing (BON) website at <http://www.bon.state.tx.us/index.html>. However, to assist in clarifying this question and to avoid 1245 facilities in Texas contacting the BON all at once, DADS staff met with BON staff and developed the following clarification, congruent with both agencies ' guidelines. The BON does not maintain a comprehensive list of tasks that LVNs may perform. Each nurse has a different back-ground, knowledge and level of competence and must use their judgment in deciding to accept an assignment. A LVN who has demonstrated competency in providing respiratory therapy services may train other LVNs to provide respiratory therapy, using the following guidelines: The curriculum used to train other LVNs must be developed and approved by a certified respiratory therapist, registered nurse, or physician trained to provide respiratory therapy services. A LVN may participate in developing the training curriculum to train other LVNs, but cannot develop the curriculum and training materials independently. The LVN must demonstrate competency in training other LVNs. This includes having a system in place to document the competency of the LVN to both provide respiratory therapy services and train other LVNs in respiratory therapy services. There must be a system in place to periodically establish continued nursing competence - at least annually or at some other specified interval. Record review of the facility Proficiency audits for LVN ' s did not include that LVN ' s doing training for Respiratory Therapy demonstrated competency in training other LVNs. There was a system in place to document the competency of the LVN to provide respiratory therapy services, but not to train other LVNs in respiratory therapy services. Record review of the facility Proficiency audits for the three LVN ' s delegated by the DON to train other LVN's for Respiratory Therapy revealed ADON A, ADON B and LVN C had signed off on training other LVNs but reflected no training on how to train which is not part of the scope of practice for an LVN. In an interview on 11/20/14 at 3:30 PM the Administrator stated that she felt like part of the problem with the tracheostomy care was that LVN D missed the most recent Tracheostomy Care training by the Respiratory Therapist a few weeks ago, because LVN D was out with a health related condition. Review of the facility ' s infection control policy for Hand Hygiene with a revised date of September 2010 reflected: Policy: Hand hygiene is the most important component for preventing the spread of infection. Proper handwashing technique is to be accomplished at all times that handwashing is indicated. When to wash hands: Hand washing must be done in all of the following instances ? ?When hands are visibly soiled: Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practices); ? ?Before and after performing invasive procedures ? ?Before and after assisting a resident with personal care ? ?Upon and after coming in contact with a resident ' s intact skin ? ?After contact with a resident ' s mucous membranes and body fluids or secretions ? ?After handling soiled or used dressings ? ?After handling soiled equipment ? ?After removing gloves Review of the facility's Tracheostomy Care competency check off dated July 17, 2008 reflected: Purpose: To provide a standard procedure to ensure that qualified personnel giving tracheostomy care provide the maximum respiratory support with minimal incidence of infection ? ?If the inner cannula is disposable, don gloves and remove the old inner cannula and soiled tracheostomy dressing. Discard gloves and dressing in the trash, wash hands, don sterile gloves and proceed with stoma care. After stoma is cleaned insert new disposable inner cannula. Record review of Policy/Procedure for Tracheostomy Tube Cleaning dated September 2007 received from the DON on 11/20/14 reflected Policy: Tracheostomy tubes will be cleaned regularly to decrease the possibility of infection and to maintain a patent airway. Procedure: The following steps are followed when a tracheostomy tube is cleaned. 1.?Gather equipment. 4.?Wash hands. 5.?Place the patient in a comfortable position with neck hyperextended. 6.?Put on sterile gloves. 7.?Open sterile catheter using aseptic techniques and pour solution into bowl. 8.?Remove dressing and discard into plastic bag. 9.?Remove gloves, wash hands and put on sterile gloves. 10.?Suction entire length of inner cannula according to procedure. 11.?With non-dominant hand, unlock inner cannula by turning lock 90 degrees counter-clockwise. Remove inner cannula. 15.?Inspect cannula for encrustations and repeat cleaning as needed. 17.?Suction outer cannula 18.?Insert the inner cannula in the direction of curvature by grasping outer flange of inner cannula and lock in place. 19.?Clean tracheostomy site and apply new dressing. 20.?Clean area and dispose of equipment in appropriate areas. 21.?Wash hands. 22.?Check patient comfort. Record review of Policy/Procedure for Tracheostomy Suctioning dated September 2007 received from the DON on 11/20/14 reflected Policy: Tracheostomy tubes will be suctioned regularly to decrease the possibility of infection and to maintain a patent airway. Procedure: The table below explains the procedure for tracheostomy suctioning. 2.?Gather equipment. 5.?Wash hands. 6.?Place the patient in a comfortable position with neck hyperextended. 7.?Put on sterile gloves. 8.?Connect suction catheter to tubing and machine maintaining dominant hand as sterile. Hold sterile catheter in dominant sterile hand and connect tube in other sterile hand and connect to section. 9.?Test catheter with saline or water; also serves to lubricate the end of the tube. 10.?Insert the catheter 10-12.5 cm or until the patient coughs. 11.?Apply suction for 5-10 seconds. 12.?Rotate the catheter as you slowly withdraw it. Suction saline or water through catheter to clear tubing. 13.?Encourage the patient to breathe deeply and cough. 14.?Repeat steps 9-12 until airway is clear. 15.?Turn off suction and disconnect the catheter from suction tubing. 16.?Hold catheter in gloved hand, grasp the cuff of glove with other hand, and peel the glove off so that it turns inside out over the catheter. Remove other glove by grasping cuff and peeling off so it turns wrong side out. 17.?Discard disposable equipment appropriately. 18.?Check patient for comfort. 19.?Observe secretions suctioned for amount, color, odor, thickness, etc. 20.?Clean appropriate equipment. An Immediate Jeopardy was identified and the facility Administrator was notified on 11/20/14 at 1:45 PM. The Plan of Removal was accepted on 11/21/14 at 4:05 PM and included: All nurses currently on duty and caring for tracheostomy patients on 6 a.m. - 2 or 2-10 shifts will be in-serviced on proper tracheostomy care within one hour of IJ by DON. Clinical check offs will be completed using return demonstration on each nurse providing tracheostomy care on 6-2 and 2-10 shift prior to them giving tracheostomy care to their patients. Checks offs will be done by D.O.N. Prior to 10-6 shift taking the floor, D.O.N. will in-service those nurses providing tracheostomy care, and clinical competency check-offs will be completed using return demonstration for them as well. An observation of Resident #1 on 11/21/14 at 9:05 a.m. revealed the DON and LVN D were in his room with tracheostomy equipment. The DON stated that they were doing practice demonstrations for tracheostomy care. The DON said LVN D had to do it several times and they would come to get investigators when they were ready for LVN D to be observed performing tracheostomy care on Resident #1. Observation on 11/21/14 at 9:11 A.M. of tracheostomy care and suctioning for Resident # 2 revealed that LVN C maintained aseptic and clean techniques during invasive suctioning and care of Resident #2 ' s Tracheostomy and provided care appropriately according to facility policy and procedure and professional standards of practice. Observation on 11/21/14 at 10:00 A.M. of tracheostomy care and suctioning for Resident # 1 revealed that LVN D maintained aseptic and clean techniques during invasive suctioning and care of Resident #1 ' s Tracheostomy and provided care appropriately according to facility policy and procedure and professional standards of practice. The facility Assistant Director of Nurses ADON B stated that the facility had two Residents with Tracheostomies on 11/18/14.

Based on observation, interview and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to ensure that one (1) of three (3) residents (Resident # 1) was provided care in a manner to prevent recurrent nosocomial infections when: A. The facility failed to ensure that each nurse was adequately trained and competent in the skills of [MEDICAL CONDITION] care and suctioning when the DON delegated LVN ' s that have not been trained on how to train others on Respiratory Therapy perform the skills check offs audits for other LVN ' s, by not observing individual nurse techniques, and by not monitoring the nurses proficiency in performing procedures and providing direct Resident care of Resident # 1 ' s [MEDICAL CONDITION]. B. The facility failed to practice standard precautions by not using adequate hand hygiene or changing gloves appropriately during invasive suctioning and [MEDICAL CONDITION] care for Resident #1 whom had recurrent nosocomial infections. C. The facility failed to provide and maintain aseptic and clean techniques by breaking sterility and not following procedure during invasive suctioning and [MEDICAL CONDITION] care for Resident #1 whom had recurrent nosocomial infections. This failure to ensure staff were proficient in providing [MEDICAL CONDITION] care and suctioning resulted in Resident # 1 receiving unsanitary treatments and procedures which had the potential to cause harm from recurrent infections and lead to impairment, and/or death for Resident # 1 and could affect all residents dependent on staff for [MEDICAL CONDITION] care. An Immediate Jeopardy (IJ) was identified on 11/20/14. While the IJ was removed on 11/21/14, the facility remained out of compliance at a severity level of "Potential for more than minimal Harm that is not immediate jeopardy," and scope of "Isolated," because the facility had yet to provide retraining with return demonstration for all nursing staff. Findings include: Resident # 1 ' s face sheet dated 6/4/14 reflected he was admitted to the facility on [DATE] with a [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Resident # 1 ' s most current MDS assessment dated [DATE] reflected he was a [AGE] year old male with the following Diagnoses: [REDACTED]. This assessment reflected his cognition was intact, scoring 15 out of 15 on a BIMS scale. The MDS assessment included the following special treatments and procedures: Under the section reflecting Respiratory Treatments; [MEDICAL CONDITION] Care and Suctioning were both checked indicating that Resident #1 received these services. Resident # 1 ' s most recent Care Plan with a readmission date of [DATE] reflected: Focus-Resident has [MEDICAL CONDITION] related to late effects of [MEDICAL CONDITION]. Goals- 1. Resident will have clear and equal breath sounds bilaterally through the next review date 2. Resident will have no signs and symptoms of infection related to [MEDICAL CONDITION] through the next review date 3. Resident will have no abnormal drainage [MEDICAL CONDITION] through the next review date Interventions- Check Oxygen saturations every shift and as needed, Provide Oxygen as ordered, Oxygen via [MEDICAL CONDITION] mask at 28% as needed for low oxygen saturations of less than 90% or when Resident requests for shortness of breath, Monitor for and document restlessness, agitation, confusion, increased heart rate or decreased heart rate and notify physician as needed, and monitor, document and report to the physician as needed s/s of respiratory distress, increased heart rate, restlessness, diaphoresis, h/a, lethargy, confusion, atelectasis, hemoptysis, cough, pruritic pain, and accessary muscle usage. Review of the Physicians Order summary report for Resident # 1 dated September 2014 reflected: 1. Oxygen [MEDICAL CONDITION] at 3 lpm as needed for low oxygen sats below 90% or as patient requests as needed for shortness of breath related to [MEDICAL CONDITION] status and keep saturation settings at 28%. 2. Oxygen saturation checks every shift to maintain sats greater than 90%. 3. Replace Shiley 6DIC once a month on the 9th and as needed [MEDICAL CONDITION] out of stoma. Use sterile technique related to [MEDICAL CONDITION] Status. 4. Suction [MEDICAL CONDITION] as needed for increased mucus every shift as needed. 5.[MEDICAL CONDITION] twice a day and as needed. Sponge should not be moist or soiled. Observation on 11/18/14 at 2:45 PM revealed a heavily bearded Resident #1 sitting up in bed. Resident #1'[MEDICAL CONDITION] dressing was intact under the flange or face plate of his [MEDICAL CONDITION]. A humidifier was located on a table to the left of the Resident #1 and a suction machine was located on a table to the right of the Resident #1. Resident # 1 did not have an ambu bag hanging on his wall. During an interview on 11/18/14 at 2:50 PM ADON B stated that Resident # 1 was alert and oriented to person, place, and time. ADON B said Resident # 1 made his needs known and communicated using his Dynabox. ADON B stated that facility staff provided all of the [MEDICAL CONDITION] care for Resident # 1 and that he did not provide any of his own [MEDICAL CONDITION] care. ADON B stated that Resident # 1 gets frequent infections at least 1-2 a month. ADON B stated she was not sure why Resident #1 got so many infections because Resident # 1 was usually good about not messing with his [MEDICAL CONDITION]. Record review of the monthly Resident Infection analysis form used by the facility to track and trend infections reflected: A nosocomial infection is one that was not present or incubating at the time of admission to the facility. If the incubation period is unknown and the infection developed more than 72 hours after admission, it is called nosocomial. Review of an infection control log, lab cultures, and physician's order [REDACTED]. 1. On 9/2/14 Resident # 1 was started on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. 2. On 9/28/14 Resident #1 was started on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. 3. On 10/1/14 Resident # 1 was started on the Corticosteroid [MEDICATION NAME] and treated for [REDACTED]. 4. On 11/2/14 Resident # 1 was started on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. A sputum culture was ordered. 5. On 11/7/14 Resident # 1 was continued on the Antibiotic [MEDICATION NAME] and treated for [REDACTED]. Review of the sputum culture dated 11/6/14 reflected: 1. Heavy growth of Pseudomonas Aeruginosa (Isolate 1) 2. Moderate growth of Proteus Mirabilis (Isolate 2) Review of the Centers for Disease Control and Prevention (CDC) website at www.cdc.gov <http://www.cdc.gov> in regards to Diseases and Organisms in Healthcare Settings reflected: 1. Pseudomonas infection is caused by strains of bacteria found widely in the environment; the most common type causing infections in humans is called Pseudomonas aeruginosa. Pseudomonas can be spread on the hands of healthcare workers or by equipment that gets contaminated and is not properly cleaned. In the healthcare setting, careful attention to routine infection control practices, especially hand hygiene and environmental cleaning, can substantially lower the risk of infection. 2. Proteus mirabilis is A common inhabitant of animal fecal material found particularly in soil and water and is a common cause infection of the eye, skin, urinary, and respiratory tract. Review of Resident # 1 ' s Physician provider visit note dated 9/29/14 at 5:27 PM reflected: Subjective: Pt seen in the nursing home today for f/u for cough congestion and fever. He was started on [MEDICATION NAME] yesterday. Pt has [MEDICAL CONDITION] wears 02 at all time. Increased sputum production with yellow and brown sputum. Review of the Physician provider visit note dated 10/06/14 at 4:05 PM reflected: Subjective: Pt seen in the nursing home today to f/u on [MEDICAL CONDITION], HTN, [MEDICAL CONDITION], Depression, and Upper Respiratory Infection. He has completed all [MEDICATION NAME] and [MEDICATION NAME] Pt has [MEDICAL CONDITION] wears 02 at all time. Increased sputum production. White and frothy. In an interview on 11/21/14 at 12:35 PM. DON stated that Resident has had frequent infections since admission to the facility. DON stated that the ADON ' s were in charge of analysis and reports and that ADON B was responsible for tracking the infections for Resident #1. DON stated that once a month she and the Medical Director would discuss and respond to problems or concerns identified by the infection control analysis and reports. DON said that they have discussed with Resident #1 the importance about not touching [MEDICAL CONDITION] his hands in the past after his admission, but nothing recently. In an interview with the DON and ADM on 11/19/14 at 9:08 A.M. the DON stated nurses were trained and checked off prior to admission of a resident with a [MEDICAL CONDITION]. Observation on 11/19/14 at 9:40 AM revealed Resident #1 was sitting up in bed. A clean intact dressing was observed under the flange or face plate of his [MEDICAL CONDITION]. In an interview on 11/19/14 at 9:40 AM LVN D stated that she had just finished performing [MEDICAL CONDITION] Care and suctioning for Resident # 1. LVN D stated that all of Resident #1' s supplies [MEDICAL CONDITION] are kept in some drawers at his bedside. LVN D opened a chest of drawers to the right of Resident # 1 ' s bed and showed investigator Resident # 1 ' s extra Trach,[MEDICAL CONDITION] kits, sterile gauze sponges, and inner cannulas. LVN D stated that Resident # 1 was supposed to have an ambu bag available in his room for emergencies, but was unable to locate it. LVN D excused herself from Resident # 1' s room to go retrieve an ambu bag for Resident # 1. In an interview on 11/19/14 at 9:50 AM Resident # 1 stated that he did usually have an ambu bag in his room and he pointed up at the wall that he had his hats hanging up on, directly above the table where his suction machine was located. The bag was not observed hanging on the wall. Resident # 1 agreed to allow investigator to observe [MEDICAL CONDITION] scheduled for 11/20/14 at 9AM. Resident did not voice any complaints regarding his care. Resident # 1 stated that if he had any problems that he would report to the Director of Nurses. Observation on 11/19/14 at 9:55 AM revealed LVN D return to Resident #1 ' s room with an ambu bag. Resident # 1 directed LVN D to hang it up at the wall that he had his hats hanging up on, directly above the table where his suction machine was located. LVN D attempted to hang bag but the tack was not strong enough to support the weight of the bag, so Resident agreed to allow LVN D to place the ambu in a bottom drawer with his [MEDICAL CONDITION]. Observation of [MEDICAL CONDITION] suctioning and care on 11/20/14 at 9:00 AM revealed LVN D not performing procedures according to the facility ' s outlined method as indicated by acceptable professional practice, not maintaining aseptic and clean techniques, not following standard precautions in regards to hand hygiene and glove changing, and LVN D cross contaminating Resident #1 and Resident #1s supplies and equipment during both [MEDICAL CONDITION] suctioning and [MEDICAL CONDITION] care when: 1. LVN D did not properly assemble and handle Resident #[MEDICAL CONDITION] using aseptic technique when she dumped the [MEDICAL CONDITION] supplies directly onto a towel that she took from a clean linen closet shelf which in turn compromised the sterility of the supplies. 2. LVN D applied one sterile glove to her un-sanitized left hand and did not apply a glove to her right hand. LVN D then used both hands to move Resident # 1 ' s beard off of the outer face plate of the [MEDICAL CONDITION], open an individually wrapped suction catheter that was laying on the edge of Resident # 1 ' s bedside table, and connect the suction catheter to Resident #1 ' s suction machine. 3. LVN D then went to the clean field of supplies and removed and applied the 2nd sterile glove. LVN D then set up and assembled the suctioning [MEDICAL CONDITION] containers and other supplies that were on the towel. LVN D then proceeded by suctioning Resident #1 using these same gloves. 4. After suctioning of [MEDICAL CONDITION] complete, LVN D removed her gloves and threw them in the trash. LVN D did not wash her hands, but did apply a new pair of non-sterile clean gloves prior to removing the inner cannula and old dressing from around Resident # 1 ' s trach. LVN D did not change the gloves or wash her hands. The contaminated non-sterile gloves were then used to provide stoma care and to insert the new disposable cannula for Resident #1. Resident # 1 was coughing up a moderate amount of opaque, green, and yellow colored sputum from [MEDICAL CONDITION] during care. 5. LVN D failed to restrain or cover Resident # 1 ' s beard. LVN D did not successfully prevent Resident # 1 ' s beard from coming in direct contact with the [MEDICAL CONDITION] site during care causing further cross contamination. During an interview on 11/20/14 at 9:40 AM LVN D stated that Resident #1 had just completed an antibiotic for a Respiratory infection and he had not yet received his medication that helps to dry up his secretions and that was the reason for the moderate amount [MEDICAL CONDITION] from [MEDICAL CONDITION]. LVN D stated that she normally [MEDICAL CONDITION] the same way she did today with the exception of being watched by someone. LVN D stated she had training in the earlier part of the year which consisted of watching videos the DON provided and being coached through the procedural steps [MEDICAL CONDITION] and suctioning. LVN D stated that the only time she was ever watched [MEDICAL CONDITION] was when the DON assisted her in changing out the [MEDICAL CONDITION] for Resident #1 one time, because she had never done it before. LVN D stated she had never been observed performing [MEDICAL CONDITION] suctioning or site care for Resident # 1. In an interview on 11/20/14 at 10:00 AM LVN C stated that he had re-training about 2-3 weeks ago by the corporation Respiratory Therapist [MEDICAL CONDITION]. LVN C stated [MEDICAL CONDITION] training prior to the last one took place with the DON. LVN C stated that the DON went over how to clean, suction trachs, and how to monitor for infection. LVN C stated he was also watched and checked off on the procedure at that time. LVN C stated that he provides care for Resident # 2 ' [MEDICAL CONDITION] previously provided care for Resident # 3 ' [MEDICAL CONDITION] Resident # 3 discharged . LVN C stated that Resident # 2 has been a Resident for approximately 3 months. LVN C stated that Resident # 2 was treated for [REDACTED]. In an interview on 11/20/14 at 11:30 A.M. LVN D stated Resident #1 is the only resident with a [MEDICAL CONDITION] she has cared for in the facility. LVN D said she trained before Resident #1 was admitted to the facility approximately a year and a half ago and has been taking care of Resident #1 ' s [MEDICAL CONDITION] since that time. LVN D said she does primary care on Resident #1 ' s [MEDICAL CONDITION] once per day and suctioning as needed. LVN D said she checks on Resident #1 approximately every 30 minutes. In an interview on 11/20/14 at 1:40 PM DON stated that she expected nurses to [MEDICAL CONDITION] using aseptic technique and expected nurses to keep the dominant hand used for Resident suctioning sterile. DON stated that she expected nurses to keep hands sanitized and gloves changed appropriately. DON stated that Resident # 1 's beard should have been concealed with a cover or mask prior to the procedures. DON stated that she didn't know why LVN D missed the last training session [MEDICAL CONDITION] a few weeks ago. DON stated that all nurses are not individually checked off by return demonstration [MEDICAL CONDITION] and suctioning. DON stated that they are done in groups and simulate by verbalizing steps in the process. DON stated that there are too many to do at one time and the facility does not have manikins to enable a physical return demonstration simulation by each nurse. DON stated that she was trained by the Respiratory Therapist [MEDICAL CONDITION] and suctioning. DON stated that she has LVN ' s such as LVN C and the ADON ' s whom are also LVN ' s train other LVN ' s [MEDICAL CONDITION] and suctioning, because it is within a LVN ' s scope of practice to train other LVN ' s [MEDICAL CONDITION] and suctioning. (Respiratory Therapy). Record review of The MDS Mentor dated March 2011 VOLUME 4, ISSUE 1, an article in regards to LVN ' s conducting Respiratory Training written by BSN, RN, RAC-CT MDS Clinical Coordinator and MDS Automation Coordinator reflected: Can a LVN Conduct Respiratory Training? When the title question was asked, CMS wrote " It is a facility responsibility to ensure that staff that conduct respiratory therapy follow their state practice act. " A challenge has been that many facility staff are not familiar with the requirements of their state practice act, including the Nursing Practice Act , available on the Texas Board of Nursing (BON) website at <http://www.bon.state.tx.us/index.html>. However, to assist in clarifying this question and to avoid 1245 facilities in Texas contacting the BON all at once, DADS staff met with BON staff and developed the following clarification, congruent with both agencies ' guidelines. The BON does not maintain a comprehensive list of tasks that LVNs may perform. Each nurse has a different back-ground, knowledge and level of competence and must use their judgment in deciding to accept an assignment. A LVN who has demonstrated competency in providing respiratory therapy services may train other LVNs to provide respiratory therapy, using the following guidelines: The curriculum used to train other LVNs must be developed and approved by a certified respiratory therapist, registered nurse, or physician trained to provide respiratory therapy services. A LVN may participate in developing the training curriculum to train other LVNs, but cannot develop the curriculum and training materials independently. The LVN must demonstrate competency in training other LVNs. This includes having a system in place to document the competency of the LVN to both provide respiratory therapy services and train other LVNs in respiratory therapy services. There must be a system in place to periodically establish continued nursing competence - at least annually or at some other specified interval. Record review of the facility Proficiency audits for LVN ' s did not include that LVN ' s doing training for Respiratory Therapy demonstrated competency in training other LVNs. There was a system in place to document the competency of the LVN to provide respiratory therapy services, but not to train other LVNs in respiratory therapy services. An Immediate Jeopardy was identified and the facility Administrator was notified on 11/20/14 at 1:45 PM. In an interview on 11/20/14 at 3:30 PM the Administrator stated that she felt like part of the problem with [MEDICAL CONDITION] was that LVN D missed the most [MEDICAL CONDITION] training by the Respiratory Therapist a few weeks ago, because LVN D was out with a health related condition. Review of the facility ' s infection control policy for Hand Hygiene with a revised date of September 2010 reflected: Policy: Hand hygiene is the most important component for preventing the spread of infection. Proper handwashing technique is to be accomplished at all times that handwashing is indicated. When to wash hands: Hand washing must be done in all of the following instances ? When hands are visibly soiled: Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practices); ? Before and after performing invasive procedures ? Before and after assisting a resident with personal care ? Upon and after coming in contact with a resident ' s intact skin ? After contact with a resident ' s mucous membranes and body fluids or secretions ? After handling soiled or used dressings ? After handling soiled equipment ? After removing gloves Review of the facility 's [MEDICAL CONDITION] Care competency check off dated July 17, 2008 reflected: Purpose: To provide a standard procedure to ensure that qualified personnel giving [MEDICAL CONDITION] care provide the maximum respiratory support with minimal incidence of infection ? If the inner cannula is disposable, don gloves and remove the old inner cannula and [MEDICAL CONDITION]. Discard gloves and dressing in the trash, wash hands, don sterile gloves and proceed with stoma care. After stoma is cleaned insert new disposable inner cannula. Record review of Policy/Procedure for [MEDICAL CONDITION] Cleaning dated September 2007 received from the DON on 11/20/14 reflected Policy: [MEDICAL CONDITION] will be cleaned regularly to decrease the possibility of infection and to maintain a patent airway. Procedure: The following steps are followed when a [MEDICAL CONDITION] is cleaned. 1. Gather equipment. 2. Provide privacy. 3. Identify the patient and explain procedure to the patient. 4. Wash hands. 5. Place the patient in a comfortable position with neck hyperextended. 6. Put on sterile gloves. 7. Open sterile catheter using aseptic techniques and pour solution into bowl. 8. Remove dressing and discard into plastic bag. 9. Remove gloves, wash hands and put on sterile gloves. 10. Suction entire length of inner cannula according to procedure. 11. With non-dominant hand, unlock inner cannula by turning lock 90 degrees counter-clockwise. Remove inner cannula. 12. Soak the inner cannula in hydrogen peroxide solution several minutes to loosen secretions. 13. Clean entire inner cannula with brush moistened in sterile saline. 14. Rinse by agitation in saline. 15. Inspect cannula for encrustations and repeat cleaning as needed. 16. Remove excess moisture by tapping on sterile surface of bowl and using sterile pipe cleaners. 17. Suction outer cannula 18. Insert the inner cannula in the direction of curvature by grasping outer flange of inner cannula and lock in place. 19. [MEDICAL CONDITION] and apply new dressing. 20. Clean area and dispose of equipment in appropriate areas. 21. Wash hands. 22. Check patient comfort. Record review of Policy/Procedure for [MEDICAL CONDITION] Suctioning dated September 2007 received from the DON on 11/20/14 reflected Policy: [MEDICAL CONDITION] will be suctioned regularly to decrease the possibility of infection and to maintain a patent airway. Procedure: The table below explains the procedure for [MEDICAL CONDITION] suctioning. 1. Obtain physician orders. 2. Gather equipment. 3. Provide privacy. 4. Identify the patient and explain procedure to the patient. 5. Wash hands. 6. Place the patient in a comfortable position with neck hyperextended. 7. Put on sterile gloves. 8. Connect suction catheter to tubing and machine maintaining dominant hand as sterile. Hold sterile catheter in dominant sterile hand and connect tube in other sterile hand and connect to section. 9. Test catheter with saline or water; also serves to lubricate the end of the tube. 10. Insert the catheter 10-12.5 cm or until the patient coughs. 11. Apply suction for 5-10 seconds. 12. Rotate the catheter as you slowly withdraw it. Suction saline or water through catheter to clear tubing. 13. Encourage the patient to breathe deeply and cough. 14. Repeat steps 9-12 until airway is clear. 15. Turn off suction and disconnect the catheter from suction tubing. 16. Hold catheter in gloved hand, grasp the cuff of glove with other hand, and peel the glove off so that it turns inside out over the catheter. Remove other glove by grasping cuff and peeling off so it turns wrong side out. 17. Discard disposable equipment appropriately. 18. Check patient for comfort. 19. Observe secretions suctioned for amount, color, odor, thickness, etc. 20. Clean appropriate equipment. Review of the job description for the Charge Nurse (LVN) with a revision date of May 2014 reflected: The charge nurse LVN is to deliver care to patients requiring long term care and rehabilitative care and reports to the DON and ADONS. ? Works under direct supervision using the Nurse Practice Act, Legend Healthcare Standards, Policies and Procedures, and Nursing Judgment ? Maintains patient care supplies, equipment, and environment ? Procedures are performed according to methods outlined in the procedure manual ? Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions Review of the job description for the Assistant Director of Nursing (ADON) with a revision date of May 2014 reflected: The ADON assists the Director of Nursing in an overall management of the Department of Nursing. The ADON ' s responsible for the orientation and continuing education of the nursing staff. ? Assists in ensuring quality of care to all patients. ? Assists in ensuring nursing department compliance with all federal, state, and local regulations ? Participates in the quality assessment and improvement process and activities ? Assists with the evaluation of performance of nursing service personnel. ? Assesses technical skills of nursing personnel by observation of various nursing procedures. ? Identifies clinical problem areas for the Director of Nursing and assists in the development of the plan of correction. ? Implements infection control policies and procedures as outlined in the company program. Ensures that nursing staff is educated and utilize infection control practices that protect patients, staff, and families. Review of the job description for the Director of Nursing (DON) with a revision date of May 2014 reflected: The Director of Nursing is responsible for effective overall management of the Nursing Department and coordination with all other disciplines to provide quality care and ensure to all patients. ? Ensure that all patients receive quality care and maximize quality of life ? Establish and direct the implementation of all written policies and procedures that reflect the goals, objectives and requirements of the nursing department; ensure that all nursing employees understand and follow established policies, procedures, and systems. ? Monitor the outcome of nursing service activity by evaluating the performance of nursing staff, ensure compliance with all facility and regulatory agency standards, policies and procedures, coordinating facility committees and monitor the effective and efficient use of budgeted resources (employees, supplies, and equipment) ? Ensures that nursing staff is educated and utilizes infection control practices that protect staff, patients, and families. ? Observe the performance of nursing personnel on the nursing units and audits nursing practices to ensure adherence with established objectives, standards, policies, and procedures. Review of the job description for the Administrator with a revision date of May 2014 reflected: Responsible for directing the overall operation of the facilities activities in accordance with applicable federal, state and local standards, guidelines and regulations, and as directed by the governing board and for ensuring that the highest degree of quality patient care is maintained at all times. ? Ensure that patients receive quality of care and maximize quality of life. ? Ensure that all employees are appropriately oriented, on boarded and trained, according to company policy and procedure The Plan of Removal was accepted on 11/21/14 at 4:05 PM and included: All nurses currently on duty and caring [MEDICAL CONDITION] on 6 a.m. - 2 or 2-10 shifts will be in-serviced on [MEDICAL CONDITION] within one hour of IJ by DON. Clinical check offs will be completed using return demonstration on each nurse [MEDICAL CONDITION] on 6-2 and 2-10 shift prior to them [MEDICAL CONDITION] to their patients. Checks offs will be done by D.O.N. Prior to 10-6 shift taking the floor, D.O.N. will in-service those nurses [MEDICAL CONDITION], and clinical competency check-offs will be completed using return demonstration for them as well. An observation of Resident #1 on 11/21/14 at 9:05 a.m. revealed the DON and LVN D were in his room [MEDICAL CONDITION]. The DON stated that they were doing practice demonstrations [MEDICAL CONDITION]. The DON said LVN D had to do it several times and they would come get us when they were ready for us to watch LVN D [MEDICAL CONDITION] on Resident #1. Observation on 11/21/14 at 9:11 A.M. of [MEDICAL CONDITION] care and suctioning for Resident # 2 revealed that LVN C maintained aseptic and clean techniques during invasive suctioning and care of Resident #2 ' s [MEDICAL CONDITION] and provided care appropriately according to facility policy and procedure and professional standards of practice. Observation on 11/21/14 at 10:00 A.M. of [MEDICAL CONDITION] care and suctioning for Resident # 1 revealed that LVN D maintained aseptic and clean techniques during invasive suctioning and care of Resident #1 ' s [MEDICAL CONDITION] and provided care appropriately according to facility policy and procedure and professional standards of practice. Facility census submitted on 11/18/14 by the Administrator was 108. The facility Assistant Director of Nurses ADON B stated that the facility had two Residents with Tracheostomies on 11/18/14.

Based on observation, interview and record review, it was determined the facility failed to ensure each resident had the right to be free from sexual abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to ensure Resident #1 was free from sexual abuse. Resident #1 was sexually assaulted on the night of 07/25/14. After that, Resident #1 was withdrawn from facility staff and her family, she did not get out of bed, she ate very little, and slept little on 07/26/14 and 07/27/14. Resident #1 reported the attack on Monday morning, 07/28/14, to two CNAs. The resident also had a large bruise on her buttocks and an abrasion on her buttocks and was experiencing pain. This failure could affect the other 105 residents, by placing them at risk for sexual abuse and/or mistreatment resulting in decreased self-worth, shame, embarrassment, anxiety, withdrawal, hopelessness, and post-traumatic stress syndrome. Findings included: 1. Resident #1's Face Sheet, dated 08/13/14, reflected she was admitted to the facility on [DATE]. Resident #1's MDS assessment, dated 05/27/14, reflected she was readmitted on [DATE] and was a [AGE] year-old female with [DIAGNOSES REDACTED]. Resident #1 had clear comprehension and made herself understood. Resident #1's recall score was five out of six points. Resident #1 had little interest or pleasure in doing things and had the feeling of being tired or having little energy half or more of the days in the previous two weeks. Resident #1 required extensive assistance from one person with bed mobility, transfers, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. Resident #1 used a wheelchair and was always continent of bowel and only occasionally incontinent of bladder. Resident #1 was 68 inches tall and weighed 111 pounds. Resident #1's Mental and Behavioral Health Visit Note, dated 07/22/14, reflected, "Patient reported that every day one of her family members is there to be with her. She has returned to enjoying working puzzles and socializing with others at the facility. She denies active symptoms of anxiety or depression at this time...Individual therapy is terminating at this time due to the patient meeting treatment goals with managing her depression and adjustment to the facility successfully...." Resident #1's Nurse's Notes, dated 07/27/14 at 9:00 AM, reflected her UA (urinalysis) and lab results were received and there were no critical values. The Notes also reflected the resident was fed by LVN L and all she would accept was "yogurt and approx. (approximately) 480 cc h2O (sic)." Resident #1's Progress Notes, dated 07/28/14 and completed by LVN F, reflected, "...I was called to resident's room at 0730. When I entered the room, aides states that resident had alleged rape by a staff member. When I questioned her she said, '(CNA D) raped me.' I asked her when and she said last night. I did quick head to toe assessment and found one large bruise to right buttock with small open area and small amount of blood from rectum. Rectum was slightly red and irritated. I left the room and reported incident to DON... and to ...the administrator. I reentered room at 0845 and questioned her. She stated that the man was tall and husky. He was possibly 'Mexican.' 'I have never seen him before' 'He told me, Don't fight back and it won't hurt so much. He threw me on the bed and pulled my clothes down. He raped me with his hand.' When questioned further she stated 'I'm sure it was his penis.' 'I was fighting back and couldn't get a good look at him. He hit me in my left eye and it was blurry. He was very strong and he held my hands down. I don't remember anything about his clothes. He possible (sic) went in my bottom because it hurts. I don's (sic) remember anything else. It was a horrible experience.' Resident was not crying or terribly upset, she was just nervous." A statement, signed by LVN F and dated 07/28/14, reflected, "At 0730 (7:30 AM) I was called to (Resident #1's room) by my aide CNA C. When I entered (Resident #1's) room, she was lying on her bed. The aides explained that she had stated she had been sexually assaulted. When I questioned her she said, '(CNA D) raped me.' She was very nervous, not crying. I did a quick assessment & noted new bruise to her right buttock. I then called (the DON) & (Administrator) to inform them of allegation. At 0845 (8:45 AM) I again went in to speak with (Resident #1). I questioned her about what the man looked like. She said he was tall & husky, possibly Mexican. She stated she had never seen him before, & didn't know who he was. 'It was dark & I was fighting, I don't know what he was wearing. I guess I should but it was such a horrible experience.' He told me, don't fight back and it won't hurt so much. He threw me on the bed & pulled my clothes down. He raped with his hand.' When questioned further she stated 'I'm sure it was his penis.' 'He hit me in my left eye & it was blurry. He was very strong and he held my hands down. I don't remember anything about his clothes. he possibly went in my bottom because it hurts. I don't remember anything else." On 07/28/14 at 12:30, LVN F said she had examined Resident #1 after the aide came and got her that morning. She revealed upon examination she did not see any bruising or tearing of the vagina or rectal area or bruising on her inner thighs. LVN F stated Resident #1 told her he hit her on her cheek and Resident #1 had used her fingers and tapped her own left cheek. LVN F said her left cheek was red, but she felt it was from the tapping the resident did. LVN F revealed Resident #1 told her she had fought him and she did have bruising to her bilateral arms but she always had bruising to her bilateral arms as she would bump into things and she bled easily and bruised easily. LVN F said she called the pharmacist as Resident #1 had just started the antibiotic Bactrim and the pharmacist told her it could cause hallucinations, nocturnal delusions and [MEDICAL CONDITION] in some patients. An untitled skin sheet, dated 07/28/14 and completed by LVN G, reflected, "New 7/28/14...reddness (sic) over buttocks and periarea blanchable has area near anas (sic) with bright red discoloration at 0.4 x (by) 0.8 with scant blood drainage...New 7/28/14...rt (right hip) area to back bruise 0.8x2 rt hip/back area 1x2...New 7/28/14 scratch area rt buttock 0.1x0.5...." An undated Affidavit, signed by LVN G, reflected, "Was called to room by charge nurse after Resident stated she had been 'raped' last night. (Resident #1) Resident started by stating 'You dont (sic) know of any break ins last night do you cause I dont (sic) know how he got in. When asked about the man if she had known who it was Resident had stated that she had never seen him before. Resident described the man as being tall and huskey (sic) looking possibly mexican but not sure. States that she didn't get good look at him. Did ask Resident if man had said anything. Resident stated he said don't fight back and it wont hurt as bad.' Resident asked if he spoke with any kind of Accent & Resident stated 'no.' Resident states that if she were to see this man again is not sure if she would be abel (sic) to identify him. then states again 'She hadn't seen him before. Resident asked what the man did to her. Resident states he held her down on bed and pulled her clothes down and Raped me. States she believed that he raped her with hand/penis. Resident stated she fought back but doesn't Recall if she screamed out when asked. At this time Resident did c/o (complain of) her bottom hurting. I asked Resident if he [MEDICATION NAME] (sic) her in anal area. 'Resident states with everything going on at the time she didn't recal (sic). Was asked if man had hit her in anyway. SStates (sic) she felt like he did all over. Resident states when it was over the man just got up and left. At this time skin assessment Head to toe completed with nurse in Room X3 by me." An observation on 07/29/14 at 12:58 PM of Resident #1's buttocks revealed a dark, red mark approximately the size of a finger on her right buttock, which was about one inch to the right of her rectum and extended to her right side. A typewritten account of the Administrator's interview with Resident #1, conducted on 07/30/14 at approximately 11:00 AM with the resident's family member present, reflected, "We asked (Resident #1) to explain any events that occurred with her over the last couple of days and if she knew why she felt so bad. She said no honey I just didn't feel good. (Family member) then prompted her and said (Resident #1) - you know what they are talking about - tell them what happened to you Friday night....the person that hurt you. She said the rapist, whoever he was, he was just throwing my knees back and forth, he kept us in the dark, I tried to fight back. He told me don't fight it won't hurt as much. She said he hit her eye - and she pointed to her left eye. When (Administrator) asked her about (CNA D) - she stated I don't know who he is. She was reminded that he takes care of her on the night shift, she didn't appear to recollect who he was. She said this person was big and strong - but she couldn't give any description because he kept them in the dark." Resident #1's Resident Survey, dated 07/30/14, reflected, " Has anyone been rough with you? not that I know who they are......I was in bed asleep Saturday night about 12 -1 AM quite upsetting. he raped me. I fought back. He said don't fight back & it won't hurt so bad. I haven't eaten or slept for 3 days. He was big and strong. No lights on, so I didn't get a good look at him. A horrible experience for a woman 91 yo (years old) to go thru. I think he hurt my eye (L) (left). He spoke quietly so my roommate probably did not hear him. I can't imagine, since our beds are so close together. She's 88 yo & kind of forgetful. safe? yeah comfortable? Well, most of the time. Resident #1's Psychosocial Well-Being Evaluation, dated 07/30/14 and completed by the social worker, reflected she had bruising and increased anxiety since her last assessment. The evaluation also reflected her cognition had deteriorated slightly since the last assessment. She was progressing through grief and talking about her feelings and emotions. The Summary of Findings reflected, "Resident expresses a shaky sense of safety. Cognition appears to have diminished some and may be temporary as resident states she has difficulty concentrating. Resident exhibits (no) sadness, hopelessness, and denies depression. She is coping well by focusing on eating more & spending most of the day (with) others, not alone in room...Resident states she is grateful for immediate attention on her behalf & that the facility has taken immediate actions to secure the facility, locking doors, checking alarms & police surveillance inside & outside the building. Resident denies blame, shame or anger towards herself & states she just wants him (perpetrator) caught." Observation during the initial tour on 07/28/14 at 10:05 AM revealed Resident #1 in bed with the covers on her. The surveyor did not go in at that time, since the resident reported someone had sexually assaulted her and the police as well as her family were there. On 07/28/14 at 10:45 AM, LVN F informed the surveyor Resident #1 left for the hospital for a rape examination and the facility's van took her. Resident #1's Emergency Department Physician Note, dated 07/28/14, reflected she was alert and oriented to person, place, and time. The Note also reflected, "9:36 PM Bruises and abrasions consistent with assault, no lacs (lacerations) in need of repair per SANE nurse...Encounter Diagnoses...Sexual assault (primary encounter diagnosis)...." It further reflected the resident wanted "STD ([MEDICAL CONDITION]) [MEDICATION NAME]" but otherwise she was ready for discharge. Resident #1's Emergency Department Discharge Instructions, dated 07/28/14, reflected a [DIAGNOSES REDACTED]. Usually infection does not develop as a result of sexual assault. Antibiotics are sometimes used to prevent this problem. You should have blood tests for syphilis [MEDICAL CONDITION] 6 weeks to be certain about your condition. [MEDICAL CONDITION] test should be repeated in 6-12 months... Sexual assault is the ultimate invasion of privacy. It often causes severe psychological reactions. You may feel: Shock. Disbelief. Fear. Anger. Depression. It is very important that you see your doctor or a counselor to help you deal with these feelings. You may not want to talk to anyone today. Remember your caregiver can arrange for further medical care or counseling. You are not to blame for being attacked. It is also important to understand that sexual assault is a violent, life-threatening crime, and the perpetrator is a criminal. Talking about it with friends, family, or counselors trained to assist rape victims can shorten the recovery process. Call your caregiver if you need help." On 07/29/14 at 8:50 AM, the Administrator informed the surveyors Resident #1's family thought the incident happened on Friday night (07/25/14) as Resident #1's behavior changed on Saturday. The Administrator said Resident #1 had not gotten out of bed, eaten, was incontinent and not talking to her family or anyone. The Administrator revealed the family brought her behavior up to the nurse on duty, and they called the physician and received orders for a UA C&S as well as blood work. The Administrator outlined what the facility was going to do to prevent any further incidents. She revealed her corporate persons were there along with her and they were investigating as well as putting into motion new security cameras for each hall, changing all master codes to the locks on their doors, they had obtained an off duty police officer to remain in the facility until they had all their new procedures in place. On 07/29/14 at 10:20 AM the surveyors spoke with Resident #1's family members. The family informed the surveyors Resident #1 had endured a two and a half hour physical examination for rape the previous evening and while talking amongst themselves figured the incident happened on Friday night, 07/25/14. One family member stated he/she and other family members had been at the facility Friday evening until around 8:00 to 8:30 PM and the resident was fine. He/She stated he/she came in early Saturday morning and other family members throughout the weekend and Resident #1 would not get out of bed, eat or drink, talk to them, was incontinent. He/She stated, "She would just pee on herself..." The family member revealed Resident #1 just lain in her bed holding her covers up to her chest. He/She stated they could tell something was wrong and they thought maybe it was another UTI. They brought it to the attention of the nurse on Saturday. He/She said they did a UA and blood work. Resident #1's family member stated on Sunday Resident #1 still would not eat much, talk much or get up out of bed. He/She revealed when he/she asked for the test results on Sunday night, the nurse said they were normal. Finally on Monday morning when he/she came in Resident #1 seemed much better, she ate a good breakfast, and after breakfast he/she went out and asked the aides to come in and change her. The family member stated when the aides came in as he/she was walking out, he/she heard Resident #1 say there was a male aide that had been very rough. He/She said after a few moments one of the aides came out of her room and went to get the nurse. A few minutes after the nurse went in, she came out and when he/she asked her what was wrong, the nurse said the resident had a bruise on her hip. The family all agreed when they heard maybe the Bactrim had caused her to hallucinate they thought maybe that was what it was. They stated, "We were hoping it was a dream." Another family member revealed he/she was in the room during the two and a half hour extensive rape exam and Resident #1 said she did it so hopefully no other old lady would have to go through what she had. He/She stated on the way to the hospital, Resident #1 said she had blood under her fingernails. The family member told the resident to leave it, so they could take it for evidence. He/She revealed the facility did manicures for the ladies every Friday and Resident #1 always got hers done. He/she said he/she knew on Friday the resident did not have blood under her finger nails and hoped it was whoever had done this to her. The family member revealed they had taken all her finger nail scrapings as evidence but were told it would be months before the results came back. Resident #1's family also said Resident #1 was cognitively "very sharp" some days and other days not as much. On 07/30/14 at 1:40 PM, the surveyor requested an interview with Resident #1 and her family member. The resident and family member both stated they just finished an interview with the Administrator. The family member revealed the resident had spoken about it enough. Resident #1 stated she just wanted to visit with her family member. On 07/30/14 at 5:20 PM, LVN L was interviewed. LVN L revealed she performed an in and out catheterization on Saturday around 1-2:00 PM on Resident #1. She stated Resident #1 was very calm during the procedure, but she noticed a difference in the resident's behavior on Saturday. Resident #1's family member reported the resident had not eaten for a couple days, so LVN L called the physician and received orders for a UA C & S and blood work. LVN L stated Resident #1 was not eating or drinking, she was incontinent and usually was continent, she kept her eyes closed, but would open them when she called her name although would not keep them open. When asked if she had noticed anything different such as marks, tears, bruising or abrasions during the catheterization procedure, LVN L replied no. She revealed she did not see anything unusual as the resident was on her side facing her with her knees drawn up towards her chest. LVN L stated Resident #1 would not open her legs when she was on her back, and she assumed it was because of her leg or hip hurting as she had broken it previously and it caused her pain. She said she did not see or notice any marks on her buttocks as she was concentrating on her vaginal area while catheterizing her. LVN L revealed Resident #1 was on her right side when she catheterized her and she was working from the residents' right side as well. When asked if she had spoken anything to Resident #1 during the procedure, LVN L replied just what she was going to do and that it might be a little uncomfortable. She said Resident #1 did not cry out or moan during the procedure. LVN L stated she had worked for the facility about three years and only doubles on the weekends. The facility's Provider Investigation Report, faxed to the State survey and certification agency on 08/01/14, reflected Resident #1 was interviewable and had the capacity to make informed decisions. The Description of the Allegation reflected, "Resident first stated that rough care was given during the night. A little later she stated, '(CNA D) raped me.'" The Provider's response reflected, "DADS, police (case number), physician and family were immediately notified upon knowledge of the allegation on 7/28/14. Resident was sent to (local hospital) for examination by SANE (Sexual Assault Nurse Examiner) nurse. SANE nurse unavailable until 7p.m. Therefore patient was transferred to (another hospital). Approximately 10:00 p.m. administrator called facility to make sure all doors were secure. When patient returned, 15 minute checks were initiated. Armed police officers were in place at 6 a.m. on 7/29, 24/7. Alleged perpetrator was suspended. Staff were assigned to be Door Monitors and placed on duty on 7/29/14 to monitor hall doors including front door until door codes could be changed...Only female staff will provide ADL care on (Resident #1) per family request...Investigation Summary...Investigation revealed a change in (Resident #1's) behavior Saturday. She wasn't eating as well as (sic) refusing her medication, and appearing withdrawn, eyes closed, not wanting to talk, etc...According to (CNA C), she (Resident #1) said, 'Thank God ya'll are finally here.' When asked what was wrong, she told them that a man had handled her rough when he was changing here during the night. She kept saying she had tried to fight back. She went on to say he had hit her in the eye...(CNA C) then went to get nurse (LVN F). When (LVN F) asked the resident what happened the resident stated '(CNA D) raped me.' Nurse did quick head to toe assessment and found one large bruise to right buttock with small open area and small amount of blood from rectum (resident has hemorrhoids). Rectum was slightly red and irritated...'...He told me, don't fight back and it won't hurt so much. He threw me on the bed and pulled my clothes down. He raped me with his hand.' When questioned further by the nurse, she stated 'I'm sure it was his penis. I was fighting back and couldn't get a good look at him. He hit me in the left eye and it was blurry. He was very strong and he held my hands down. I don't remember anything about his clothes. He possible (sic) went in my bottom because it hurts. I don't remember anything else. It was a horrible experience.' The nurse stated the resident was not crying or terribly upset, she was just nervous...Resident's ER report from (hospital) stated she had bruises and abrasions consistent with assault...Provider Action Post-Investigation: In-servicing staff on reporting abuse, neglect and prevention of abuse are being conducted with all staff. Completion of in-services will be 7/29/14. On 7/29/14, armed police officers were assigned to be on duty 24 hours a day until Sunday 8/3/14...Starting Sunday, 8/3/14 a full time security guard will be in place 6 p.m. to 6 a.m. Codes were changed on all the door key code locks...Additional security cameras will be installed that can view down all 4 hallways. A tablet has been purchased so that all halls can be portably monitored...Nursing staff in-serviced on detecting early warning signs of resident behaviors related to sexual inappropriateness...." Attached to the facility's Provider Investigation Report was an undated Employee Questionnaire completed by Nurse Trainee I. The questionnaire reflected, "3. Did you notice any difference in resident's behavior from Friday night through the week-end? Noticed she was rambling through the day. Unlike last weekend when she was coherent...." An undated Employee Questionnaire completed by RN H reflected, "3...Sat (Saturday)...very lethargic, not eating, not getting out of bed, not opening eyes, ate 2/3 of fortified pudding Sun (Sunday)...still somewhat lethargic, but eyes open, still lying in bed not sure about eating...." An undated statement signed by CNA D reflected he came on duty, got report, and started his shift. He checked on Resident #1 between 12:00 AM and 12:40 AM and she was clean. He thought the resident seemed to be in pain so he told the nurse who said she was feeling sick. The last time CNA D checked on Resident #1 was at 5:30 AM and she was wet. He changed her and that was the last time he saw her. He told the oncoming shift that Resident #1 acted like she was in pain. On 05/29/14 at 3:00 PM, CNA D, the alleged perpetrator, was interviewed. CNA D had worked for the facility about one year and worked the 10:00 PM to 6:00 AM shift. CNA D stated he had found out about the allegation of sexual abuse on Monday and he thought maybe it was a hallucination. CNA D revealed when he was first told it, had occurred on Sunday night. He said Friday and Saturday were regular nights and nothing unusual had happened at least as far as he could remember. When asked if he took residents to the bathroom in the middle of the night he said if they were continent and wanted to go to the bathroom he would. When asked if he would take Resident #1 to the bathroom, he replied she very seldom called for him as she slept through the night, but if she called for him he would. CNA D stated when he came in on Sunday he received report from the previous shift's aide and began his first round with Resident #1 around 12:40 AM. He said "When I rotated her she kind of moaned ..." He revealed she was dry so he had left her and reported to the nurse about her moaning. CNA D said the nurse told him she did not feel good, so he assumed that was why she had moaned. CNA D revealed later he checked her again and she was wet so he had changed her and again she moaned. When asked what he would do if a resident became combative during care, he replied he would leave and come back later and try again. CNA D said if they were still combative, he would go and tell the nurse. When asked if he had seen any male residents go into Resident #1's room he said no. CNA D said he did not know why he was the only aide being suspended as there was another male aide who had worked with her on Friday from 2:00 PM to 10:00 PM shift named MA K and for that matter, it could be a female who did it as well. When asked if he knew of any staff member who had visitors during the night shift he said no. An undated statement signed by CNA C reflected, "On Monday July 29, 2014 myself and (CNA E) went into (Resident #1's) room to get her up and showered for the day. When she grabbed my hand and said thank God ya'll are finally here, I asked her what was wrong. She told (CNA E) and I that a man had handled her Ruff (sic) when he was changing her during the night. She kept saying I tried to fight back I tried, then she was grabbing her mouth telling us it hurt as well because he was holding his hand over her mouth. She told us he hit her left eye hard and it was Red. She never told me anything about being sexually abused. What she was telling me was bad enough that (CNA E) stayed and I pagged (sic) (LVN F) to the Hall.... Myself and (LVN F) went back to the Room. (LVN F) ask (sic) her whats (sic) wrong and plain as day she stated '(CNA D) Raped me.'" On 07/30/14 at 2:14 PM, CNA C informed the surveyor Resident #1 told her what happened. CNA C stated when she and CNA E went in to check Resident #1 around 7-7:15 AM on Monday, she got by the bed and called out Resident #1's name. Resident #1 grabbed her forearm and said "Thank God it's you." CNA C revealed Resident #1 began to touch her own cheeks and eyes and said "I tried to fight him off, I'm sorry; I tried to fight him off." CNA C said she then asked CNA E to stay with the resident and she paged the nurse, LVN F. CNA C stated before she left after the nurse came back in, she heard three descriptions. First Resident #1 said the name of CNA D, then she said it could have been a husky Mexican and then she called the perpetrator a strong young man. CNA C said when we looked at her bottom "she had a line across the top of her bottom like someone pulled the brief off of her hard." When asked if she had seen a dark red mark about the size of a finger which was about one inch from her rectum which extended towards the right of her buttock she said she had not noticed that. An undated statement signed by CNA E reflected, "Monday morning about 7:15 AM (CNA C) and I went to get (Resident #1) up & ready for breakfast. She grabbed (CNA C) & said thank God it is ya'll. We ask (sic) her if she was okay & she said I tried to fight him off. And we ask (sic) her who. She said he hit her in the face & pointed to her cheek & that her mouth was very sore & she hurt all over. She kept saying 'I tried, I tried.' I sat with her while (CNA C) went to get (LVN F). When they returned to the room (Resident #1) said that (CNA D) raped her." Review of CNA D's personnel file revealed a Corrective Action Notice, signed by him and the Administrator on 08/01/14, which reflected, "...Date of Incident/Issue? 07/25/14...This is the employee's 1st (first) written counseling. Type of Action...Termination... 1. Description of incident or issue...Unverified allegations of serious misconduct...4. In order to correct this issue, the employee must: Immediate Discharge 5. Employee's comments... (box was blank)...." His file also reflected he was 5 feet 10 inches tall and weighed 200 lbs. Resident #1's Mental and Behavioral Health Visit Note, dated 08/01/14, reflected, "The pt (patient) was re-referred for individual therapy due to her being raped on the night of 7/25/14. She was taken to a hospital and it was confirmed that she was sexually assaulted. (Resident #1) is showing symptoms of shock, and acute stress reaction to the trauma. The goal of the session was to create a safe place for her to share her thoughts and feelings...She did not want to discuss the events of the rape at that time...Her affect was unusually flat and withdrawn. Her emotional spectrum was limited...Pt is uncharacteristically withdrawn. Individual therapy will continue to assist her with managing her traumatic experience reactions with the goal of preventing [MEDICAL CONDITIONS]...." Observation of Resident #1 on 08/13/14 at 1:15 PM revealed she was taking a nap in her bed. Resident #1 opened her eyes while her roommate was being interviewed and when the surveyor asked how Resident #1 was doing she immediately closed her eyes again. An interview with LVN F on 08/13/14 at 12:20 PM revealed the resident had done really well the last week. She stated Resident #1 was really traumatized over the weekend when it happened. LVN F revealed the resident trusted the CNAs on days and on Monday she was able to talk about it. She stated Resident #1 had not required more medications. LVN F stated they started the resident on antibiotics on the weekend because no one could figure out what was wrong with the resident. Interview on 08/13/14 at 1:25 PM with CNA C revealed on Monday (seven days after the incident was reported) Resident #1 was very confused and came out of her room in a gown. CNA C stated, "She looked confused and lost." Resident #1 was adamant that it was night when it was daytime. She perked up on Tuesday and Wednesday. The facility's current Abuse Prevention Policy, revised June 2009, reflected, "The facility will prohibit abuse, neglect...for all patients through the implementation of seven components...The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect...for all patients, and to treat all patients at the facility with dignity and respect at all times...Sexual abuse Includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Sexual assault is defined as a sudden violent attack, an unlawful attempt to threat to do bodily harm and/or rape...Each Legend Healthcare facility will take actions to prevent abuse, neglect...." The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 07/30/14 and signed by the Administrator, reflected a census of 106 residents.