Every finding on record at Lubbock Health Care Center

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 in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. [NAME] D failed to ensure food was stored, prepared, and served under sanitary conditions. Food items-including butter and rolls were left uncovered for extended periods while in the kitchen. Resident drink cups were stored on 12/7/25 by DA A and DA E: Trays were stacked directly on top of uncovered cups, exposing the rims of the cups to the unsanitary underside of serving trays. DM failed to discard spoiled sweet potatoes that were visibly rotten and stored with fresh food items. DA A and DA E failed to label and date beverages stored in the walk-in refrigerator. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 12/7/25 in Kitchen A:Butter:The butter remained uncovered while not actively being served during the following times: 9:45 AM to 10:20 AM 11:22 AM to 11:45 AM 2:00 PM to 2:05 PM Uncovered or Improperly Stored Items:At 9:45 AM, a large container of tea was observed in the kitchen sink with a large tea bag steeping inside. At 10:02 AM, DA E removed the tea from the sink and placed it on a table near the kitchen entrance. The large tea container remained uncovered while DA E filled smaller pitchers one at a time to fill resident cups. The larger container remained uncovered throughout this process. At 9:50 AM, three trays of glasses were observed stacked on top of one another, exposing the rims of the glasses to the underside of the serving trays. A total of 48 glasses had exposed rims. At 10:05 AM, DA A unstacked the cups, allowing DA E to fill them with tea. DA A then covered the filled cups with saran wrap and placed them in the walk-in refrigerator. Unlabeled Food/Drink Items:At 9:52 AM, 39 cups of unknown liquids with lids were observed in the walk-in refrigerator. The liquids were not labeled or dated. Spoiled/Rotten Food:At 9:56 AM, 17 spoiled sweet potatoes with visible white fuzzy substance were observed stored in a plastic bag dated 11/26/25 with fresh russet potatoes. The spoiled sweet potatoes remained present until the investigator exited at 10:20 AM. The spoiled sweet potatoes remained present during subsequent observations at 11:36 AM to 11:45 AM and again at 2:00 PM to 2:05 PM. Rolls:Cook D removed trays of rolls from the oven at 9:59 AM and 10:02 AM. Both trays remained uncovered and not actively being served or buttered until 10:20 AM. During this time, DA A was observed sweeping near the uncovered rolls.The following observations were made on 12/8/25 in Kitchen A:Butter:The butter remained uncovered while not actively being served during the following times: 7:03 AM to 7:11 AM 11:30 AM to 12:35 PM At 6:30 PM, saran wrap was observed covering the butter; however, the utensil remained in the container. Spoiled/Rotten Food:The spoiled sweet potatoes dated 11/26/25 remained stored with russet potatoes during observations at: 7:04 AM to 7:11 AM 11:35 AM to 12:35 PM At 6:44 PM, the investigator brought the spoiled sweet potatoes to DA C's attention. Unlabeled Food/Drink Items:At 7:10 AM and again at 6:45 PM, the same 39 unlabeled cups of liquid remained in the walk-in refrigerator until addressed by the investigator. During an interview on 12/08/25 at 6:44 PM, DA C stated that he was unaware of the rotten sweet potatoes. He counted the sweet potatoes and confirmed there were 17 in total. DA C stated that he was unaware that the juices were in the refrigerator unlabeled and not dated. He stated that he believed they were orange juice and cranberry juice. He stated that he was unaware of when they were made. DA C stated that he did not see the rotten sweet potatoes in the walk-in dry pantry. He stated that when he counted them, he could smell that they were rotten and was unsure how they were missed. He stated that regarding the butter, it was his job to cover the butter at the end of the night and place it in the refrigerator. He stated that when he came in, the butter was generally always uncovered and was left for him in the evening as one of his tasks. DA C stated that the potential negative outcome of having spoiled or rotten food stored with residents' fresh or ready-to-eat food was that they could not use even the fresh food. He stated that having spoiled or rotten food could affect the overall health of the residents. He stated that the potential negative outcome of not labeling food was the same as having spoiled food stored with fresh food. He stated that they would not be able to use food that was not labeled or dated because it could be old and affect the overall health of the residents. He stated that if food such as butter was not covered, then items could fall into the butter, staff could spray something and it could get into the food, or staff could be cleaning around the food and debris could get into the butter. He stated that this could make residents sick if they consumed it. He stated that he was familiar with the food storage policy but had only been at the facility a short time. DA C stated that the system to ensure foods were being labeled timely was to label food and drink items as they were prepared. He stated that spoiled food should be discarded immediately and not stored with fresh food items. He stated that all food not being used should be covered. He stated that he did not have a reason for the juices not being dated and labeled, the spoiled sweet potatoes being stored with other food items, nor did he have a reason why the butter was not covered and left for him to cover in the evenings. He stated that he had been trained to cover food items not actively being served but had never been trained to cover the butter. He stated that he knew to discard spoiled food items, but generally the DM discarded the food items. He stated that the aides typically dated and labeled the juices. DA C stated that all staff were responsible for ensuring that food was properly covered, discarded when appropriate, and dated and labeled. During an interview on 12/09/25 at 8:12 AM, the DM stated that he was familiar with his facility's policies and expectations regarding food storage and labeling. He stated that the potential negative outcome for not covering food was related to infection control. He stated that items could get into the food without staff knowing and could then be served to residents. He stated that the potential negative outcome for not discarding spoiled or rotten food and storing it with fresher food was that the fresher food could be contaminated and potentially harm residents if served. The DM stated that the potential negative outcome for not labeling and dating food was that the food could be spoiled. He stated that a person may not know how long the food or drink item had been stored or even what the item was. He stated that it could be something that a resident was allergic to and could harm that resident. The DM stated that he was unaware at the time of the potential violations. He stated that he did not observe the stacked glasses. He stated that he assumed the rolls were cooling and that was why they were uncovered. He stated that it was normal practice for staff to allow items to cool uncovered. He stated that he was unaware that staff were leaving the large tea container uncovered in the kitchen sink while the tea steeped. The DM stated that he was unaware that the spoiled or rotten potatoes were in the dry pantry, as he would have normally discarded them. He stated that he was unaware of the unlabeled juices in the walk-in refrigerator. He stated that his system to monitor and ensure food items were not spoiled was that they generally ordered fresh food items weekly to meet menu needs. He stated that following policies and procedures such as the first in, first out method helped ensure that food items that arrived first were used before newer items. He stated that staff assisted one another in the kitchen to ensure food was covered, labeled, and that no spoiled or rotten food was present. He stated that he expected food not actively being served or prepared to be properly stored and labeled according to company procedures. He stated that the butter should have been covered. He stated that glasses should never be stacked in a manner that exposed the rims to the underside of the serving tray. He stated that the facility had lids for cups and that those lids should have been used. He stated that juices should have been labeled and dated. He stated that the facility had stickers indicating the date, item name, expiration date, and staff initials. The DM stated that all spoiled or rotten foods should have been discarded immediately. The DM stated that it was everyone's responsibility to cover food not actively being served, date and label food items, and discard spoiled or rotten foods. He stated that cooks specifically handled fresh or raw food items. The DM stated that he did not have a reason for the uncovered food items, unlabeled drink items, or spoiled food being stored with fresh food and stated these were items that were simply missed. During an interview on 12/09/25 at 8:37 AM, [NAME] D stated that she was familiar with the facility's policies and expectations regarding proper food storage and labeling. She stated that the potential negative outcome of stacking resident cups and exposing the rims of the glasses to the underside of the serving tray was that bacteria could get on the rim and cause residents to become ill. She stated that the potential negative outcome of food and drink items not being covered while actively being served was that something could get on or into the item. She stated that chemicals or trash could get into the item and potentially make residents sick. She stated that similar to stacked resident cups, staff would not be able to tell what may have contaminated the cups. [NAME] D stated that if food and drink items were not labeled, staff would not know how long the items had been present and they could potentially make residents sick. She stated that the potential negative outcome of not discarding spoiled or rotten food and storing it with fresh food was contamination, which could ultimately make residents sick. [NAME] D stated that she was aware of the uncovered butter and stated that this was how it had been done and that the butter was always readily available for use. [NAME] D stated that she was aware of the tea being uncovered in the sink but was unaware of the unlabeled juices in the walk-in refrigerator. She stated that she observed aides place juice in the walk-in refrigerator. She stated that she was unaware of the stacked resident glasses and the rotten sweet potatoes. [NAME] D stated that she did not think to cover the rolls because she was allowing them time to cool. She stated that she was unaware that the rolls needed to be covered while cooling. [NAME] D stated that the system to monitor food storage and labeling was education and monitoring provided by the DM. She stated that the DM would review policies with staff and correct them if issues were observed. She stated that she and her coworkers had been trained regarding food storage and labeling. She stated that she expected all food to be covered, dated, labeled, and that spoiled food be discarded. [NAME] D stated that all staff were responsible for food storage and labeling. She stated that the reason the rolls were uncovered was because she was allowing them to cool. She stated that she did not have a reason why the butter remained uncovered, as it had always been done that way. She stated that she believed she buttered the rolls while the HHSC investigator was in the kitchen. During an interview on 12/09/25 at 10:02 AM, DA E stated that she was familiar with the facility's expectations and policies regarding food storage and labeling. She stated that the potential negative outcome for not covering food properly when it was not actively being used was that germs could get into the food or drink item and negatively affect residents. She stated that the potential negative outcome for storing rotten or spoiled food with fresh food items was contamination and potential illness to residents. She stated that the potential negative outcome for stacking resident cups and exposing the rims to the underside of the serving tray was contamination, and residents could place their mouths on contaminated surfaces and become sick. DA E stated that the potential negative outcome for not labeling and dating food or drink items was that staff may forget when the items were prepared, and items such as juice could spoil quickly. DA E stated that she was aware of the tea being uncovered and was taught by another staff member, who was no longer employed at the facility, to do it that way. She stated that she believed it was acceptable. She stated that on 12/08/25, she placed a lid on the container. DA E stated that she was aware that cups were stacked without lids but stated that she did not always correct others because she did not want to be perceived as mean. DA E stated that she was unaware of the spoiled or rotten potatoes. She stated that she typically checked bananas and potatoes because they spoiled quickly. She stated that staff had been focused on cleaning the walls recently. She stated that she did not observe the rolls or butter uncovered. She stated that she was aware of some juice not being labeled. She stated that she labeled trays as orange juice but that one tray that was not individually labeled contained apple juice and cranberry juice in addition to orange juice. DA E stated that the system to monitor proper food storage and labeling was reviewing errors when they occurred and receiving correction and coaching from the DM. She stated that staff sometimes corrected one another. She stated that she expected all food to be covered and labeled, especially when not actively being used. She stated that cups should not be stacked and that juice could be prepared one tray at a time. She stated that cups should be covered with lids or saran wrap and that tea should be covered. She stated that all staff were responsible for ensuring food was properly labeled and stored, spoiled food was discarded, food was covered when not actively being used, and resident cups were not stacked and exposed to the underside of serving trays without a lid or barrier. DA E stated that she did not have a reason why the observations occurred. She stated that she focused on drinks, while the cook typically focused on food. During an interview on 12/09/25 at 10:24 AM, DA A stated that she was familiar with the expectations and policies regarding food labeling and storage. She stated that the potential negative outcome for stacking cups and exposing the rims to the underside of the serving tray was that the bottom of the tray could be dirty and residents could become sick if exposed. She stated that it did not cross her mind to consider the risk when stacking trays. She stated that the potential negative outcome for storing spoiled or rotten food with fresh food was contamination, and that one bad apple ruins the bunch, which could make residents sick. She stated that the potential negative outcome for not covering food that was not actively being served or prepared was that food could develop freezer burn in the refrigerator, collect bacteria, or make residents sick. She stated that the butter had been left uncovered since she started working at the facility and that she had been there approximately six or seven months. She stated that uncovered food could allow gnats or flies into the food, especially when the back door was opened. She stated that while sweeping, dust could have entered uncovered food and made residents sick. She stated that the potential negative outcome for not labeling and dating food was that staff would not know when the food was placed in the refrigerator and that it could be expired. She stated that staff may not know what the food item was, which could result in giving residents food to which they were allergic. She stated that she was aware of the tea being left uncovered in the sink. She stated that she and another aide alternated monthly duties, with one responsible for drinks and the other responsible for ice. She stated that she was aware of stacked cups, uncovered butter, and uncovered rolls but was unaware of the spoiled sweet potatoes in the dry pantry. She stated that she was aware of apple and cranberry juice not being labeled. She stated that the system to monitor and prevent violations was to label items immediately after preparation and discard spoiled food immediately. She stated that there was no system in place for covering butter, as it had always been left uncovered throughout the day. She stated that the pantry was checked and cleaned at least twice a week. She stated that she had been trained on labeling but was unaware that the sweet potatoes were spoiled, although she knew to discard spoiled food. She stated that she had been trained not to stack cups and expected all items to be labeled. She stated that she attempted to check for spoiled food. She stated that all staff were responsible for kitchen tasks, and that if a staff member prepared a food or drink item, they were responsible for ensuring it was done properly. She stated that staff worked as a team and anyone could complete tasks. She stated that everyone was responsible for discarding spoiled food and ensuring items were properly labeled. She stated that she did not have a reason why the observations occurred. During an interview on 12/09/25 at 12:00 PM, the ADM stated that she was familiar with the expectations and policies regarding food storage and labeling. She stated that all food should be stored according to policy. She stated that all food and drink items should be labeled upon receipt. She stated that the potential negative outcome for not labeling and dating food was that the food could spoil without staff realizing and could be served to residents, causing food poisoning or illness. She stated that the potential negative outcome for not discarding spoiled or rotten food was cross-contamination and food poisoning. She stated that the potential negative outcome for not covering food that was not actively being served or prepared was cross-contamination, debris entering the food, and illness or food poisoning. She stated that the potential negative outcome for stacking cups and exposing rims to the underside of serving trays was cross-contamination, infection control concerns, and residents consuming debris. She stated that she was unaware of the observations in the kitchen until she was informed by the HHSC investigator on 12/08/25. She stated that she had been trained regarding food storage and labeling during her AIT process. She stated that kitchen staff had been trained on facility expectations and policies regarding food storage. She stated that all staff should be aware of the guidelines. She stated that she expected kitchen staff not to place residents at risk for cross-contamination. She stated that she expected routine tasks such as labeling food, covering food not actively being served or prepared, and discarding spoiled or rotten items to be completed immediately. She stated that responsibility initially rested with individual kitchen staff and was overseen by the DM, with tasks to be completed properly and routine inspections conducted. She stated that she did not have an excuse for the observations that occurred and stated that the fact it was a weekend may have had an impact. Record review of the facility's policy titled and dated, Food Storage and supplies (2012), reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin and insects. Open packages of food are stored in closed containers with covers or in sealed bags, and data is to when open. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to market by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a Best Buy for use by date. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as when 2 when it is received, the chef stable items will be stored in a first in first out manner to be used within one year. On perishable foods, microorganisms such as mold, yeast, and bacteria can multiply and cause food to spoil. Filled foods will develop in labor or texture due to natural spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten. The bacteria that can be found on food: pathogenic bacteria, which is caused foodborne illness, and spoilage bacteria, which causes flu to deteriorate and develop unpleasant characteristics such as an undesirable taste or odor making the food non wholesome, but do not cause illness. Record review of 2022 Food Code U.S. Food and Drug Administration revealed:Preventing Contamination from the premises (Food Storage):3-302.11(A)Food shall be protected from contamination by storing food: Where it is not exposed to splash, dust, or other contamination. This includes:Covering food using lids, wrappers, foil, sneeze guards, or other protective barriersPreventing exposure to dust, debris, insects, drips, splash, equipment surfaces, and employees3-303.12(A) Food on display shall be protected from contamination by packaging, sneeze guards, or other effective means.Sections 2-301.14 and 2-301.15

Based on observations, interviews, and record review the facility failed to ensure a resident has a right to a safe, clean, comfortable and homelike environment for 1 of 20 residents reviewed for physical environment. A handrail in the shower room on South Hall was loose. This deficient practice has the potential to place residents at risk for injuries related to falls that could result in bruising, skin tears, wounds, fractures, and decreased quality of life. Findings include: During a confidential interview held on 12/08/2025 at 2:00 PM, 3 of 7 confidential residents mentioned a loose handrail in the shower room on South Hall. 3 of 7 confidential residents stated the handrail had been loose for an unknown period of time. The confidential residents stated staff who assist them with bathing were aware of the loose handrail in the shower room. During an observation on 12/08/2025 at 03:15 PM the left side (under the shower head) handrail in the first shower was noted to be loose and this surveyor was able to move the handrail back and forth approximately 1-2 inches on the near side of the handrail. The handrail was secured on each end, and the far end of the handrail was secure, with no movement. During an interview on 12/08/2025 at approximately 3:30 PM, CNA H stated he was aware there was a handrail loose in the shower room on South Hall. CNA H stated the loose handrail had been reported to the maintenance supervisor, but he did not know the status of the repair. CNA H stated his job duties included assisting residents with bathing. CNA H stated he was unsure how long the handrail had been loose. CNA H stated he did not use the shower room on South Hall often, to assist residents in bathing, since he primarily used the shower room on East Hall. During an interview on 12/09/2025 at 10:10 AM, CNA G stated her job duties included assisting residents with bathing in the shower room located on the South Hall (across from the nurse's station). CNA G stated she had worked at the facility for approximately 3 years. CNA G stated she was aware the left handrail in the first shower stall was loose. CNA G stated the handrail had been loose for as long as she had worked at the facility. CNA G stated she reported this concern to the maintenance supervisor, and the handrail had been fixed in the past. CNA G stated the handrail became loose after it was fixed, and it was reported again to maintenance. CNA G stated she was advised the tile would have to be removed for the handrail to be fixed properly, but she did not know when that would be done. CNA G stated she ensured residents did not use that handrail by informing residents of the loose handrail and asking them not to use it. CNA G stated she could not prevent residents from grabbing the loose handrail if they reached out for it out of instinct. CNA G stated she did not feel residents were at risk of falling because she wouldn't let them fall. CNA G stated there was a risk the handrail could break completely if a resident put their weight on it, but she did not feel this was a risk to the residents since she advised them not to use it. CNA G stated no residents had fallen due to the loose handrail. CNA G stated there were no residents who showered independently. During an interview on 12/09/2025 at 10:30 AM the MS stated he had worked at the facility for approximately one year. The MS stated he was aware the handrail (on the left side) in the first shower stall of the shower room on South Hall was loose. The MS stated the handrail had become loose several times, and he has continuously tightened it. The MS stated the tile in the shower would have to be removed to fix the handrail properly to ensure it did not become loose again. The MS stated he had submitted a proposal for a bid to have the shower on East Hall renovated, and the loose handrail in the shower on South Hall was included in the bid. The MS stated he did not think the bid was approved by the facility's corporate office due to pricing, and a new bid was being proposed to break down the renovation into individual sections. The MS stated he did not know the status of the new bid. The MS stated he would begin checking the handrail in the shower room more frequently until the repair could be completed. The MS stated the facility had a process of reporting necessary repairs by staff placing the needed repair in the Maintenance Care system. The MS stated if the repairs were more urgent, staff could have reported the repair to him directly. The MS stated the loose handrail had been reported to him on multiple occasions by the Maintenance Care system as well as by staff directly. The MS did not know when the last report was received regarding the loose handrail or when he last tightened it. The MS stated he checked the Maintenance Care system daily to prepare his daily scheduled maintenance. The MS stated he did not check the shower rooms daily, and he relied on staff to report maintenance needs. The MS stated he did not feel the loose handrail in the shower room was at risk of breaking completely. The MS stated the handrail was secured with a toggle bolt, so the tile would have to break off for the handrail to come off of the wall completely, and he did not feel this was possible. The MS stated the loose handrail impacted residents since they could not use it to help them stand or support their weight. The MS stated he did not know if the loose handrail was a risk to a resident falling or incurring an injury. The MS stated he was the person responsible for fixing the loose handrail, as long as it was reported to him by staff. During an interview on 12/09/2025 at 11:00 AM the DON stated she was not aware of the loose handrail in the shower room on South Hall. The DON stated all maintenance requests were reported to the MS directly or through the Maintenance Care system. The DON stated the MS was responsible for ensuring all repairs were completed timely. The DON stated she was not aware of any falls or accidents due to the loose handrail in the shower room on South Hall. The DON stated it was her expectation that repairs would be completed as soon as possible, and for nursing staff to report needed repairs as they became aware of the need for repair. The DON stated a loose handrail in a shower staff could pose a safety hazard to a resident and could potentially result in a fall and/or injury. During an interview on 12/09/2025 at 11:20 AM the ADM stated she was not aware of a loose handrail in a shower stall in the South Hall shower room. The ADM stated it was her expectation that all needed repairs be reported directly to the MS or in the Maintenance Care system. The ADM stated the MS is responsible for checking Maintenance Care daily and prioritizing tasks based on resident need and safety. The ADM stated she was not aware the handrail had been loose, ongoing, for potentially 3 years. The ADM stated it had not been reported to her previously. The ADM stated renovations of the shower room on East Hall were pending, but she was not certain if this included the handrail in the South Hall shower room. The ADM stated she would follow up to ensure the handrail was fixed as soon as possible. The ADM stated there was a risk to residents if a handrail were loose since it could potentially break and result in a resident falling or incurring an injury. Record Review of the facility's document titled, Scheduled Tasks, created on 09/12/2025, included the following: Resident Bathing: Inspect shower room and shower equipment Runs 2nd MONDAY of month in: ALL MONTHS At 09:00 Record Review of the facility's policy pertaining to handrails revealed the following: The Facility was unable to provide a policy related to handrails.

Based on observation, record review, and interview, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 (Resident #4) of 20 reviewed for accidents and supervision. The facility failed to consistently supervise Resident #4 while smoking and failed to ensure the use of a smoking apron, despite assessments and negotiated risk agreements identifying the need for direct supervision due to the risk of injury. These failures had the potential to result in resident harm, including burns or other smoking-related injuries. Findings included: A record review of Resident #4's face sheet dated 12/08/25 revealed that Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include a cognitive communication deficit. A record review of Resident #4's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C (Brief Interview for Mental Status) score of 09, indicating moderately impaired cognition. Section J (Health Conditions) revealed Resident #4 used tobacco. A record review of Resident #4's care plan dated 12/01/25 revealed that Resident #4 smoked and was frequently noncompliant with scheduled smoking times. The stated goal was for Resident #4 to be able to smoke without causing injury. Interventions included redirecting Resident #4 to scheduled smoking times and requiring the use of a smoking apron while smoking. The care plan did not include supervision while smoking. A review of progress notes dated 10/07/25 through 12/08/25 revealed the following: On 10/16/25 at 10:30 AM, the ADM documented she was notified that Resident #4 was outside smoking outside of supervised smoking hours. The smoking policy and schedule were explained, and Resident #4 stated she did not care and felt the rules were unfair. On 10/19/25 at 5:08 PM, LVN J documented Resident #4 was resistant to education regarding smoking safety. The Resident Representative was notified. On 11/06/25 at 4:17 PM, the SW documented a negotiated risk agreement was completed due to Resident #4 being observed falling asleep while smoking. The agreement stated Resident #4 would be supervised while smoking. On 11/07/25 at 12:50 PM, the DON documented that Resident #4 was required to wear a smoking apron due to falling asleep while smoking. A review of Resident #4's negotiated risk agreements dated 11/06/25 and 12/08/25 revealed that Resident #4 agreed to wear a smoking apron and to be supervised while smoking. Attendees included the POA, ADM, Resident #4, and the Medical Director. A review of the smoking assessment dated [DATE] revealed Resident #4 required direct supervision while smoking and a fire-resistant smoking apron. Record review of weekly skin assessments dated 12/04/25 and 12/11/25 revealed no smoking-related injuries. Record review of an incident report dated 12/15/25 revealed no smoking-related incidents between 09/15/25 and 12/15/25. On 12/07/25 at 12:30 PM, Resident #4 was observed returning from smoking. An unknown staff member was present outside with Resident #4 and multiple residents. On 12/09/25 at 10:23 AM, Resident #4 was observed outside smoking without a smoking apron. She was alert while smoking her cigarette. MA B was observed coming in from the patio. On 12/09/25 at 11:15 AM, Resident #4 was observed in the kitchen with no burn holes on her clothing or blanket. On 12/09/25 11:20 AM, Resident #4 was observed outside smoking unsupervised and without a smoking apron. She was She was alert while smoking her cigarette. During an interview on 12/09/25 at 11:15 AM Resident #4 stated she could smoke independently and did not need supervision or a smoking apron. She stated staff sometimes watched her smoke, but she did not need assistance. When asked who let her out to smoke on 12/09/25 she did not answer. When asked who gave her the cigarette and a lighter, she became upset and asked why the HHSC investigator was asking all of the questions and stopped answering questions. During an interview on 12/09/25 at 12:00 PM, the ADM stated that she was familiar with the expectations and policy regarding incidents and accidents. She stated that the potential negative outcome for not preventing incidents and accidents was resident harm. She stated that Resident #4 could potentially fall if not supervised. She stated that it was documented that Resident #4 did not adhere to the smoking policy. She stated that she and staff informed Resident #4 about the risks of her actions. The ADM stated that she was unaware, at the time she was on her way to dietary, that Resident #4 was outside smoking. She stated that she went to give one of the dietary aides a message. She stated that Resident #4 should not have had the door code but would sometimes press on the door to go outside. She stated that staff constantly made adjustments to redirect Resident #4. She stated that Resident #4 should have been supervised while smoking. She stated that Resident #4 was noncompliant with wearing her smoking apron. She stated that the system to monitor Resident #4 was constant redirection and attempts to bring her inside. She stated that staff should stay with Resident #4 and remind her of designated smoking times. The ADM stated that she had been trained on incident and accident prevention. She stated that she completed training on incidents and accidents a few months prior. The ADM stated that she expected the safety of Resident #4 and all residents to be maintained. She stated that she did not agree with allowing one resident to smoke at any given time while requiring other residents to wait. She stated that all staff were responsible for ensuring resident safety and preventing incidents and accidents. During an interview on 12/09/25 at 12:33 PM, the DON stated that she was familiar with the expectations and policy regarding incidents and accidents. She stated that the potential negative outcome was injury to the resident. The DON stated that she was unaware that Resident #4 was outside smoking unsupervised on 12/09/25 at 10:23 AM and at 11:20 AM. She stated that she was unaware of the smoking times without referencing the policy but knew that there were designated smoking times and that those times were supervised. She stated that she and her staff had been trained that smoking times were supervised and that staff were to follow the smoking assessment for each resident. She stated that she expected all staff to follow the rules. She stated that Resident #4 had a history of going outside on her own. She stated that Resident #4 refused to wear her smoking apron. She stated that staff should stay with Resident #4 if they observed her outside. She stated that all staff were responsible for preventing incidents and accidents and following assessments. She stated that the reason Resident #4 was observed outside was potentially because she let herself out. She stated that the door would alarm, but depending on staff proximity, it could be difficult to hear. She stated that staff redirected Resident #4 frequently but that Resident #4 would give staff a hard time. She stated that staff had explained the concerns to Resident #4's responsible party. She stated that there was no reason staff should not have stayed with Resident #4 if they observed her outside. During an interview on 12/09/25 at 12:50 PM, MA B stated that she went outside to give Resident #4 her medications. She stated that she was not the staff member who let Resident #4 outside. She stated that she was not normally the staff who supervised smokers. She stated that she was not thinking and went outside to administer the medication that Resident #4 was outside smoking unsupervised. She stated she went to give her the medication and went to finish her medication pass. She stated that Resident #4 would tell staff when she wanted to smoke and that she believed Resident #4 could smoke by herself. She stated that she was unaware that Resident #4 was required to wear a smoking apron. She stated that she knew Resident #4 could open the door and would become upset when staff attempted to redirect her. During an interview on 12/15/25 at 4:46 PM, Resident Representative I (Resident #4's Representative) stated that Resident #4 was determined to smoke. He stated that facility staff tried to encourage her to smoke at appropriate times, but she did not listen. He stated that he did not have concerns with facility staff, as they were always trying to encourage Resident #4 to follow the rules. He stated that Resident #4 would go outside on her own without staff because she was impatient. He referred to Resident #4 as stubborn and an old [NAME] woman and stated that this made it difficult for facility staff to get her to follow the rules. He stated that Resident #4 would think she was being singled out, but that was not the case, as facility staff were trying their best. He stated that in a perfect world, every resident would have their own personal staff, but that was impossible. He stated that he and facility staff had discussed the possible use of nicotine patches to help with Resident #4's urge to smoke. He stated that he believed facility staff were trying to help Resident #4, but that she made it difficult. During an interview on 12/16/25 at 11:02 AM, the ADM stated that staff had previously been in-serviced on the smoking policy. She stated that there was no specific training conducted solely for Resident #4. She stated that residents were not singled out and that all residents were expected to adhere to the smoking policy. She stated that staff had been working with Resident #4 and her family regarding smoking concerns. She stated that the POA was not happy with the policy and stated an intention to move Resident #4. She stated that nicotine patches had been suggested in the past but were not a request that could be accommodated. She stated that it was not recommended that Resident #4 use a nicotine patch while continuing to smoke. She stated that the facility implemented weekly changes to the door code and emphasized staff not to share the code. She stated that staff consistently spoke with Resident #4, and Resident #4's response was that it was not fair. She stated that staff consistently informed Resident #4 that the policy was for her safety. She stated that although noncompliance with the smoking apron was not specifically care planned, Resident #4's overall noncompliance with rules and care was care planned. She stated that Resident #4 would become verbally combative with staff when redirected. The ADM stated that staff were attempting to be proactive through staff training, resident redirection and education, and family communication and support. She stated that at one time Resident #4 was allowed to have her own smoking supplies, but due to changes, she was no longer permitted to do so. She stated that Resident #4 would ask other residents for cigarettes and look in ashtrays. She stated that Resident #4 had not sustained any burns or injuries related to smoking within the past 90 days. Record review of the facility's smoking schedule, undated, reflected: 7:00 AM smoke breaks supervised by housekeeping9:00 AM smoke breaks supervised by activity11:00 AM smoke breaks supervised by housekeeping and laundry1:00 smoke break supervised by dietary3:00 PM smoke break supervised by maintenance and housekeeping on the weekendthere is no smoke break during 5:00 PM during meal time.7:00 PM smoke breaks supervised by nursing8:00 PM smoke break supervised by nursing9:00 PM smoke break supervised by nursing11:00 smoke break supervised by nursingAll cigarettes and lighters must be remained at the nurses station. Residents need to be escorted by staff during smoke breaks. Record review of the facility's policy titled Smoking Policy (undated), reflected:Smoking policies must be formulated and adopted by the facility. The policies must comply with applicable codes, regulations and standards, including local ordinances. The facility is responsible for informing residents, staff, visitors, and other affected parties of smoking policies through distribution in or posting. The facilities responsible for enforcement of smoking policies which must include at least the following provisions:Matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in a residence room. A safe smoking assessment will be done regularly for each resident who smokes. Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel or visitors who are aware of the residents' limitations with smoking. The resident must be within direct view of smoking supervisor, and reasonably close proximity the supervisor, and the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor, whether staff or visitor must be aware of these responsibilities.Smoking designated location smoking patio area offset of dining area.

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for 1 of 20 resident (Resident #11) reviewed for PRN psychotropic medications, in that: Resident #11 had an active PRN order for alprazolam (Xanax) without a documented 14-day stop date, despite facility policy and regulatory requirements. This failure could place residents at risk for receiving unnecessary medications. Findings included: A record review of Resident #11's face sheet dated [DATE] revealed that Resident #11 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include anxiety. A record review of Resident #11's Comprehensive Minimum Data Set, dated [DATE] revealed the following: Section C (Brief Interview for Mental Status) score of 05, indicating severely impaired cognition. Section N (Medications) revealed Resident #11 received an antidepressant; however, the MDS did not reflect that Resident #11 received an antianxiety medication. A review of Resident #11's Psychotropic Medication Consent dated [DATE] revealed that Resident #11 provided consent and was informed of potential side effects and risks associated with alprazolam (Xanax), including agitation, appetite changes, blurred vision, confusion, dizziness, drowsiness, dry mouth, fatigue, hypotension, nightmares, sedation, slurred speech, and urinary retention. A review of Resident #11's physician order dated [DATE] revealed the following order:Xanax oral tablet 0.26 mg, give one tablet by mouth every eight (8) hours as needed for anxiety.(Order date: [DATE]; Start date: [DATE]) A review of Resident #11's Medication Administration Record (MAR) revealed: [DATE]: Resident #11 received one dose of PRN Xanax on [DATE]. [DATE]: Resident #11 did not receive any doses of PRN Xanax. A review of Resident #11's care plan dated [DATE] revealed that Resident #11 had behavioral concerns related to anxiety and depression, with a goal of no evidence of behavioral problems through the review date. Interventions included administering medications as ordered and monitoring and documenting side effects for effectiveness. During an interview on [DATE] at 7:23 AM Resident #11 did not express any concerns and did not provide information related to the facility's deficient practice regarding the absence of a 14-day stop date for PRN psychotropic medication. During an interview on [DATE] at 11:02 AM, the DON stated that she was familiar with the expectations and policy regarding psychotropic medications, specifically that PRN psychotropic medications required a 14-day stop date. She stated that after the 14 days expired on PRN psychotropic medications, the medication was either discontinued, or a new order was created. She stated that the purpose of this rule was to ensure that residents did not receive medications they did not need. She stated that the potential negative outcome for not having a 14-day stop date on a PRN psychotropic medication was that residents might receive unnecessary medications. She stated that this was a standard medication practice for hospice and that facility nursing staff were responsible for ensuring that when an order was entered, the 14-day stop date was included, even if the order came from hospice. She stated that she did have a concern that the medication might be needed and not be available in the facility. She stated that she understood these were the rules and that they needed to follow the rules. She stated that the purpose of the rules was to keep people safe. She stated that she was unaware that Resident #11 had a PRN psychotropic medication that did not have a 14-day stop date. She stated that she monitored resident medications weekly and that this issue was missed. She stated that the system to monitor resident medication orders was to review them upon admission and weekly thereafter. She stated that the nurse who entered the order would have been responsible. During an interview on [DATE] at 12:00 PM, the ADM stated that she was slightly familiar with the expectations and policy regarding psychotropic medications, specifically that PRN psychotropic medications were required to have a 14-day stop date. She stated that the potential negative outcome for a PRN psychotropic medication not having a 14-day stop date was that the medication could be administered unnecessarily, which could potentially cause harm. She stated that she was unaware that Resident #11 had a PRN psychotropic medication without a 14-day stop date. She stated that the system to monitor resident medications was that clinical staff, such as nursing, reviewed medication orders. She stated that nursing staff reviewed medication orders for requirements such as stop dates on PRN psychotropic medications. She stated that she had not been trained specifically on this requirement but assumed that nursing staff had been trained through onboarding and required training. The ADM stated that she expected the nursing staff and nursing department to adhere to all state and federal regulations and to act in the best interest of residents. She stated that psychotropic medications should not be administered past the 14-day stop date unless a new order was written. She stated that the charge nurse and the DON were responsible, and that even under her supervision, the DON was responsible. She stated that she did not have a reason why Resident #11's PRN Xanax did not have a 14-day stop date. Attempts were made to contact the Medical Director to discuss psychotropic and unnecessary medications on [DATE] at 1:45 PM and again on [DATE] at 8:50 AM; however, the Medical Director was unavailable, and messages were left. Attempts were made to contact the Nurse Practitioner to discuss psychotropic and unnecessary medications on [DATE] at 8:50 AM; however, the Nurse Practitioner was unavailable, and a message was left. Record review of the facility's policy titled and dated, Medication Administration and General guidelines (2025), reflected: Medicines are administered as prescribed, in accordance with the state regulations using good nursing principles and practices and only by persons legally authorized to do so. ProcedureModern medications are administered; the following documentation is provided:getting some administration, does route of administration and if applicable the injection site. Record review of the facility's policy titled and dated, Psychotropic Medication ([DATE]), reflected: 30 would ensure that the resident is free from chemical or strength imposed for purpose of discipline or convenience in that are not required to treat the resident medical symptoms. Residents should only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Also, interventions have been attempted in or deemed clinically contraindicated.It's like a trooper drug is any drug that affects brain activities associated with mental processes and behaviors. These drugs include, but are not limited to, drugs in the following categories: anti-anxiety PRN orders for antidepressants, hypnotic, and anti-anxiety drugs are limited to 14 days. Except if the extended beyond 14 days, he or she should document the rationale in the residence medical record and indicate the duration for the PRN order. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending position or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 2 medication carts (Medication Cart 2) reviewed.The facility failed to ensure 2 loose pills in Medication Cart 2 were properly labeled or stored. This failure could place residents at risk for medication errors and drug diversion.The findings include: During an observation on [DATE] at 10:03AM with MA B on Medication cart 2, 1 green pill and 1 white pill were found in the second drawer, unlabeled. During an interview with MA B on [DATE] at 10:08AM, she stated she had been trained on checking the medication carts monthly through in-services. She stated she had been trained to check the carts weekly and as needed throughout the week. She stated the carts are checked for expired medication, loose pills, cleanliness and making sure the narcotic count is correct. She stated the DON was responsible for checking the carts, but staff were also responsible for ensuring the carts were in working order. She stated the potential negative outcome could be mistaking the medication for a different resident's medication and administering it to the incorrect resident. She stated she had checked Medication Cart 2 on [DATE] and had been surprised to find those two loose pills in the medication cart. During an interview with the DON on [DATE] at 10:25 AM, she stated the two pills found were identified as amitriptyline (treatment of major depressive disorder) for the green pill and furosemide (used primarily to treat fluid retention and high blood pressure) for the white pill. During an interview with the DON on [DATE] at 10:23 AM, she stated nursing staff were trained to check the medications carts at least weekly. She stated training was done upon hire and as needed. The DON stated staff were trained to check for expired medication, loose pills, and overall cleanliness. She stated a potential negative outcome of having loose pills in the cart could be residents running out of their medication or potentially a staff member grabbing the medication by accident and administering it to a resident. She stated they monitor compliance by doing weekly sweeps with staff members and ensuring the carts were kept up to date. She stated it was all staff members' responsibility to ensure the carts were clean and free of loose pills any time they assume responsibility over the carts. During an interview with the ADM on [DATE] at 10:33AM, she stated staff were trained to check the carts monthly and administration does a sweep as well to ensure the carts are kept clean and updated. She stated if there were any issues that came up during those sweeps, they were addressed at that time. She stated staff should be looking for expired mediation, loose pills or any items that may not belong in the carts and ensuring the narcotic count was accurate. She stated a potential negative outcome could be residents missing medications, drug diversion, or potential medication error if the wrong medication was given to the wrong resident accidentally. She stated it is the DON's responsibility to conduct training and to make sure the cart checks were being done. Record review of facility policy titled Medication Storage in the Facility dated 2025 revealed: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations orthose of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staffmembers lawfully authorized to administer medications.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 the procedures for medication destruction, and reordered from the pharmacy, if a current order exits. 14. Medication storage areas are kept clean, well lit, and free of clutter.

Based on observation, record review, and interview, the facility failed to ensure resident essential equipment was maintained in safe and proper operating condition for 1 (Resident #7) of 20 residents. Resident #7's oxygen concentrator was observed with a red alert light illuminated, indicating a potential malfunction, and staff were unaware or failed to report and address the issue in a timely manner. This failure had the potential to result in inadequate oxygen delivery and respiratory distress, placing the resident at risk for harm. Findings included: A record review of Resident #7's face sheet dated 12/08/25 revealed that Resident #7 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit and mild persistent asthma. A record review of Resident #7's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C (Brief Interview for Mental Status) score of 13, indicating intact cognition. Section N (Medications) revealed that Resident #7 participated in oxygen therapy. A record review of Resident #7's physician order dated 12/08/25 revealed the following:Oxygen: 2-5 liters per minute via nasal cannula every shift related to mild persistent asthma (order date 08/12/25; start date 08/12/25). A record review of Resident #7's care plan dated 11/10/25 revealed that Resident #7 was on oxygen therapy with a goal of having no signs or symptoms of poor oxygen absorption. Interventions included ensuring oxygen was administered at 2-3 liters per minute via nasal cannula. A review of Resident #7's Medication Administration Record (MAR) for December 2025 revealed that Resident #7 received oxygen daily at 2-5 liters per minute and oxygen saturation levels were monitored and maintained between 94% and 100%. A review of Resident #7's oxygen report (undated) revealed oxygen saturation levels ranged from 93% to 99% from 09/10/25 through 12/05/25. A review of Resident #7's progress notes dated 10/07/25 through 12/08/25 did not reveal documentation related to oxygen therapy concerns. On 12/08/25 at 10:50 AM, Resident #7's oxygen concentrator was observed with the red alert light illuminated. The oxygen flow was measured at 3.5 liters per minute. The key located under the red light indicated the red light meant oxygen flow rate less than 0.5 liters per minute or oxygen concentration less than 73%. During an interview on 12/08/25 at 10:51 AM, Resident #7 stated her oxygen concentrator had a red light on for approximately three months. She stated the airflow did not seem as strong but that she felt she could breathe. She stated staff were aware that the red light was on. During an interview on 12/09/25 at 11:02 AM, the DON stated that she was familiar with the expectations and the policy regarding essential equipment. She stated that if something was wrong, then the essential equipment was replaced or maintenance was completed immediately. She stated the potential negative outcome for essential equipment not properly working, specifically the oxygen concentrator, was that the resident may not be getting enough oxygen or the oxygen that was prescribed by the provider. She stated that this could affect the resident cognitively, especially oxygen delivery to the brain. She stated that she was not aware that the red light was lit on the oxygen concentrator and that no one had ever reported this issue to her. She stated the system to monitor essential equipment, such as oxygen, was that nursing staff were required to go in daily to check residents' oxygen. While checking the resident's oxygen level, they would also assess the machine. She stated that nursing staff should be checking every Sunday during the overnight shift, the water and tubing, as this was changed weekly. She stated that the resident never told her about the oxygen concentrator not working properly. She stated that when the concentrator was not working properly and could not be maintained, they would contact the vendor for a new machine. The DON stated that she had been trained that essential equipment should be in operating condition. The DON stated she expected all essential equipment to be in operating condition and, if not, the equipment needed to be replaced or fixed immediately. The DON stated the Maintenance Supervisor was responsible for maintaining the equipment. She stated nursing staff could change the filters. She stated the red light or alert should have been addressed even if the machine did not make a sound or alarm. She stated she did not have a reason why Resident #7's oxygen concentrator was not addressed and that she was unaware of how long the red light had been on. During an interview on 12/09/25 at 11:35 AM, the Maintenance Supervisor stated that he was responsible for changing filters and providing maintenance when he was informed of the need. He stated that staff would tell him in passing if things needed to be fixed. He stated no one had reported to him that any resident oxygen concentrators needed maintenance. He stated that in the system he used to track maintenance tasks, a task would naturally generate to check oxygen concentrators, but it was not for one specific resident. He stated he had no way of knowing which residents had oxygen concentrators. He stated he would go room to room and check to see if anything was wrong. He stated he was unaware that Resident #7 had an oxygen concentrator. He stated he was not made aware until 12/08/25, when the issue was discussed in a group chat. He stated the potential negative outcome of a resident's oxygen concentrator not working properly was that the resident may not be able to breathe properly. He stated he had not been trained, outside of maintenance requests or system-generated tasks, to routinely service medical equipment. During an interview on 12/09/25 at 11:41 AM, Medical Supply stated that he was unaware that Resident #7's oxygen concentrator had a red alert light on. He stated he knew the concentrator was replaced on 12/08/25. He stated he did not deal with oxygen concentrators directly but believed that responsibility fell to the Maintenance Supervisor. He stated the potential negative outcome of a concentrator not working properly was that the resident may not be able to breathe properly. During an interview on 12/09/25 at 12:00 PM, the ADM stated that she was familiar with the expectations and policy regarding resident essential equipment being operational. She stated that essential equipment should be routinely cleaned. She stated that items such as filters should also be changed as needed. She stated that any preventative or other maintenance should also be adhered to. She stated that the potential negative outcome for resident essential equipment, such as oxygen concentrators, not working properly could mean that the resident would go without oxygen as prescribed by the physician, which could result in respiratory distress. She stated that she was unaware until surveyor intervention that the resident had a concentrator that was not working properly. She stated she spoke with a charge nurse, and the charge nurse had not been informed about the oxygen concentrator. She stated that she instructed nursing staff to report such issues in the future. She stated that the system to monitor residents' essential equipment, such as oxygen concentrators, was that she relied on staff to report issues as they arose. She stated she expected the Maintenance Supervisor to check oxygen concentrators on a regular basis. She stated she was unaware whether he knew which residents had oxygen concentrators. She stated she expected him to go room to room to ensure equipment was functioning properly. She stated she had been trained, and that all staff had been trained, regarding checking residents' essential equipment and reporting issues to the appropriate party, including herself, so that the appropriate vendor could repair or replace equipment as needed. She stated she did not have written documentation showing staff training but stated that training was verbally provided during orientation. She stated she expected all equipment-related issues, especially those affecting health and safety, to be reported immediately and addressed. She stated all staff were ultimately responsible for ensuring that essential equipment, specifically oxygen concentrators, was working properly for residents who required them. She stated she did not have a reason why Resident #7's oxygen concentrator had not been addressed and stated that no one reported the issue to her. Record review of the facility's policy titled and dated, Oxygen Administration (undated), reflected: Oxygen therapy includes the administration of oxygen in liters per minute. By cannula or face masks to treat hypoglycemic conditions caused by pulmonary or cardiac diseases. Oxygen therapy is also prescribed to ensure oxygenation of all body organisms and systems. The amount of oxygen by percent of concentration or by liter per minute in the method of administration is ordered by the physician. The administration, monitoring of responses in safety precautions is associated with it are performed by the nurse. GoalsMaintain oxygenation with safe and effective delivery of prescribed oxygen.The resident will maintain an effective breathing pattern with administration of oxygen.Resident will be free from infection.ProcedureCheck the tubing including any nasal prongs or mask that is in use on the patient when it malfunctions or becomes visibly contaminated. Oxygen concentrators should be cleaned according to manufacturer's recommendations. Change your clean oxygen concentrator filters according to manufacturers recommendations. Record review of the facility's policy titled and dated, Respiratory Policies and Procedures (June 2006), reflected: Every 90 days:Perform a purity and project on each unit every 90 days. Analyze the oxygen on each concentrator in service. Calibrate the oxygen analyzer according to the procedure. Attach the oxygen analyzer to the concentrator. Completed a new maintenance sticker in place on the unit. Replace the unit if necessary. Document the maintenance on the oxygen concentrator field maintenance report.

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 1 of 5 residents (Resident #1) reviewed for narcotic medication being accounted for. The facility failed to prevent Resident #1's Lorazepam Medication from being accounted for. This failure could place residents at risk for not receiving prescribed medication. Findings include: Record review of Resident #1's, undated, face sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included: depression (loss of interest), anxiety (feeling of uneasiness), acute systolic (congestive) heart failure (heart weakness), acute respiratory failure with hypoxia (lack of oxygen in body), acute respiratory failure with hypercapnia (too much carbon dioxide in the blood). Record review of a Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 09, which indicated moderate cognitive impairment. Record review of Resident #1's physician orders, dated 06/09/2025, revealed an active order for Lorazepam Intensol Oral Concentrate 2 MG/ML(Lorazepam) Give 0.5 ml by mouth four times a day related to generalized anxiety disorder. Ordered on 05/06/2025. Record review of Resident #1's Individual Control Drug Record Narcotic Count sheet for the Lorazepam Intensol 2 MG/ML revealed the facility received the medication from the pharmacy on 05/21/2025 and quantity received 101 syringes, 0.25 ml each. The record revealed on 05/21/2025, 7 were given, on 05/22-27/25 8 were given per physician orders. On 05/27/2025 there is a line drawn through the amount remaining at 12:30PM to change the amount remaining from 48 to 44 and signed by the DON and ADON. The count on the narcotic count sheet for 05/27/2025 at 12:30 PM indicated two were given with 48 remaining. The count after shift changed at 7:00PM on 05/27/2025 the narcotic count sheet indicated 2 syringes were given with 42 doses remaining. There were four syringes missing at that time. The narcotic count sheet was corrected to indicate on 05/27/2025 at 12:30PM the count needed to indicate the four missing syringes and the count was changed from 48 to 44. Then the last dose for 05/27/25 was given after the count was corrected and 42 syringes remained. There were 101 syringes received on 05/22/2025, 55 syringes were given between 05/22/2025 and 05/27/2025 at 12:30 PM. That left 46 syringes, the count was showing 48 on the narcotic count sheet, there were four syringes missing so the count was corrected on 05/27/25 to indicate 44, then 2 syringes were given at 7:00 PM and the count indicated 42 remained. Record review of Resident's #1 MAR dated 06/09/2025 revealed Lorazepam Intensol 2 MG/ML give 0.5ml by mouth four times a day for generalized anxiety disorder was given as ordered on 05/27/2025. During an interview on 06/09/2025 at 11:10 AM, RN A stated on 05/27/2025 LVN B had control of the medication cart and at the beginning of the shift 6:00AM - 6:00PM, the narcotic count was correct. At the end of the shift LVN C took over the medication cart for 6:00PM - 6:00AM and the narcotic count was not correct. She stated per the facility protocol if the narcotic count is off, staff must stay at the facility, the DON must go to the facility to count the narcotics and attempt to locate the narcotics. The staff involved in any missing narcotics would be required to take a drug test. She stated LVN B agreed to the drug test however the temperature of the urine was below normal and LVN B was asked to repeat the drug test, she refused and walked out. During an interview on 06/09/2025 at 11:30 AM, the ADON stated she received a call on 05/27/2025 that the narcotic count was off by four syringes of Lorazepam for Resident #1. She stated she counted the medication cart with LVN C and looked at the narcotic record sheet for any mistakes. She searched all the medication carts for the missing medication and interviewed LVN B and LVN C. She stated LVN C reported she accepted the medication cart, however they [LVN B and LVN C] did not go to the refrigerator and count the Lorazepam in the refrigerator at shift change. She stated LVN C told her they counted the Lorazepam on the paper but forgot to go to the refrigerator and count the medication. She stated she interviewed LVN B and she told her they counted the Lorazepam on paper and forgot to go to the refrigerator and count the medication. She stated HR was at the facility and per facility policy both staff involved would need to be drug tested. She stated LVN B provided her urine sample, and the temperature was too low for the test to be accurate and LVN B was asked to provide a second test. She stated LVN B refused the second test and walked out of the facility. She stated medication carts are to be counted at shift change 6:00AM and 6:00PM. She stated she expected staff to count the medication carts correctly, notify the DON and herself immediately, staff to remain at the facility until administrative staff arrived. She stated to count the medication cart correctly all medications should be counted including all medications in the refrigerator. During an interview on 06/09/2025 at 11:51 AM, the DON stated she received a call from LVN C and the narcotic count was off by four syringes of Lorazepam for Resident #1. She stated all medication carts were checked and interviewed LVN B and LVN C. She stated LVN C admitted at shift change they [LVN B and LVN C] did not count the Lorazepam in the refrigerator for Resident #1. She stated LVN B told her she grabbed all four syringes of Lorazepam for Resident #1 and placed them in her pocket at the beginning of her shift. LVN B stated Resident #1 takes two syringes at a time and that is given twice per her shift 6:00AM - 6:00PM. LVN B assured her she gave all four syringes to Resident #1 and was not sure where the four missing syringes were. She stated per facility policy staff involved in missing medication concerns would be drug tested. She sated LVN B gave her urine sample to HR and it was not the correct temperature and LVN B was told she would need to provide another sample. She stated LVN B refused to provide a second sample and walked out of the facility. She stated medications carts are to be counted at the time of shift change. She stated staff are to count all pills in the medication carts one staff to check the paper record and the other staff to check the medication to ensure they match and to count all medication in the refrigerator. She stated nurses are aware medications are kept in the refrigerator. The facility replaced the missing medication and Resident #1 did not miss any medication. The facility in-serviced all nurses and medication aides on counting all narcotic medication in the medication carts and the refrigerators. During an interview on 06/09/2025 at 12:06 PM, LVN C stated she worked on 05/27/2025 from 6:00PM - 6:00AM. She stated when she arrived for her shift, she counted the narcotics in the medication cart with LVN B, but not the Lorazepam in the refrigerator. She stated that a little after shift changed, she went to get the Lorazepam for Resident #1 out of the refrigerator and noticed there were four syringes less than what the narcotic count sheet showed. She stated she sent a text to the ADON and called LVN B. She stated LVN B returned to the facility, and they could not locate the four syringes of Lorazepam. She stated that LVN B told her she grabbed all four syringes at one time and kept two in her pocket for the next dose during her shift. She stated after the DON and ADON arrived they counted all the medication carts and could not find the four syringes of the Lorazepam for Resident #1. She stated she had to take a drug test and received coaching for not counting the medication in the refrigerator. She stated the reason they did not count the medication in the refrigerator is they trusted each other, and it didn't seem like a concern at the time, and she knew better. She stated, there are a lot of pre-filled syringes in the refrigerator, and it is time consuming to count them all. She stated the DON had her call and get the four syringes replaced for Resident #1 and he did not miss any Lorazepam. She stated since the incident she was trained and in-serviced on counting narcotics. During an attempted interview on 06/09/2025 at 12:27 PM, LVN B did not answer the phone call, or reply to the text message that was sent to her regarding the investigation. During an interview on 06/09/2025 at 12:30 PM, the ADM stated he contacted the local police department case number 250080395and filed a report, however he was not sure they would do anything, since the cost of the medication was $1.00. During an interview on 06/09/2025 at 1:45PM, HR Manager stated she received a call from LVN C and was told medication was missing. She stated the facility protocol is they must drug test everyone that had access to the medications and that night it was LVN B and LVN C. She stated she went to the facility and informed both LVN B and LVN C they needed to provide a drug test. She stated LVN B provided a urine sample, and the temperature was too low, and the test would not provide accurate results. She stated she informed LVN C that she would need to provide another urine sample as part of the protocol. She stated LVN B refused the second test. She stated she informed LVN B that as part of her employment anytime there was an incident involving medications staff would be drug tested and if she refused, she would self-terminate her employment. She stated LVN B refused and walked out of the facility. She stated LVN B signed the Employee Agreement and Consent to Drug and/or Alcohol testing on 02/27/2025 and received the Employee Handbook on that same date. During an interview on 06/09/2025 at 4:34PM, Resident #1 stated all he knew about his medications is that at times he had refused the Lorazepam because he didn't have anxiety. Record review of in-service dated 05/27/2025, instructor DON, subject: Narcotic Count each nurse/medication aide must count narcotics with the oncoming nurse/medication aide no matter what. You do not skip any narcotic counts. All narcotics that are kept in the refrigerator must be counted as well. If the count is off, please notify DON/ADON immediately. Record review of Employee Agreement and Consent to Drug and/or Alcohol Testing for LVN B signed by LVN B on 02/27/2025. The document revealed: the employee agreed to submit to a drug or alcohol and to furnish a sample of my urine, breath, and/or blood analysis. I understand and agree that if I at anytime refuse to submit to a drug or alcohol test under company policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. Record review of the facility policy Controlled Medications - Administration dated 03/2025. Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedure 8. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech, or equivalent as allowed by your State regulatory agency and is documented on an audit record. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience for 1 (Resident #1) of 3 residents reviewed for physical restraint. The facility failed to ensure the Licensed Vocational Nurse (LVN D) notified the physician (P J), Director of Nurses (DON), and Member F prior to tying Resident #1's hand to his bed on 02/18/25, and as of 03/04/25 the physician confirmed he had not written an order for this restraint. This LVN said he tied Resident #1's hand to prevent him from pulling out his dialysis port, while he administered the residents' medications. The port is defined as a (medical device used to provide access to a patient's bloodstream for hemodialysis treatment, which is a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so). This failure could prevent residents from having an environment that was free from any physical or chemical restraints. Findings included: Record review of Resident #1's Face Sheet, dated 03/04/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included metabolic encephalopathy (brain function is impaired.), sepsis (a life-threatening complication of an infection.), acute posthemorrhagic anemia (occurs when someone rapidly loses a large amount of blood, resulting in a low red blood cell count of hemoglobin levels.), myocardial infarction (occurs when blood flow to the heart muscle is blocked, causing damage of death of heart tissue.), atrial fibrillation (an irregular, often rapid heart rate that commonly cause poor blood flow.), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should.), and acute kidney failure with tubular necrosis (a type of kidney injury characterized by damage to the kidney tubules, which are responsible for filtering waste products from the blood). Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated, he had a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired). This MDS indicated his Self-Care assessment required substantial/maximal assistance for toileting, lower body dressing, putting on/taking off footwear, and was dependent for a shower/bath. This MDS indicated Resident #1 required substantial/maximal assistance to rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff to transfer from chair/bed-to-chair. Record review of Resident #1's Order Summary Report with Order Date Range between 02/01/25 to 02/28/25 did not include applying a restraint on Resident #1. Record review of Resident #1's Order Summary Report with Active Orders as of 02/28/25 did not include an order for applying a restraint. Record review of Resident #1's chart form 02/16/25 to 03/05/25 did not include documentation by LVN D indicating he had tied Resident #1's hand to the bed, nor that an order for a restraint had been pursued from the physician. Record review of Resident #1's Care Plan Report, dated 01/14/25, addressed the need for dialysis that was initiated on 12/11/24. This plan was edited on 03/04/25 to reflect Resident #1's behavior of pulling his dialysis port after he returned from the hospital on 02/16/25. The steps included allowing resident to make decisions about his treatment, education, wrapping with ace bandage, double shirts, and adhesive dressings, and if resident resist with ADLs, leave and return 5 minutes later and try again. Record review of Resident #1's Nursing Note dated 02/16/25 indicated he was readmitted to the facility from the hospital via post fall. Resident #1's decision making was poor, required reminders, cues, and supervision in planning, organizing, and correcting daily routines. Resident #1 was not oriented to person, place, time, nor situation, and his Activities of Daily Living (ADL) assistance needs were bed mobility and transfers with 2 persons assist, and eating, toileting, dressing/hygiene, and bathing with 1 person assist. Record review of Resident #1's SBAR 3.0 - V4 report dated 02/17/25 at 1:45 pm with admitted [DATE], indicated he was having a behavior change that started on 02/17/25 due to being a danger to self or others. The treatment initiated at 8:16 am he was administering Tramadol, because he might be agitated due to pain, and a bandage was placed over the dialysis port. This condition, symptom, or sign had not occurred before. Resident took bandage off and continued to pull his port. The MD or NP were notified on 02/17/25 at 1:41 pm. The new order was for hydroxyzine 50 mg (milligrams) PRN (as needed) every 6 hours. This report included date and time of notification as 02/17/25 at 6 pm, and LVN A signed this report on 02/18/25. Record review of CNA H's written Witness Statement dated 02/18/25 revealed I was doing round when I noticed pt (Resident #1) hand restraint to the bed. Notified the charge nurse (LVN D) and charge nurse confirmed that it was in protection of pt. and everything was taken care of. Record review of LVN D's personnel file revealed he signed Restraint Reduction dated 03/09/21 indicating All residents must have an order from the physician before a restraint can be applied. Seat belts, lap trays, and any device that keeps a resident from accessing willful movements are considered a restrain. During an interview on 03/04/25 at 10:39 AM, Physician J (P J) indicated Resident 1's restraint on 02/18/25 was unfortunate. If LVN A had called him or his nurse practitioner and informed them that Resident #1 was making attempts to remove his dialysis port, he would have discussed the situation and tried other avenues instead of a restraint. P J said if Resident #1 had removed his port, which was deep into his veins, he could have suffered uncontrolled bleeding that would have required putting pressure on the wound and calling 911. In addition, pulling on this port could have resulted on a piece breaking off inside his body leading to a serious outcome. During an interview on 03/04/25 at 11:25 AM, Resident #1, who was sitting in his wheelchair and had a port attached to the upper right chest area, did not respond to questions asked of him. Observation on 03/04/25 at 11:30 am indicated Resident #1's bed had a metal frame that was under and around his mattress. During an interview on 03/04/25 at 12:57 AM, the Director of Nurses (DON) indicated on 02/18/25 at 7 AM he discovered Resident #1's hand was tied to a blanket and to the bed frame. The DON questioned Licensed Vocational Nurse (LVN A), and Certified Nurse Aide (CNA B and C), who said they were unaware of Resident #1's restraint. The DON assessed Resident #1, who had no injuries or bruises noted, and asked him if he was hurting; however, he responded by mumbling but did not answer questions asked of him. Afterwards, The DON said he interviewed LVN D, who cared for Resident #1 from 6 PM on 02/17/25 to 6 AM on 02/18/25, and he confirmed he had tied Resident #1's hand to protect him from pulling out his dialysis port. The DON said LVN B confirmed he failed to notify Resident #1's physician, responsible party, and the DON, before applying this restraint. The DON said if LVN D had called the physician it's possible the physician might have ordered a soft restraint to keep him from trying to pull out the port. The DON said LVN D was protecting Resident #1 from bleeding to death; however, he did not follow the facility's policy and procedure for notifications and restraints. During an interview on 03/04/25 at 1:17 PM, Registered Nurse (RN E) said after Resident #1 returned to the facility on [DATE], he displayed the behavior of trying to pull out his port. This behavior was addressed through frequent monitoring redirection, redirection, and covering the port with a dressing several times, because he was able to remove the dressing. RN E indicated if Resident #1 had pulled out his port, this could have cause him to bleed to death. RN E said LVN D was trying to protect Resident #1; however, he failed to follow the policy and procedure for notification and restraints. During an interview on 03/04/25 at 2:48 PM, Member F (M F) indicated Resident #1 was discharged from the hospital with altered mental status, and to her knowledge, he was not trying to take out his dialysis port at the hospital. M F said she understood how dangerous it could have been if Resident #1 had pulled out his port. During an interview on 03/04/25 at 3:04 PM, the Minimum Data Set Coordinator (MDS G) indicated she had not incorporated a restraint into Resident #1's Care Plan, nor has she incorporated a restraint into any of the residents' Care Plans, because this is against the facility's policy and procedures. During an interview on 03/04/25 at 3:48 PM, LVN A said she started her shift on 02/18/25 at 6:18 AM and was unaware Resident #1's hand was tied to the bed frame. LVN A said she received shift report from LVN D that included Resident #1 was pulling at his port since returning from the hospital on 02/16/24; however, he did not inform her Resident #1s hand was restraint. After the morning meal, LVN A said she requested an order to send Resident #1 to the hospital because he was very confused. LVN A said she knew it was not inappropriate to restrain a resident, instead the physician, DON, and RP should be notified when there is a change of condition. During an interview on 03/04/25 at 4:26 PM, LVN D said he received report on 02/17/25 at approximately 6 PM from the outgoing LVN A, who said Resident #1 was confused and trying to take out his port. LVN D said Resident #1 slept on 02/16/25 from approximately 6 PM until 10 PM. That's when Resident #1 displayed the behavior of taking off his clothes. LVN D said he monitored Resident #1 every 15 minutes and applied a dressing over his port and two t-shirts; however, he would remove his shirts and dressing so he could pull his port. LVN D said at approximately 4 AM on 02/18/25 Resident #1 pulled off his gown and shirt, and he tried to put them back on but he resisted. Afterwards, LVN D said he wrapped a small blanket around Resident #1's hand and tied the other end of this blanket to the bed frame, so he could continue administering residents' medications. LVN D said Resident #1 did not struggle or tried to remove this restraint. LVN D said he monitored Resident #1 by parking his medication cart approximately 6 feet away from Resident #1's doorway to his room and going into Resident #1's room as he administered medications. LVN D said he knew he was not supposed to restraint a resident, but for his safety, he thought this would better than letting Resident #1 pull out the port and bleed to death. LVN D said he did not call the physician, RP, or DON, because the restraint would just be for a brief time until he could finish the residents' medication pass. LVN D said he was not trying to hurt Resident #1; he was trying to keep him from dying. LVN D said he was suspended and terminated due to using a restraint on Resident #1. During an interview on 03/04/25 at 6:58 PM, CNA H said she received report on 02/17/25 at approximately 7:15 PM from LVN D, who said Resident #1, who returned from the hospital, had been tugging at his port on the previous shift (6 AM to 6 PM). CNA H said she entered Resident #1's room on 02/17/25 at approximately 7:30 AM and put a t-shirt on him to keep him from pulling at his port. CNA H said on 02/17/25 at 10 PM she checked on Resident #1, who was asleep, did not have his hand tied to the bed. CNA H said on 02/18/25 at approximately 1 AM she checked on Resident #1, who was asleep, and had his right hand tied to the bed frame with a mini colorful blanket. CNA H said Resident #1 could move his arm; however, he could not reach his port. CNA H said she saw smeared blood on the skin surrounding the skin around Resident #1's port. CNA H said she immediately reported this to LVN D, because she feared being blamed for the restraint, which she knew was against the facility's policy. CNA H said she informed LVN D Resident #1's hand was tied to the bed, and this facility was a no restraint facility. CNA H said LVN D informed her he had tied his hand to keep him safe from pulling his port because he could die. CNA D said she reported Resident #1's restraint to CNA I, who agreed a restraint is not allowed in this facility unless a doctor order it, and maybe that's why LVN D said he took care of it. CNA H said she checked on Resident #1 on 02/28/25 at 2 AM, 4 AM and 5 AM, before she left at 6 AM. CNA H said she was not asked to check on Resident #1 sooner than every two hours; however, she witnessed LVN D administered residents' medications from the cart near Resident #1's room. CNA H said she witnessed LVN D enter Resident #1's room several times during the night, and he remained at this cart throughout most of the night. During an interview on 03/04/25 at 7:34 PM, CNA I said on 02/18/25 at approximately 1 AM CNA H informed her that she saw Resident #1's hand was tied to the bed frame, and she informed LVN D. LVN D told her he had to restrain him for his safety or else he could bleed to death if he pull out the port. CNA I said she informed CNA H that a resident can be restraint if a doctor orders it. Observation on 03/05/25 at 10:30 AM of the facility's video camera recording dated 02/18/25 indicated LVN D entered Resident #1's room at 12:16 AM, 12:19 AM, 12:24 AM, 1:12 AM, 2:19 AM, 2:39 AM, 3:18 AM, 3:24 AM, 4:11 AM, 4:35 AM, 4:50 AM, and 5:32 AM. During an interview on 03/05/25 at 11:25 AM, LVN A indicated she worked on 02/17/25 from 6 AM to 6 PM and filled out an SBAR because Resident #1 was displaying behavior trying to pull out his port. LVN A said she notified the NP, who gave orders for Hydroxyzine every 6 hours, which she administered to Resident #1 at 8:16 AM. LVN A said she placed a bandage over Resident #1's dialysis port; however, he pulled of the bandage and continued to pull at his port. LVN A said she had to bandage this port 5 times on her 6 AM to 6 PM shift. If he had pulled out the port this would have cause him to bleed to death. LVN A said she did not have to call the NP or his physician because after she administered Hydroxyzine at 1 PM, Resident #1 calmed down. LVN A said during shift report she informed LVN D that she had called the NP, who gave the order for Resident #1 to be administered Hydroxyzine, applying a bandage on the port, and a gown and t-shirt to prevent him from pulling the port: however, he was able to pull off the gown and t-shirt. During an interview on 03/05/25 at 11:45 AM, CNA K said she witnessed Resident #1 trying to pull his port after he returned to the facility from the hospital on 02/16/25. CNA K said she would grab his hand and ask him to stop, and he would comply for a short while then try again. Afterwards, CNA K reported this to LVN A, who entered Resident 1's room and was seen talking to him. During an interview on 03/05/25 at 12:06 PM, the Administrator confirmed LVN D did not follow the facility's policy and procedure for notification and restraint. Since this incident, the Administrator had all nurses and CNAs, who were provided the Administrator's phone number, were in-serviced to report directly to her if a resident is discovered in a restraint. The Administrator said LVN D was suspended after the incident but before returning to work After the investigation was completed, LVN D was terminated. Record review of the facility's policy and procedure for Restraints dated 02/1/07 reflected it is the policy of this facility to maintain an environment that prohibits the use of restraint for discipline or convenience. Restraint usage shall be limited to circumstances in which the resident has medical symptoms that warrant the use of restraints. A restraint Assessment Committee will evaluate and establish the need for restraint use or restraint reduction, for residents in our facility. The facility is committed to nurturing the autonomy and independence of our residents by attempting to provide a restraint-free environment. A physical restraint was defined as any manual method or physical/mechanical device, material, or equipment attached or adjacent to the resident's body that the resident cannot move easily, which restricts freedom of movement or normal access to one's body. Physical restraints include, but are not limited to leg restraints, arm restraints, hand mitt, soft tie or vest, wheelchair safety bars, Geri-chairs, lap cushions and trays that the resident cannot remove. Restraints will only be applied after it has been determined that a medical symptom requiring restraint usage exist, and only after other alternatives have been tried unsuccessfully. A physician's order shall be necessary to begin a restraint assessment/evaluation for the resident. The Restraint Assessment Committee shall meet to assess the necessity of restraints for a resident by completing a Pre-Restraining Assessment. Restraints will only be used with informed consent from the resident and/or the resident's representative or responsible party and the resident's physician. Physical restraints for behavior control shall only be used in an emergency, which threatens to bring immediate injury to the resident or others. In such an emergency an order may be received by telephone and shall be signed by the physician withing 45 hours. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint use, and the length of effectiveness of the restraint time, and the name of the individual applying such measures shall be entered into the resident's medical record. Every effort shall be made to calm the resident; however, personal safety must be considered. There shall be no PRN (as needed) orders for behavioral restraints.

Based on observations, interviews and record review, the facility failed to ensure a resident received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for quality of care. 1. The LVN D failed to notify Resident #1's physician and Member F of Resident #1's change of condition. 2. LVN D failed to obtain an order from the physician to restrain Resident #1's arm to prevent him from pulling out his dialysis port (a medical device used to provide access to a patient's bloodstream for hemodialysis treatment, which is a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so). 3. LVN D failed to notify the DON or LVN A, who was the oncoming charge nurse, of the restraint left on Resident #1's arm prior to leaving his shift. These failures could result in decreased quality of care for residents. Findings include: Record review of Resident #1's Face Sheet, dated 03/04/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included metabolic encephalopathy (brain function is impaired.), sepsis (a life-threatening complication of an infection.), acute posthemorrhagic anemia (occurs when someone rapidly loses a large amount of blood, resulting in a low red blood cell count of hemoglobin levels.), myocardial infarction (occurs when blood flow to the heart muscle is blocked, causing damage of death of heart tissue.), atrial fibrillation (an irregular, often rapid heart rate that commonly cause poor blood flow.), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should.), and acute kidney failure with tubular necrosis (a type of kidney injury characterized by damage to the kidney tubules, which are responsible for filtering waste products from the blood. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated, he had a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired). This MDS indicated his Self-Care assessment required substantial/maximal assistance for toileting, lower body dressing, putting on/taking off footwear, and was dependent for a shower/bath. This MDS indicated Resident #1 required substantial/maximal assistance to rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff to transfer from chair/bed-to-chair. Record review of Resident #1's Order Summary Report with Order Date Range from 02/01/25 to 02/28/25 did not include applying a restraint on Resident #1. Record review of Resident #1's Care Plan Report, dated 01/14/25, addressed the need for dialysis that was initiated on 12/11/24. This plan was edited on 03/04/25 to reflect Resident #1's behavior of pulling his dialysis port after he returned from the hospital on 02/16/25. The steps included allowing resident to make decisions about his treatment, education, wrapping with ace bandage, double shirts, and adhesive dressings, and if resident resist with ADLs, leave and return 5 minutes later and try again. Record review of Resident #1's Nursing Note dated 02/16/25 indicated he was readmitted to the facility from the hospital via post fall. Resident #1's decisis non making was poor, required reminders, cues, and supervision in planning, organizing, and correcting daily routines. Resident #1 was not oriented to person, place, time, nor situation, and his Activities of Daily Living (ADL) assistance needs were bed mobility and transfers with 2 persons assist, and eating, toileting, dressing/hygiene, and bathing with 1 person assist. Review of Resident #1's SBAR 3.0 - V4 report dated 02/17/25 at 1:45 PM with admitted [DATE], indicated he was having a behavior change that started on 02/17/25 due to being a danger to self or others. The treatment initiated at 8:16 AM was to administer Tramadol, because he might be agitated due to pain, and to place a bandage over the dialysis port. This condition, symptom, or sign had not occurred before. Resident took bandage off and continued to pull his port. The MD or NP were notified on 02/17/25 at 1:41 pm. The new order was for hydroxyzine 50 mg (milligrams) PRN (as needed) every 6 hours. This report included date and time of notification as 02/17/25 at 6 pm, and LVN A signed this report on 02/18/25. Record review of CNA H's written Witness Statement dated 02/18/25 revealed I was doing round when I noticed pt (Resident #1) hand restraint to the bed. Notified the charge nurse (LVN D) and charge nurse confirmed that it was in protection of pt. and everything was taken care of. During an interview on 03/04/25 at 10:39 AM, Physician J (P J) indicated Resident 1's restrain on 02/18/25 was unfortunate. If LVN D had called him or his nurse practitioner and informed them that Resident #1 was making attempts to remove his dialysis port, he would have discussed the situation and tried other avenues instead of a restraint. P J said if Resident #1 had removed his port, which was deep into his veins, he could have suffered uncontrolled bleeding that would have required putting pressure on the wound and calling 911. In addition, pulling on this port could have resulted on a piece breaking off inside his body leading to a serious outcome. During an interview on 03/04/25 at 11:25 AM, Resident #1, who was sitting in his wheelchair and had a port attached to the upper right chest area, and he did not respond to questions asked of him. Observation on 03/04/25 at 11:30 am indicated Resident #1's bed had a metal frame that was under and around his mattress. During an interview on 03/04/25 at 12:57 AM, the Director of Nurses (DON) indicated on 02/18/25 at 7 AM he discovered Resident #1's hand was tied to a blanket and to the bed frame. The DON questioned Licensed Vocational Nurse (LVN A), and Certified Nurse Aide (CNA B and C), who said they were unaware of Resident #1's restraint. The DON assessed Resident #1, who had no injuries or bruises noted, and asked him if he was hurting; however, he responded by mumbling but did not answer questions asked of him. Afterwards, The DON said he interviewed LVN D, who cared for Resident #1 from 6 PM on 02/17/25 to 6 AM on 02/18/25, and he confirmed he had tied Resident #1's hand to protect him from pulling out his dialysis port. The DON said LVN D confirmed he failed to notify Resident #1's physician, responsible party, and the DON, before applying this restraint. The DON said if LVN D had called the physician it's possible the physician might have ordered a soft restraint to keep him from trying to pull out the port. The DON said LVN D was protecting Resident #1 from bleeding to death; however, he did not follow the facility's policy and procedure for notifications and restraints. During an interview on 03/04/25 at 1:17 PM, Registered Nurse (RN E) said after Resident #1 returned to the facility on [DATE], he displayed the behavior of trying to pull out his port. Resident #1's behavior was addressed through frequent monitoring, redirection, and having to cover his port with a dressing several times, because he was able to remove the dressing. RN E indicated if Resident #1 had pulled out his port, this could have cause him to bleed to death. RN E said LVN D was trying to protect Resident #1; however, he failed to follow the policy and procedure for notification and restraints. During an interview on 03/04/25 at 2:48 PM, Member F (M F) indicated Resident #1 was discharged from the hospital with altered mental status, and to her knowledge, he was not trying to take out his dialysis port at the hospital. M F said she understood how dangerous it could have been if Resident #1 had pulled out his port. During an interview on 03/04/25 at 3:48 PM, LVN A said she started her shift on 02/18/25 at 6:18 AM and was unaware Resident #1's hand was tied to the bed frame. LVN A said she received shift report from LVN D on 02/18/25 that included Resident #1 was pulling at his port since returning from the hospital on 02/16/24; however, he did not inform her Resident #1s hand was restraint. After the morning meal, LVN A said she requested an order to send Resident #1 to the hospital because he was very confused. LVN A said she knew it was inappropriate to restrain a resident, instead the physician, DON, and RP should be notified when there is a change of condition. During an interview on 03/04/25 at 4:26 PM, LVN D said he received report on 02/17/25 at approximately 6 PM from the outgoing nurse, who said Resident #1 was confused and trying to take out his port out. LVN D said Resident #1 slept on 02/17/25 from approximately 6 PM until 10 PM. That's when Resident #1 displayed the behavior of taking off his clothes. LVN D said he monitored Resident #1 every 15 minutes and applied a dressing over his port and two t-shirts; however, he would remove his shirts and dressing so he could pull his port. LVN D said at approximately 4 AM on 02/18/25 Resident #1 pulled off his gown and shirt, and he tried to put them back on Resident #1 but he resisted. Afterwards, LVN D said he wrapped a small blanket around Resident #1's hand and tied the other end of this blanket to the bed frame. LVN D said he monitored Resident #1 by parking his medication cart approximately 6 feet away from Resident #1's doorway to his room and going into Resident #1's room as he administered medications. LVN D said he knew he was not supposed to restraint a resident, but for his safety, he thought this would better than letting Resident #1 pull out the port and bleed to death. LVN D said he did not call the physician, RP, or DON, because the restraint would just be for a brief time until he could finish the residents' medication pass. LVN D said he was not trying to hurt Resident #1; he was trying to keep him from dying. During an interview on 03/04/25 at 6:58 PM, CNA H said she received report on 02/17/25 at approximately 7:15 PM from LVN D, who said Resident #1, who returned from the hospital, had been tugging at his port on the previous shift (6 AM to 6 PM). CNA H said she entered Resident #1's room on 02/17/25 at approximately 7:30 AM and put a t-shirt on him to keep him from pulling at his port. CNA H said on 02/17/25 at 10 PM she checked on Resident #1, who was asleep, did not have his hand tied to the bed. CNA H said on 02/18/25 at approximately 1 AM she checked on Resident #1, who was asleep, and he had his right hand tied to the bed frame with a mini colorful blanket. CNA H said Resident #1 could move his arm; however, he could not reach his port. CNA H said she saw smeared blood on the skin surrounding the skin around Resident #1's port. CNA H said she immediately reported this to LVN D, because she feared being blamed for the restraint, which she knew was against the facility's policy. CNA H said she told LVN D Resident #1's hand was tied to the bed, and this facility was a no restraint facility. CNA H said LVN D replied he had tied his hand to keep him safe from pulling his port because he could die. During an interview on 03/05/25 at 11:25 AM, LVN A indicated she worked on 02/17/25 from 6 AM to 6 PM and filled out an SBAR because Resident #1 was trying to pull out his port. LVN A said she notified the NP, who gave orders for Hydroxyzine every 6 hours, which she administered to Resident #1 at 8:16 AM. LVN A said she placed a bandage over Resident #1's dialysis port; however, he pulled of the bandage and continued to pull at his port. LVN A said she had to bandage this port 5 times on her 6 AM to 6 PM shift. If he had pulled out the port this would have cause him to bleed to death. LVN A said she did not have to call the NP or his physician because after she administered Hydroxyzine at 1 PM, Resident #1 calmed down. LVN A said during shift report she informed LVN D that she had called the NP, who gave the order for the Hydroxyzine, a bandage on the port, and to put a gown and t-shirt on Resident #1; however, he was able to pull off the gown and t-shirt. During an interview on 03/05/25 at 11:45 AM, CNA K said she witnessed Resident #1 trying to pull his port after he returned to the facility from the hospital on 02/16/25. CNA K said she would grab his hand and ask him to stop, and he would comply for a short while then try again. During an interview on 03/05/25 at 12:06 PM, the Administrator confirmed LVN D did not follow the facility's policy and procedure for notification and restrain. Since this incident, the Administrator had all nurses and CNAs, who were provided the Administrator's phone number, were in-serviced to report directly to her if a resident is discovered in a restraint. Record review of facility's policy and procedure for Notifying the Physician of Change in Status dated 03/11/13 indicated The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the INTERACT to, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician. The nurse will notify the physician immediately with significant change I status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 6 of 6 confidential residents. 1. The facility failed to make information known to Resident's and their Representatives either individually or through postings in prominent locations throughout the facility on who the facility grievance official was, their contact information, how to file an anonymous grievance and their right to obtain a written decision related to their grievance. 2. The facility failed to ensure 6 of 6 confidential residents had information known to them on how to file a grievance or concern, who the grievance official was, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. The facility failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and Record Review during Resident Council on, 9/9/2024 at 2:00pm, attendees 6 of 6 confidential residents, stated they did not know the grievance process; they did not know where to obtain or submit a grievance form. Residents attending the group meeting did not know how to file a grievance. Residents did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. 6 Residents attended the meeting, 1 of the Residents who attended the meeting was a new Admit, the other 5 Residents were tenured Residents. The grievance offered is a blank sheet of paper followed by two additional forms with questions that are to be answered by staff. Interview on 9/9/24 at 4:45 PM, the Activity Director confirmed she had never discussed Grievances in Resident Council as she did not know Residents were able to file grievances on their own or anonymously. The AD did not know the Grievance process for Residents filing a grievance without the assistance of a staff member. The AD stated she has been employed by the facility for 18 months. The AD stated she had documented grievances in the facility electronic records when complaints were discussed individually with her and during Resident Council. The AD stated she was a licensed AD. The AD stated she had not been explained the Grievance procedure and she did not know there was a Grievance policy she could request to review. The AD stated she did her best to decide what complaints reported in Resident Council warrant her filing a Grievance. The AD stated there is no written documentation kept for filed grievances. The AD stated she and the Social Worker file grievances, however, all grievances are documented in their electronic records. The AD stated she did not understand, nor had she been trained on the importance of a Grievance; in addition, it was the Social Workers' responsibility to follow up on grievances once they are submitted into the electronic records. During an interview, observations, and record review with the Social Worker on September 8, 2024, at 3:42pm Surveyor requested to review all grievance forms from March 2024-September 2024; the Social Worker printed the information she had submitted into the facility's electronic records. The electronic records information consisted of questions answered by the Social Worker, the questions in the electronic record were questions only a staff member could answer, such as, who followed up on the grievance, who was assigned the grievance, and what was the resolution to the grievance. Surveyor requested the handwritten grievances completed by staff, residents, and residents' representatives; the Social Worker stated there are no written grievances as written grievances are never completed by staff, residents, or residents' representatives. The Social Worker stated the only information that could be provided to Surveyor was the print outs from their electronic records. Surveyor asked Social Worker if she was aware documentation of grievances must be kept for three years; the Social Worker stated she was not aware and she had no handwritten grievances from the past three years to provide to the Surveyor. The Social Worker stated the facility started using the electronic process for grievance information within the last year. Record Review of the facility undated Grievance form refelcted a blank sheet of paper followed by two additional forms with questions that are to be answered by staff. Interviewed the ADM on 9/10/2024 at 1:30pm; the ADM stated the Grievance form is in a box next to the SW office, in addition, there is a box for submitting the Grievance form. The procedure for the Grievance process consisted of the SW reviewing the Grievance; the SW contacted the head of the department the Grievance should be assigned to, the Department head contacted the Resident and discussed the Grievance, and a resolution to the Grievance is discussed with the Resident. The time frame for addressing a Grievance once it had been submitted is immediately. Authors of Grievances were interviewed once a Grievance is submitted. The documentation of the completed interviews were typed into their electronic records. The findings of the Grievances were also documented in the electronic records. not accessible unless a resident asks the SW for the form. The resolutions to Grievances are provided to Residents via a Resolution Letter delivered to the Resident by the SW. The ADM stated unhappy Residents was the potential negative outcome if the Grievance procedure is not followed. During an interview, observations, and record review on 9/10/2024 at 3:30pm, the SW stated the Grievance procedure she followed included discussing the Grievance with the ADM, the ADM decided what department is assigned to the Grievance. The Grievance form is kept in a box outside the SW office and a mail slot is offered for submission of the Grievance. The SW stated she did not know who is responsible for assigning a staff member to address a Grievance. The SW stated the time frame for addressing the Grievance is immediate. The SW stated authors of Grievances are interviewed the same day the Grievance is submitted; the interviews are documented in their electronic records. The SW stated findings of the Grievance are documented in the electronic record, then the author of the Grievance is provided with a resolution letter provided by the SW. The SW stated the potential negative outcome for Residents if the Grievance procedure is not followed is the Residents' needs may not be met. Grievance Policy Policy: The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Policy Interpretation and Implementation: 1. The facility will notify residents on how to file a grievance orally, in writing, or anonymously with postings in prominent locations. 2. The grievance official of this facility is the administrator or their designee. 3. The grievance official will: Oversee the grievance process Receive and track grievances to their conclusion Lead any necessary investigations by the facility Maintain the confidentiality of all information associated with grievances Issue written grievance decisions to the resident Coordinate with state and federal agencies as necessary 4. As needed, the facility will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated 5. All grievances involving alleged violations of neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the abuse preventionist. 6. All written grievances decisions will include: The date the grievance was received A summary statement of the residents grievance The steps taken to investigate the grievance A summary of the pertinent findings or conclusions regarding the resident's concern(s) A statement as to whether the grievance was confirmed or not confirmed Any corrective action taken or to be taken by the facility as a result of the grievance The date the written decision was issued 7. The facility will take appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation of any of these residents' rights within its area of responsibility 8. Maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

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 10 of 18 residents (Resident #3, #39, #40, #41, #43, #44, #49, #53, #56, #60) and 1 of 1 staff (LVN A) reviewed for infection control. 1. LVN A failed to properly clean multi-use equipment between each resident during medication administration for Resident # 39, #40, #56, and #60. 2. LVN A failed to sanitize hands between residents during medication administration for Resident #3, #39, #40, #41, #43, #44, #49, #53, #56 and #60. These failures could place residents at risk for spread of infection and cross contamination. Findings included: 1. During a medication pass observation on 09/08/24 at 04:00 PM, LVN A took a wrist blood pressure device to the room of Resident #40, who was sitting upright in bed, and took her blood pressure on the left wrist. She then took the wrist blood pressure device and placed it on top of the medication cart. LVN A did not sanitize the wrist blood pressure device before or after use. During a medication pass observation on 09/08/24 at 04:17 PM, LVN A picked up the wrist blood pressure device from the top of the medication cart and took it to the room of Resident #39, who was watching tv in bed, and took her blood pressure on the right wrist. She then took the wrist blood pressure device and placed it on top of medication cart. LVN A did not sanitize the wrist blood pressure device before or after use. During a medication pass observation on 09/08/24 at 04:22 PM, LVN A picked up the wrist blood pressure device from the top of medication cart and went to the room of Resident #60, who was asleep in bed, and took his blood pressure on the right wrist. She then took the wrist blood pressure device and placed in on top of the medication cart. LVN A did not sanitize the wrist blood pressure device before or after use. During a medication pass observation on 09/08/24 at 04:41 PM, LVN A picked up the wrist blood pressure device from the top of the medication cart and took it to the room of Resident #56, who was resting in bed, and took his blood pressure on the right wrist. LVN A took the wrist blood pressure device and placed it back on top of the medication cart. LVN A did not sanitize the wrist blood pressure device before or after use. 2. During an observation of medication pass on 09/08/24 at 04:06 PM, LVN A prepared medications for Resident #40 and administered her medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/08/24 at 04:17 PM, LVN A prepared medications for Resident #39 and administered his medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/08/24 at 04:22 PM, LVN A prepared medications for Resident #60 and administered his medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/08/24 at 04:29 PM, LVN A prepared medications for Resident #43 and administered his medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/08/24 at 04:34 PM, LVN A prepared medications for Resident #44 and administered his medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/08/24 at 04:37 PM, LVN A prepared medications for Resident #3 and administered his medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/08/24 at 04:41 PM, LVN A prepared medications for Resident #56 and administered his medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/08/24 at 04:46 PM, LVN A prepared medications for Resident #49 and administered his medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/08/24 at 04:48 PM, LVN A prepared medications for Resident #53 and administered her medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/08/24 at 04:52 PM, LVN A prepared medications for Resident #41 and administered her medications. LVN A did not sanitize her hands before or after medication administration. During an interview on 09/08/24 at 04:57 PM with LVN A, she stated she did not know why she failed to sanitize her hands and wrist blood pressure device between residents during medication administration. She stated, you just get into a groove and get thrown off when someone is watching. She stated she has been trained by nursing administration to sanitize her hands between every 2-3 residents, but she has not been trained to sanitize medical devices between residents. She stated facility training for infection control practices usually occurred quarterly. LVN A stated a potential negative outcome for failure to properly sanitize hands and multi-use medical devices was the spread of infection. During an interview on 09/10/24 at 11:45 AM with the ADM, she stated nursing administration was responsible for staff training on proper hand sanitizing and sanitizing of multi-use medical devices during medication administration. The ADM stated training was conducted through in-services as well as computer-based training and was conducted quarterly and as needed. The ADM stated her expectation of staff for proper sanitation of hands and multi-use medical devices was that staff follow policy and do things properly. She stated a potential negative outcome of failure to properly sanitize hands and multi-use medical devices was spreading disease. During an interview on 09/10/24 at 11:53 AM with the DON, she stated the ADON was responsible for training staff on proper hand sanitizing and sanitizing multi-use medical devices during medication administration. She stated staff are trained monthly through in servicing and computer-based training. The DON stated her expectation of staff for proper sanitizing of hands and multi-use medical devices was that staff sanitize hands and medical devices between each resident. She stated a potential negative outcome of failure to properly sanitize hands and multi-use medical devices was spreading infection. Record review of the facility-provided certificate of completion titled Infection Control: Essential Principles, dated 03/07/24 revealed LVN A completed the course training. Record review of the facility-provided in-service titled, Infection Control, dated 08/12/24 was signed by LVN A. Record review of the facility's policy titled, Infection Control Plan: Overview, dated 2019 revealed: Infection Control The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Preventing Spread of Infection . (3) The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. INTENT The intent of this policy is to assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The program will: Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination;

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 18 residents (Residents #42) reviewed for advanced directives, in that: Residents #42 were listed as DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was missing required information. These failures could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #42 Record review of Resident #42's face sheet, undated, revealed a 5-year-old-female was admitted to the facility on [DATE] with diagnoses to include Cerebral infarction (lack of blood supply to the brain), muscle weakness (decreased strength in muscles), Hypertension (high blood pressure), Major Depressive Disorder (persistent depressed mood), and Type 2 Diabetes (problem with blood sugar). The face sheet also revealed under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #42's physician order summary dated 09/11/24 revealed the following order: DNR-Do Not Resuscitate dated 12/22/23. Record review of Resident #42's care plan, dated 08/14/23, revealed care plan for DNR. Record review of Resident #42's OOH-DNR form dated 12/20/23 revealed there was no physician's license number associated with the physician's signature, no printed name associated with the physician's signature. During an interview on 09/10/24 at 3:05pm with the Social Worker, she stated the OOH DNR was not valid if it's not filled out correctly. She stated she was responsible for ensuring OOH-DNRs are completed correctly. She verified missing information on OOH-DNRs for Residents #42. She stated she was the system for monitoring OOH-DNRs for accuracy. She stated the reason the DNR was not complete was human error. She stated the potential negative outcome for Residents without a completed DNR was the wishes of the Resident may not be followed. She stated she had been trained on how to complete OOH DNRs. During an interview on 09/10/24 at 1:45PM with the ADM, she stated the OOH DNR was not valid if not filled out correctly. She stated the Social Worker was responsible for making sure the OOH DNR was completed accurately. She stated the Social Worker should check DNRs for accuracy and the DNRs are audited by the DON quarterly. She verified missing information on OOH DNR for Residents #42. She stated she does not know why the information was missing. She stated the potential negative outcome was the Resident's wishes may not be followed. She stated she had been trained on how to complete OOH DNR and her expectations were for them to be filled out completely and be correct. Record review of the Social Services Policies and Procedures Advanced Directives (Revised October 2013) revealed the following: Policy The facility will honor two types of Do Not Resuscitate orders: a physician's order for Do Not Resuscitate and the Texas Out-of-Hospital DNR Order. Out of Hospital DNR Form The Out Of Hospital DNR form was designed by the Texas Department of Human Services to comply with the requirements as set forth in the Health and Safety Code for the purpose of instructing Emergency Medical personnel and other health care professionals to forgo resuscitation attempts. Procedure: Texas Out of Hospital DNR Form Any resident may initiate an Out of Hospital DNR Order. The resident's attending physician will document the presence of the terminal condition in the resident's permanent medical record. If the resident is capable of providing informed consent for the order, he/she will sign and date the DNR order on the front of the official DNR form from the state of Texas. All validly executed DNR orders will be honored by the facility. Social services will assist all interested family members and residents will information, education, and execution of the DNR form.

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 11 of 16 toilets reviewed for safe environment, in that: - On June 25, 2024, the toilets in rooms #3, #8, #13, #16, #32, #50, #51, #52, #56, and Resident #2's and #3's rooms were unsecured to the floor and unstable. These failures could place the residents and public at risk for injury and falls. The Findings include: Record review of Resident #2's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had a history of hypoxia (oxygen is insufficient at the tissue level), hypertension (high blood pressure), anxiety, and seizures. Record Review of Resident #2's BIMS assessment dated [DATE], revealed Resident #2 had a BIMS score of 15 which indicates Resident #2 was cognitively intact. Record review of Resident #2's care plan dated 6/10/2024 revealed Resident #2 required 1 staff assistance for toilet use. Record review of Resident #3's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #3 had a history of morbid obesity, unspecified lack of coordination, hypertension (high blood pressure), and seizures. Record review of Resident #3's BIMS assessment dated [DATE] revealed resident had a BIMS score of 15, which indicated Resident #3 was cognitively intact. Record review of Resident #3's care plan dated 5/17/2024 revealed resident required 1 staff assistance for toileting. During an interview with ADM on 6/25/24 at 10:32 AM, she stated on new admission they will be checking the toilets. She stated the last maintenance staff had since quit and a new staff will begin Monday July 1st. She stated all the toilets had been checked by ADM and an Admission staff and a list had been given to maintenance to have the loose toilets assessed. She stated they only found one loose toilet and it was reinforced. During an interview with Maintenance Staff on 6/25/24 at 10:53 AM he stated I wasn't here that day (6/15/24) since I was off for the weekend. They called me that day and they let me know the toilet had fallen on a resident. They stated she had been sitting down and she fell and tried to grab the toilet and the toilet tilted on her. They told me they would call the plumbers that day and by the time I got back on 6/18 I went to check on it, but it still had a bit of a wobble. The toilet couldn't be tightened anymore because it would break the base. The ADM made a list of toilets to assess, and I checked them all. I tightened two of them, and noted the bolts were old and rusted, so I replaced them. If there were any toilets that had issues the facility usually would let me know but it was not a part of my monthly check up. I think the facility could do the checks monthly, but it was never something that had been brought. I had been here 10 months and my last day was 6/24/24. During an interview with Resident #2 on 6/25/24 at approximately 11:47 AM, she stated she had been told her toilet was loose but did not think anyone had come to fix it. Resident #2 stated she had used the toilet for the first time the previous night and had noted it was still loose. During an interview with Resident #3 at approximately 11:48 AM, he stated his toilet was too short for him but had not noticed if it was loose. During an observation of rooms #50, #51, #52, #56, and Resident #2's room on 6/25/24 at approximately 11:50AM, the toilets were loose, not secured to the floor and were unstable. During an interview with CNA A on 6/25/24 at 1:05pm she stated, I have not noticed any other issues with any other toilets in the facility. The facility did an in-service on the toilet and toilet seats. They told us to notify maintenance as soon as possible if the toilet was having issues and not let residents use them. I think maintenance should check the toilets regularly. This type of incident had not happened before. During an interview with Admission staff on 6/25/2024 at 3:05 pm, she stated she checked the toilets for being loose by grabbing the center of the toilet with both her gloved hands and attempted to move the toilet. She stated the ones that were loose were circled on a sheet and the ones not circled were fine. She stated when she was done checking the toilets, she gave the list to the ADM. She stated she does not typically do these types of checks. During an observation of the facility toilets on 6/25/2024 at approximately 3:11 PM, toilets in rooms #3, #8, #13, #16, #32, #50, #51, #52, #56, and Residents #2's and #3's rooms were found to be unsecured to the floor and unstable. Observations of the toilets were conducted with Admission Staff and the ADM. During an interview with the Housekeeping Supervisor on 6/25/24 at 4:31pm, she stated I give a checklist to the housekeepers, and they mark what is missing and if something was loose. They must check everything on the list and as soon as they give me the paper, I put it in maintenance box if there is something that needs to be repaired. Two staff members told me there were two loose toilets in Resident #2's room and I can't remember the other room. There was supposed to be a sign on Resident #2's room saying it was out of order. I was not aware of any of the other rooms having loose toilets. The bathrooms are cleaned daily. The housekeepers are supposed to check the toilets and to make sure they are cleaning around but not removing the caulking. My expectations are for the housekeepers to clean the bottom and around the toilet and removed any urine buildup or stains. I in serviced my staff to start checking the toilets after the incident with Resident #1. Prior to this recent in-service we had not had any other training or in servicing regarding toilet maintenance. During an interview with ADM on 6/25/24 at 4:44pm, she stated the negative consequences of the toilets not being secured appropriately could be injury to a resident. The facility will be monitoring and doing safety and environmental rounds. I will most likely go through and check the toilets myself. Record review of page titled Resident Room Roster dated 6/15, revealed room [ROOM NUMBER], #5, #13, #30, #31, #35, #39, #54, and #53 had been circled for further assessment of the toilets. The page was signed by Admission Staff and ADM. Record Review of facility policy titled Preventative Maintenance/Work- Order Request, revealed: 1. The facility will repair or replace damaged/broken equipment or building amenities as needed. 2. the facility will educate all staff members on the procedure for requesting repair of damages to the building or equipment.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 1 of 1 resident (resident #1) reviewed for accidents in that: - On June 15, 2024, Resident #1 ambulated to the bathroom and sat on the toilet, the toilet was unstable and loose causing Resident #1 to fall. These failures could place residents at risk for injury. The findings include: Record review of Resident #1's undated face sheet, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 was discharged [DATE], per resident and family request. Resident #1 had a history of emphysema (a type of lung disease that causes breathlessness), CHF (congestive heart failure), and hypertension (high blood pressure). Record Review of Resident #1's BIMS assessment dated [DATE], revealed Resident #1 had a BIMS score of 14 which indicates Resident #1 was cognitively intact. Record review of Resident #1's care plan dated 6/16/2024 did not reveal Resident #1 required assistance to the bathroom or incontinence care. Record review of the facility Provider investigation report dated 6/21/2024 revealed on 6/15/2024 at 3:35pm Resident #1, took herself to the bathroom. Resident #1 was found on the floor, Resident #1 stated that when she was going to the bathroom the toilet wobbled and she fell . The toilet was leaning on her. Aide and 2 nurses attended to the resident. Resident #1 had a laceration on wrist. The ADM called plumbers. Resident #1 refused to move rooms. ADM brought a bedside commode. Bruise is on the neck later after skin assessment, nurse went back in to assess. Resident #1 complained of aches and pains, x-ray was ordered. No issues found on X-ray. Sunday- resident arm is showing a bruise. Complaining of aches and feels sore. Provider investigation report signed by ADM on 6/16/2024. During an interview with ADM on 6/25/24 at 10:32 AM, she stated she saw the toilet herself and the toilet was leaning slightly. She stated the bolts were both still in the toilet but one of the bolts had stripped from the floor. She stated Resident #1 had gone to the bathroom and her assumption is Resident #1 was wiping and when she leaned over the resident may have fallen at that point. She stated CNA A found her. She stated Resident #1 had a bruise to her arm, and a laceration to the wrist, and later a bruise to her neck. ADM stated Resident #1 denied hitting the sink but was found under the sink. She stated Resident #1 had denied pain at the time of the incident but a few hours later, she began to complain of left arm pain and her back. She stated the facility performed x-rays on her left arm and back and the reports were negative for acute fractures. She stated Resident #1 had been admitted on [DATE] on the same day of the incident. She stated Resident #1 did not want to change rooms, so a bedside commode was brought in. She stated Resident #1 had discharged two days later unrelated to the incident, as the resident was unwilling to do therapy. ADM stated Resident #1 had come in for skilled nursing due to COPD. During an observation of Resident #1's toilet, on 6/25/24 at approximately 11:45AM, the toilet was secured to the floor and unmovable. During an interview with CNA A on 6/25/24 at 1:05pm she stated I heard Resident #1 screaming and I went into her room, and Resident #1 was on the floor and the toilet was leaning over but not on top of her. I screamed because I didn't want to leave her alone and the nurse came in. Resident #1 had a scrape on her left arm. The toilet was easily moveable at that point. The side the toilet was leaning on was still connected to the floor, and the other side was lifted. During an interview with ADM on 6/25/24 at 4:44pm, she stated the negative consequences of the toilets not being secured appropriately could be injury to a resident. She stated the facility would be monitoring and doing safety and environmental rounds. She stated she would most likely assess the toilets herself. During an interview with Resident #1's family member on 6/25/24 at 4:30pm, they stated they had checked on Resident #1 later that afternoon the day of the fall. She stated Resident #1 was having pain in her back and left forearm. She stated she obtain a couple of significant bruises on her arm and left side of the neck. She stated Resident #1 had end stage COPD (chronic obstructive pulmonary disease, a condition of the airway and difficulty or discomfort in breathing) and often confused. She stated Resident #1 was able to walk short distances. She stated Resident #1 had gone to the bathroom and sat on the toilet and the toilet bolted and she fell off with the toilet leaning on Resident #1. She stated the facility put a bedside toilet by her bed until they could get the toilet fixed. She stated Resident #1 did not want to be there and was discharged to the assisted living she was at prior. She stated the staff was very attentive but not very knowledgeable and either not aware of or not concerned with the issue at hand. During an interview with Resident #1 on 6/26/24 at 11:43 AM she stated, I feel that this incident was 100 % preventable. I walked into the bathroom, sat on the toilet and the whole thing turned over and I fell over, the toilet fell on top of me. I didn't even get a chance to take off my pants. I had a cut on my left wrist that has a butterfly band aid, and they x-rayed me to make sure I didn't break anything. I did not break anything, but my left wrist is still bruised and sore. The bruise on my neck looks fine, it is still sore but no problem there. The facility seemed concerned, but I think it was because they didn't want to get sued, I don't feel like it was genuine. Record review of facility undated policy title Event Reporting; Completion of, revealed: 1. The facility will complete an Event report on variances that occur within the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others. 7. Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a thorough investigation of the events of the reported Event including persons, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form.

Based on record review, interviews, and facility policy review, the facility failed to ensure a quarterly trust fund statement was provided for 3 (Resident #1, Resident # 2 and Resident #3) of 6 residents reviewed for resident rights. The facility failed to provide quarterly statements for Residents #1, #2, and #3 for the 3rd quarter (June 2023-September 2023). This failure could place the residents at risk for not having access to their personal funds and not having their personal needs met. Findings included: Record review of Resident #1's face sheet, dated 12/14/23, revealed a [AGE] year-old-male admitted to the facility on [DATE] with a diagnosis to include dementia (loss of cognitive function). Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: the resident's Brief Interview for Mental Status revealed a score of 07, which indicated the resident's cognition was severely impaired. Record review of Resident #2's face sheet, dated 12/22/23, revealed a [AGE] year-old-female admitted to the facility on [DATE] with a diagnosis to include dementia (loss of cognitive function). Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: the resident's Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was moderately impaired. Record review of Resident #3's face sheet, 12/22/23, revealed an [AGE] year-old-male admitted to the facility on [DATE] with a diagnosis to include type 2 diabetes. Record review of Resident #3's Comprehensive Minimum Data Set, dated dated [DATE], revealed: the resident's Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was intact. During an interview with the Business Office Manager (BOM) on 12/14/23 at 11:42 AM, she stated that she and the ADM were responsible for the resident trust funds. She said her Area Business Office Consultant was also responsible for resident trust funds in the facility. She stated she reviewed all resident trust funds at least every other day to monitor deposits so that she can pull care costs. She said resident trust funds were reconciled every month. During an interview with Resident #2 on 12/14/23 at 10:22 AM, she stated that she knew something was happening with her money but did not know what. She said she went to the BOM and was told she needed to take money out, but when she tried, she could not. She was unable to say when this encounter occurred. She said she was sent back to her room. She stated that she did not know what was going on. She said she never received anything in writing regarding her trust fund account. Attempted to call Family Member C to discuss Resident #2, but there was no answer. A message was left with return call information. During an interview with Resident #1 on 12/15/23 at 10:26 AM, he stated does not receive any trust fund statements from the BOM. He stated he trusted Family Member A to handle his business at the facility. He told the facility staff that Family Member A could make financial decisions for him. He stated he would like to know what is in his trust fund account. He stated he would like to know what was in his trust fund account. During an interview with Resident #3 on 12/15/23 at 10:32 AM, he stated he had never received a quarterly trust fund statement. He said his son may have, but no one ever came to him and gave him any papers. He stated he would have liked to know what he had in his trust fund account. During an interview with Family Member B on 12/15/23 at 10:40 AM, he said he never received any trust fund statements. He said that he issued a check to pay for his father's stay and that the facility staff was supposed to give his father his $60.00 monthly allowance out of that. He stated he would like to see the statements to see if that was happening but did not know he could have access to his trust fund statement. During an interview with Family Member A on 12/15/23 at 11:15 AM, she stated that she never received a quarterly statement for Resident #1. She said she would like to see his statements to help Resident #1 monitor his trust fund account. She stated she thought he did not have any money until she was notified in November that she had to spend his money in a couple of days before he lost his Medicaid. During an interview with the ABOC on 12/15/23 at 11:30 AM, it was stated if a resident had not receive their quarterly statement, then the resident or family member would not be able to see the quarterly recap that the quarterly statements show. He said the residents could not see or monitor what was being spent out of their account. He stated the BOM signed a quarterly attestation, meaning that she received the quarterly statements and distributed them to the residents the same day. He stated the systems in place to assist the BOM was he sent out a calendar with deadlines that the BOM must meet. He said everything is placed on the calendar such as when quarterly statements should be sent out. He stated he had provided the business office calendar to the BOM, which encapsulates the year. He said he had been trained regarding providing residents quarterly statements and the BOM has also been trained. He said it had been a while since an audit was done, and he was unaware that quarterly statements were not being distributed. He said he expected that once the BOM received the email with the resident's quarterly statements, she would sign the attestation, mail those that needed to be mailed out to the family, and hand out the ones to the residents in the facility. He stated one copy should be kept on file with the resident's signature. He said that he expected the BOM to personally ensure quarterly trust statement were handed out and not rely on assistance from other staff. He stated that the BOM was responsible for issuing the resident quarterly statements. He said he was not sure why the quarterly statements were not distributed. During an interview with the ADM on 12/15/23 at 11:47 AM, it was stated that the potential negative outcome for a resident not receiving their quarterly statements was that they may not know how much money they have. She stated she was unaware that residents were not receiving their quarterly statements. She said the systems were in place to monitor where the BOM was supposed to submit to corporate monthly. She stated the ABOC was monitoring the BOM. She stated she was not on that email list. She said she was unaware if the BOM ever sent the email to the ABOC regarding the completion of sending quarterly statements. She said the BOM had been trained on the expectation of quarterly statements to be given to the residents. She said her training as the administrator was limited but that she knew that residents should receive their quarterly statements. She stated she expected that the trust fund statements should be delivered quarterly. She said she expected the facility policy should be followed. She stated the BOM is responsible for providing the families and residents with their quarterly statements. She stated she was not aware of any reason as to why the monthly statements were not given quarterly. During an interview with the BOM on 12/15/23 at 12:10 PM, she stated that she was unaware she was supposed to keep a copy of the quarterly statements. She stated she located the quarterly statements she was supposed to deliver to Residents in October 2023. She stated she did not give them out. She stated she was about to go on vacation, and she was also training a new staff member for admissions. She stated she did not report that she had not delivered them to anyone. She stated that when she realized she had them, she thought she would give them once she returned to work. She stated she did not realize that she had not delivered them until the day of the interview on 12/15/23. She stated she had nothing to verify that she had given any quarterly statements for 2023. She stated she had the attestation but did not know she was supposed to keep a copy of the quarterly statements. She stated she thought the attestations were enough to verify that she had given the quarterly statements to the residents. She stated she may have been rushing to get things done was why she did not deliver the quarterly trust fund statements. She stated she had a calendar that told her what to do but she had not been following the calendar. She stated that she had been busy working on the Medicaid pending applications and the Medicaid Applications took up a lot of her time. She stated in the morning meetings, she had notified the ADM of what she had going on as far as what she needed to complete daily. She stated she had talked with the ABOC, and he was trying to help her get things done. She stated the ABOC was unaware that she had not delivered her quarterlies. She stated she was unaware if she had been trained to keep a copy of the quarterly trust fund statements. She stated she had been trained to meet the deadlines on the calendar. She said she expected all the residents to receive their trust fund at least quarterly. She stated she was responsible for monitoring the resident's trust fund accounts and issuing the quarterly statements. Record review of trust fund attestation for June 2023 signed by the ADM and the BOM on 07/27/23 attest that all trust fund statements were sent to each resident/responsible party according to state regulation. Record review of trust fund attestation for March 2023 signed by the ADM and the BOM on 04/27/23 attest that all trust fund statements were sent to each resident/responsible party according to state regulation. No attestation was provided for October 2023. Record Review of the facility's policy Resident Rights (undated) revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Self-determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds. Accounting and records The individual financial record must be available to the resident through quarterly statements and upon request. Record Review of the facility's policy Trust Fund Policy and Procedure (undated) revealed: Objective: The objective is to ensure that proper procedure is followed for daily record keeping of the resident trust fund. RFMS as well as manual techniques will be used to ensure all state regulations are followed. The petty cash kept in the business office will be a designated amount per facility that must be signed for by either the Resident or court-appointed Guardian for disbursement. If a resident is unable to sign and has no Guardian in place, two witnesses must sign to verify legitimacy of the transaction. The Trust Fund is to be consistently maintained and always balanced. The facility must follow all State guidelines, TAC rules, as well as CSNHC company policy and procedure always regarding the Resident Trust Fund. Procedure: Please adhere to the following procedures to maintain the Resident Trust Fund. Quarterly Trust Fund Statements Resident Trust Fund statements must be mailed to the Responsible Party or given to resident quarterly. These are mailed to the facility by RFMS. Once received, make copies to put in the Trust Fund binder and send originals to Responsible Party. Trust Fund Attestation Form- upon completion of the generation of the Quarterly Trust Fund Statements this form will be completed with date that statements were mailed and signed by the Business Office Manager and Administrator. This signed form is to be kept with the copies of the Quarterly Trust Fund Statements that were mailed for the respective ending quarter. If a resident or Responsible Party asks at any time, a Trust Fund statement should be given upon request, this is a resident's right to know all information pertaining to Trust Fund Account. The required statements should be done at these times: o March 31st o June 30th o September 30th o December 31st

Based on interview and record review, the facility failed to notify each resident that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the SSI resource limit for one person, and that if that amount reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI for 2 (Resident #1 and 2) of 6 residents reviewed resident rights. 1. The facility failed to communicate with Resident #1 and his preferred family contact that his trust fund account was over the resource limit and he could lose his eligibility. 2. The facility failed to provide Resident #1 and his preferred family contact with a written notice per the facility's trust fund policy that his trust fund account was over the resource limit and he could lose his eligibility. 3. The facility failed to communicate with Resident #2's POA that her trust fund account was over the resource limit and she could lose her eligibility. 4. The facility failed to provide Resident #2's POA with a written notice per the facility trust fund policy that his trust fund account was over the resource limit and she could lose his eligibility. These failures could place residents whose funds were managed by the facility, at risk of losing their Medicaid insurance benefits. Findings Included: Record review of Resident #1's face sheet, dated 12/14/23, revealed a [AGE] year-old-male admitted to the facility on [DATE] with a diagnosis to include dementia (loss of cognitive function). Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: the resident's Brief Interview for Mental Status revealed a score of 07, which indicated the resident's cognition was severely impaired. Record review of Resident #1's Resident Statement, dated 12/15/23, revealed the following: Resident #1 was over the $2000.00 Medicaid limit from 01/03/23 until 10/12/23. Resident #1 was within $200.00 of the $2000.00 Medicaid limit from 10/24/23 until 10/26/23 Resident #1 was over the $2000.00 Medicaid limit 11/03/23 until 12/01/23. Record review of Resident #2's face sheet, dated 12/22/23, revealed a [AGE] year-old-female admitted to the facility on [DATE] with a diagnosis to include dementia (loss of cognitive function). Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: the resident's Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was moderately impaired. Record review of Resident #2 Resident Statement, dated 12/15/23, revealed the following: Resident #2 was over the $2000.00 Medicaid limit from 01/03/23 until 12/01/23. During an interview with the Business Office Manager (BOM) on 12/14/23 at 11:42 AM, she stated that she and the ADM were responsible for the resident trust funds. She said her Area Business Office Consultant was also responsible for resident trust funds in the facility. She stated she reviewed all resident trust funds at least every other day to monitor deposits so that she can pull care costs. She said resident trust funds are reconciled every month. She stated that when a resident gets to $1500.00, she then starts having a conversation with the residents to let them know that they are getting close 2000.00 and they need to consider things that they can spend their money on. She stated the facility policy was to give the resident a written notice at $1800.00, but she does not like to wait that close because some residents do not want to spend their money. She said that for residents like that, she liked to start early. She stated they like to start at the $1500.00 limit, so if a resident does not move fast, they will have additional time to spend their money down. She said if a resident does not adhere to the $2000.00 limit notice, the resident could lose their Medicaid benefits and would have to become a private pay resident by default and use their personal funds. She said the $1500.00 notice was verbal. Once the resident comes within the $200.00 limit of $2000.00, they should receive a physical letter notifying them that they are within $200.00 of their $2000.00 Medicaid limit. She said regarding Resident #1, he has always given permission for Family Member A to make financial decisions for him. During an interview with Resident #2 on 12/14/23 at 10:22 AM, she stated that she knew something was happening with her money but did not know what. She said she went to the BOM and was told she needed to take money out, but when she tried, she could not. She said she would be sent back to her room. She stated that she did not know what was going on. She said she has never received anything in writing regarding her trust fund account. Attempted to call Family Member C to discuss Resident #2, and he did not answer. A message was left with return call information. During an interview with Resident #1 on 12/15/23 at 10:26 AM, he stated that he did not know he had over $2000.00 in his trust fund account at any time. He said he never received a notice about his trust fund account. He stated he trusted Family Member A to handle his business at the facility. He told the facility staff that Family Member A could make financial decisions for him. He stated he would like to know what was in his trust fund account. He said he did not understand what Medicaid was and what the limit in his trust fund account for Medicaid was. During an interview with Family Member A on 12/15/23 at 11:15 AM, she stated she had never received a written notice from the BOM or anyone at the facility that Resident #1 was within $200.00 of the $2000.00 Medicaid limit. She said the first time she had received any notice was on 11/28/23. She said the BOM told her that she would spend $3500.00 at a funeral home for a preneed burial plan. Family Member A stated she refused to allow the BOM to take $3500.00 and spend it at the funeral home of her choice. She was then told she had until 11/30/23 to spend the money down. She stated she could contact the funeral home of her choice, obtain a preneed, and provide the nursing facility an invoice by 11/30/23 at 10:00 AM. She stated over the summer of 2023, she attempted to get a preneed for Resident #1 but was told by the BOM that Resident #1 only received $60.00 a month and would not be able to afford it. She said because the BOM told her this , she did not revisit the matter because she assumed Resident #1 had no money. She said when she was notified of the resident's financial status and that the money had to be spent, she was scared and nervous about what would happen to Resident #1 if it was not spent. During an interview with the ABOC on 12/15/23 at 11:30 AM, it was stated that if a resident exceeds the $2000.00 Medicaid limit, they could lose their Medicaid benefits and have to pay for their stay at the nursing facility. He stated private pay meant that Medicaid would not pay for anything until the facility's recertification was renewed. He stated he was aware that some residents needed to spend money down, but he was unaware that there were over $2000.00 for multiple months at a time. He stated he had addressed residents that needed to spend down their money with the BOM and thought it had been resolved. He stated the systems in place to assist the BOM was he sends out a calendar with deadlines the BOM must meet. He said everything was placed on the calendar such as when the $200.00 notices should be completed. He stated he had provided the business office calendar to the BOM, which encapsulates the year. He said he had been trained regarding issuing the $200.00 written notice. He stated the BOM has also been trained. He said it had been a while since an audit was done, and he was unaware that the $200.00 notices were not being given, and the residents were going multiple months without spending their money. He stated regarding the $200.00 limit letters, he expected the deadline indicated on the calendar to be met. The resident and the family member should be notified, issued a copy, and a copy kept in the resident's file. He expected that if the resident was within the $200.00 limit, the resident and family should be issued a letter each month. He stated the resident's trust fund should be reconciled each month. He said he expected the resident's trust fund account to be kept below the $2000.00 limit throughout the year and not just the month before recertification. He stated keeping the trust account below the $2000.00 Medicaid limit would give the resident and their families time to think about what they want to do and what they want to spend their money on. He said having to spend a lot of money in a short amount of time can put stress on them. He stated that the BOM was responsible for issuing the $200.00 written notices and resident quarterly statements. He said he was not sure why the quarterly statements were not distributed. He stated he was unsure why the $200.00 written notices were not done and why residents had exceeded the $2000.00 Medicaid limit. During an interview with the ADM on 12/15/23 at 11:47 AM, it was stated a resident not receiving the $200.00 notice or exceeding the $2000 Medicaid limit, would lose their Medicaid benefits and have to pay out of pocket to stay at the facility. She said she was aware that there were residents that were close to the $2000.00 limit. She said the BOM told her that she had notified the family and the residents when resident's exceeded the $2000.00 limit. She said she was unaware that Resident #1 was over repeatedly every month. She remembered working with the BOM on Resident #1 over the summer. She said she did not remember if she (the ADM) asked about the $200.00 written notice. She said the systems were in place to monitor where the BOM was supposed to submit to corporate monthly. She stated the ABOC was monitoring the BOM. She stated that the BOM was supposed to submit to the ABOC and corporate monthly, which residents she was notifying were within the $200.000 limit of the $2000.00 Medicaid limit. She stated she was not on that email list. She said she was unaware if the BOM ever sent it. She said the BOM had been trained on the expectation of quarterly statements to be given to the residents and the $200.00 written notices. She said her training as the administrator was limited but that she knew that the facility had to notify the residents and the families when they are reaching the Medicaid limit. She said she expected the $200.00 statements to be completed and given to the residents promptly. She said she expected the facility policy to be followed. She stated the BOMwas responsible for issuing the $200.00 written notices. She stated she was unaware of why the residents were not given $200.00 notices. She stated she was unaware of why residents were over the $2000.00 Medicaid limit for consecutive months. During an interview with the BOM on 12/15/23 at 12:10 PM, she stated that she was unable to locate or provide any $200.00 notices for any of the residents picked for sample residents. She stated that she was unaware she was supposed to keep a copy. She stated the potential negative outcome for a resident's account exceeding $2000.00 was that the resident could lose their Medicaid benefits She said that by not receiving the $200.00 notice, the resident may not be aware that they were close to the $2000.00 Medicaid limit and still ultimately have to pay out of pocket to stay at the facility. She stated that she knew there were residents whose trust accounts were close to $2000.00, but she had notified the residents and the families. She said she knew she had missed some months, but she did not always miss them. She stated she did not have a reason for not keeping a copy of the form. She stated she may have been rushing to get things done. She stated she had also been training staff for admission on and off for at least three separate occasions. She said she looked at the statements monthly, and in the last week of the month, she gave the residents notices. She stated she had a calendar that told her what to do but had not been following the calendar. She stated that she had been busy working on the Medicaid pending applications. She stated in the morning meetings, she had notified the ADM of what she had going on for that day. She stated she had talked with the ABOC, and he was trying to help her get things done. She stated the ABOC was unaware that she had not given the $200.00 to the residents monthly. She stated she was unaware if she had been trained to keep a copy of the $200.00 notices. She stated she had been trained to meet the deadlines on the calendar. She stated the residents should receive a written notice that their trust fund account was within $200.00 of the $2000.00 Medicaid limit. She stated she was responsible for issuing the quarterly statements and the $200.00 notices. She stated she was responsible for monitoring the resident's trust fund accounts. Record Review of the facility's policy Resident Rights (undated) revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Self-determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds. Notice of certain balances. The facility must notify each resident that receives Medicaid benefits- When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, and That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. Record Review of the facility's policy Trust Fund Policy and Procedure (undated) revealed: Objective: The objective is to ensure that proper procedure is followed for daily record keeping of the resident trust fund. RFMS as well as manual techniques will be used to ensure all state regulations are followed. The petty cash kept in the business office will be a designated amount per facility that must be signed for by either the Resident or court-appointed Guardian for disbursement. If a resident is unable to sign and has no Guardian in place, two witnesses must sign to verify legitimacy of the transaction. The Trust Fund is to be consistently maintained and always balanced. The facility must follow all State guidelines, TAC rules, as well as CSNHC company policy and procedure always regarding the Resident Trust Fund. Procedure: Please adhere to the following procedures to maintain the Resident Trust Fund. Trust Fund Approaching Asset Limit Letter o Upon reconciliation of the trust account monthly you will need to generate letters in RFMS for all Medicaid residents that are approaching the Asset Limit threshold of $1500.00. o Inside RFMS- Report select the $200.00 Letter o Enter Balance Range from $1500.00 to $10,000.00, click 'view report'. o Click on the Save-blue floppy disk in header. o Save as an Excel file. o Change the dollar amount to $500.00 and print the letter. o Send the letter to RP or Resident and have resident sign if they are their own RP and keep copy for file. o Monitor weekly until spend down occurs as this will need to be completed before the last day of the month

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. These failures could place residents who ate the food from the kitchen at risk for food-borne illness. Findings included: Observation of the pantry on [DATE] at 10:18AM revealed the following: 1. (1) 1-gallon container of Spicy Green Tomatoes with Best by Date of [DATE] 2. (1) 5-gallon container of vanilla with Best by Date of [DATE] Observation of the freezer on [DATE] at 10:32AM revealed the following: 1. 2 pork riblet patties in zipper seal bag, no label or date 2. 2.5 pounds of frozen onion rings, no date 3. 20 pounds of frozen cookie dough, no date Observation of the refrigerator on [DATE] at 10:44AM revealed the following: 1. (1) 50-pound box of fresh potatoes, no date; many shriveled and beginning to bear seed On [DATE] at 11:07AM, the Dietary Manager stated that the negative outcome of unlabeled and expired foods in all parts of the kitchen would be that residents could become sick if they were served unknown or expired foods. The Dietary Supervisor stated that there should be labels and dates on all food items in the refrigerator, freezer, and pantry. The Dietary Supervisor stated that all dietary staff are responsible for labeling and dating all food, immediately upon delivery or purchase. Review of the facility's Dietary Services Policy and Procedure Manual for Food Storage, dated ,d+[DATE] revealed the following: Food must be stored in a properly covered container with a date and label identifying what is in the container. Food may remain in the [NAME] box as long as content and date are easily visible on the box. Any foods removed from the [NAME] box must be dated and labeled. All of the following terms will be considered expiration dates for food products: Expires by date Best by date Use by date Sell by date Record review of the facility's Dietary Services Policy and Procedure Manual for Sanitation and Infection Control: Food Safety, dated ,d+[DATE], revealed the following: Open packaged food, or leftover food is to be tightly wrapped or covered in clean air-tight containers, labeled, and dated, and stored in the refrigerator. Do not keep leftovers in the refrigerator over 3 days (72 hours).

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 5 resident (Resident #28, #35, #44, and #48) reviewed for infection control. The facility failed to ensure that facility staff perform hand hygiene appropriately during medication pass, incontinent care, and the delivery of food trays. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. The findings include: 07/25/23 11:47 AM Observation of LVN C preparing Resident #48's insulin. LVN C did not clean glucometer and did not perform hand hygiene before donning gloves. LVN C did not perform hand hygiene after the fingerstick of Resident #48 and or the preparation of Resident #48's insulin. LVN C did perform hand hygiene after the administration of medication, and removal of gloves. 07/25/23 11:56 AM Observation of LVN C preparing Resident #44's insulin. Glucometer was cleaned with a Sani-wipe and then laid on the medication cart, with no protective barrier between the glucometer and the surface of the medication cart. Did not observe any cleaning of the surface of the medication cart. LVN C did not perform hand hygiene before donning gloves to administer medication to Resident #44. LVN C did perform hand hygiene after the administration of medication and the removal of gloves. 07/25/23 12:01 PM Interview with LVN C on why hand hygiene was not performed before donning gloves to administer medication to the last 2 residents and she stated there wasn't a reason. LVN E was asked what a negative outcome would be, LVN C stated infection. 07/25/23 12:32 PM Observation of Lunch trays were delivered to residents on Hall #1. It was observed that CNA F did not perform hand hygiene while passing trays. CNA F was observed walking down the hall, following the tray trolley, and without performing hand hygiene pulled a residents tray from the tray trolley. CNA F was observed coming out of the residents room and not performing hand hygiene once again and grabbing another tray. CNA F did come out of 2nd room and performed hand hygiene at that time. 07/25/23 12:36 PM Observation of MA I following the tray trolley; MA I grabbed a tray off of the trolley and delivered it to a resident. MA came out of that room and did not perform hand hygiene and grabbed another tray and delivered it to another resident. 07/25/23 2:33 PM Interview with CNA F on why hand hygiene was not performed when passing meal trays to residents. CNA F stated, I missed the first time, but I performed it every other time. CNA F was asked what a negative outcome of that would be, CNA F stated cross contamination. 07/26/23 9:53 AM observation of CNA G performing incontinent care on a female Resident #28. CNA G performed hand hygiene in the residents bathroom and donned gloves. Peri-care was performed on residents thighs and genital area with no concern. Resident #28 then turned to her right side, CNA G performed hand hygiene, and donned clean gloves after resident turned and was safely on her side. the residents buttocks were cleaned with peri wipes and without removing gloves or performing hand hygiene CNA G obtained a clean brief and placed it under the resident. Resident #28 then turned onto her back and the CNA G continued with closing the brief of the resident. Hand hygiene was performed after soiled brief was disposed of in the liner in the trash can. CNA G then picked up liner and disposed of the dirty brief in a closed receptacle in the hallway. 07/26/23 10:03 AM Interview with CNA G was conducted after disposal and was asked why hand hygiene wasn't performed after the cleaning of the residents buttocks, and CNA G stated that she just forgot. When asked what a negative outcome would have been, CNA G stated infection. 07/26/23 10:09 AM Observation for incontinent care of male Resident #35 this was performed by CNA E and NA K. Incontinent care was started by both CNA E and NA K performing hand hygiene in Resident #35's bathroom. Gloves were donned by CNA E and NA K and privacy was provided to resident. Resident #35 was lying on his back on his bed under a sheet and another blanket. CNA E removed front of brief and started to clean residents thighs and genitals with peri wipes. NA K then assisted resident to his right side so the CNA E could clean his buttocks. Once resident was safely on his side the CNA E went to discard gloves and perform hand hygiene. CNA E returned and donned new gloves and cleaned residents buttocks, CNA E removed dirty brief and reached for the clean brief. CNA E did not change gloves or perform hand hygiene. CNA E took clean brief and and placed it under resident. NA K assisted resident back onto his back and assisted to turn towards the CNA E. NA K then unrolled new brief and was able to complete the fastening of the brief. Resident #35 was covered, placed in a comfortable position, call light was clipped to pillowcase within reach. NA K and CNA E performed hand hygiene in residents bathroom. 07/26/23 10:19 AM Interview with CNA E was asked why hand hygiene wasn't performed and donning of new gloves before touching the new brief the CNA E stated that she didn't know. When asked what a negative outcome would have been, CNA E stated that infection it would be a bad outcome. Record review of facility policy for Infection Control Plan: Overview, dated 2019 states the following: 1. Hand Hygiene Hand hygiene contuse to be the primary means of preventing the transmission of infection. The following is a list of some situation that require hand hygiene; o When coming on duty; o When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); o Before and after performing and invasive procedure (e.g. fingerstick blood sampling) . o Before and after eating or handling food (hand washing with soap and water); o Before and after assisting a resident with meals; o Before and after assisting a resident with personal care (e.g., oral care, bathing); o Before and after handling peripheral vascular catheters and other invasive devices; o .Upon and after coming in contact with a resident's intact skin, (e.g. when taking a pulse or blood pressure, and lifting a resident); . o .Before and after assisting a resident with toileting (hand washing with soap and water); . o .After contact with a resident's mucous membranes and body fluids or excretions; o After handling soiled or used linens, dressings, bedpans, catheters and urinals; o After handling soiled equipment or utensils; . o .After removing gloves or aprons; .

Resident #35 FTag Initiation 07/27/23 10:10 AM Per interview with [NAME] MDS Manager who reviewed the chart for Resident #35 and reported that they review the 7 day look back period per his record for the nurses summary and weekly notes which had no documentation of the resident having behaviors, the medication administration record which will track resident behaviors which had no documentation of the resident having behaviors in the 7-day look back period, the progress notes which had no documentation of behaviors in the 7-day look back period, and the treatment record which had no documentation in the 7-day look back period from the 7-9-2023 Quarterly MDS. She did confirm that Resident #35 did have behavioral documentation in his progress notes twice during 6-2023 on having behavioral issues, that she was aware per his documentation that he was being treated for behaviors, and that she was aware that staff were aware of his behavioral issues but reiterated that he did not have any documented behavioral issued in his medical records during his 7-day look back period which is what they review when completing his MDS She reviewed the RAI manual for the behavioral instructions assessment and stated that it instructed that the resident is to be assessed during the 7-day look back period only from her understanding. She verified that staff and family were to be interviewed but stated, only during the 7-day look back period. She reported that she would contact her Cooperate MDS Supervisor for clarification. 07/27/23 11:19 AM Per interview with [NAME] MDS Manager who reported that she had conferred with her corporate MDS Supervisor and stated, At this time we are going to continue with out current understanding of the RAI manual and continue to use the 7-day look back period for our assessment of the residents behavioral issues. 07/27/23 01:12 PM Per interview with [NAME] MDS Manager who reported that the MDS information is based on the RAI manual and they get their information from the residents chart/documentation. 47159 Based on observation, interview, and record review the facility failed to ensure that assessments accurately reflect the resident's status for 4 of 19 residents (Residents #35, #44, #48, and #62) whose records were reviewed for MDS and Care Plan assessments. The facility failed to update Resident #35's MDS to reflect the Care Plan. The facility failed to update Resident #44's MDS to reflect the Care Plan The facility failed to update Resident #48's MDS to reflect the Care Plan The facility failed to update Resident #62's MDS to reflect the Care Plan This failure could place residents at risk of the facility mis-identifying the resident's preferences, goals of care, functional and health status, strengths and needs and proper guidance once problems have been identified. Findings included: Record review of Resident #35's MDS assessment dated [DATE] indicated that the Resident did not exhibit physical, verbal, or other behaviors toward self and others. Resident #35's Care Plan dated 7/10/23 indicated that resident exhibited physical and verbal behaviors toward staff and others on a frequent basis and had exhibited physical and verbal behaviors toward self and others since his arrival at the facility on 5/7/20. Resident #35's MDS Assessment from 7/10/23, indicated that the resident had an ADL Self-Care Deficit requiring extensive assistance from staff to complete his ADL's. Resident #35's Care Plan from 7/10/23, indicated that the resident is a 1-person assist for all ADL care. On 07/27/23 at 8:20 AM, CNA G stated that resident #35 had frequent behaviors and had come to the nurse's station, stood against the desk, hit the desk with his fist and yelled when he wanted to smoke or go outside. On 07/27/23 at 8:28 AM LVN D stated that resident #35 got agitated when he wanted to smoke or go outside. LVN D stated that Resident #35 had exited the front door on his own, but staff were able to get resident #35 back into the facility without altercation. On 07/27/23 at 8:33 AM the DON stated that resident #35 did have behaviors and had been fixated on 1 CNA. The CNA in question had to be moved to another hall due to Resident #35 stating that she was his wife. Resident got very attached to CNA not in a good way. The DON stated that resident #35 had tried to go outside without supervision and had made it outside on his own, one time. Resident #35's care plan did not indicate him as an elopement risk. The DON stated that Resident #35 also did not require ADL assistance to leave the building Record Review of Resident #44's MDS assessment dated [DATE] indicated that the Resident did not exhibit physical, verbal, or other behaviors toward self and others. Resident #44's Care Plan dated 7/3/23 indicated that Resident #44 exhibited physical and verbal behaviors toward staff and others on a frequent basis. Resident #44's MDS Assessment from 7/3/23, indicated that Resident #44 had an ADL Self-Care Deficit requiring extensive assistance from staff to complete his ADL's. Resident #44's Care Plan from 7/3/23, indicated that the Resident was a 1-person assist for all ADL care. In an interview with Resident #44 on 7/26/23 at 10:23AM Resident #44 stated that he was able to transfer to and from his wheelchair and get dressed with no staff assistance. On 07/26/23 at 10:34 AM the MDS Manager stated that Resident #44's MDS was filled out when the Resident was observed being independent. He was care planned for a 1-person assist, while the MDS stated that extensive assistance was needed. The MDS Manager stated that Resident #44 would be coded for the most dependent assistance needed. When asked how a MDS would be changed to show improvement, MDS Manager stated that there would need to be a Significant Change in Care Areas to constitute a change to the MDS. On 07/26/23 at 10:40 AM with the ADM, DON, and Corporate Nurse, Corporate Nurse stated that everyone is responsible for updating the Resident's MDS and Care Plan. The Corporate Nurse stated that a discrepancy would exist if there were an observation of an independent individual, while the Care Plan states a 1-person assist and then the MDS stated a 2-person assist. The Corporate Nurse stated that the 7-day look back would need to be investigated for the documentation to see if the resident needed 2-person assist at any time. The Care Plan would be looked at to see what the resident would need daily. Record review of Resident #48's MDS assessment dated [DATE] indicated that the Resident #48 did not have an indwelling catheter and was always incontinent of bladder. A Physician Order from 7/10/23 indicated the placement of an indwelling catheter. Observation of Resident on 7/25/23, 7/26/23 and 7/27/23 revealed that Resident #48 had an indwelling catheter. On 7/27/23 at 10:34AM the MDS Manager stated that the placement of a foley catheter would be a Significant Change in Condition, only if two other Areas of Care on the MDS were affected. The MDS Manager stated that she had not inquired whether the placement of the catheter bothered the resident in a psychosocial or decreased ADL capacity. The MDS Manager stated that the placement of the catheter should have warranted a Care Plan Meeting, but this had not been done. The MDS Manager then initiated a MDS change while surveyor was standing in her office. Record review of Resident #62's MDS assessment dated [DATE] indicated that Resident #62 did not exhibit physical, verbal, or other behaviors toward self and others. Resident #62's Care Plan dated 7/10/23 indicated the Resident exhibited physical and verbal behaviors toward staff and others on a frequent basis. In addition, Resident #62's MDS Assessment from the same date, indicated that the resident has an ADL Self-Care Deficit requiring extensive assistance from staff to complete her ADL's. Resident #62's Care Plan from 7/10/23 indicated that the resident is a 1-person assist for all ADL care. On 7/27/23 at 11:42AM the MDS Manager stated that all Care Plans should be updated to reflect the most recent MDS Assessment. 47854 Resident #35 Accidents 07/26/23 02:30 PM record review reveals the following: Date: [DATE] Lubbock Health Care Center Facility # 5138 Time: 14:30:33 CT Progress Notes User: Lubbock Surveyor Page # 1 Resident Name: [NAME] DALLAS (013180-088) Location: 1 5 - B admitted : 11/28/2022 Effective Date: 6/14/2023 15:17 Type: Nursing Progress Note after being brought back in through door. layed down by cna. no distress. not combative at this time. Author: [NAME] - LVN [e-SIGNED] 07/26/23 02:26 PM record review reveals the following Date: [DATE] Lubbock Health Care Center Facility # 5138 Time: 14:26:45 CT Progress Notes User: Lubbock Surveyor Page # 1 Resident Name: [NAME] DALLAS (013180-088) Location: 1 5 - B admitted : 11/28/2022 Effective Date: 6/18/2023 15:37 Type: Nursing Progress Note Note Text: A visitor came to the nurses station and stated that a resident went out the door when she opened it, another visitor was trying to stop him but Mr. Dallas refused to turn around. Mr. Dallas was observed just outside the door sitting in his WC calmly, a lady visitor was at his side. Myself and 2 other nursing staff asked Mr. Dallas was he going somewhere and he started smiling. We brought him back inside with no problem, 0 injuries. I asked Mr. Dallas why did he go outside and he stated that he wanted to see what it was like. I advised him that he cannot go outside by himself and to let us know when he wants to go outside and we can take him to the patio. He replied ok. Notified DON, ADON, NP [NAME] Dill and daughter [NAME] (left message on phone). Author: [NAME] - Licensed Vocational Nurse [e-SIGNED] Resident #48 hospitalization 07/27/23 01:39 PM record review revealed that resident was recently hospitalized for Note Text: [NAME] LEVACY was transferred to a Hospital on 07/06/2023 1:12 PM related to diaphoretic, chronic stomach pain. 07/27/23 01:57 PM record review revealed that order for foley catheter is as follows: Urinary Catheter _16____F/___30__cc to gravity drainage, every shift record review revealed that residents status has not been updated on residents MDS or noted in the care plan. 07/27/23 02:19 PM interview with [NAME], MDS coordinator was asked if placing a foley catheter would trigger a significant change, MDS stated she would initiate a sig change to review the other areas. MDS coordinator stated that the team should have had a care plan meeting in regards to this change in condition of resident.

Based on interview and record review the facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) for 2 (Resident #35 and Resident #62) of 19 Residents reviewed for PASRR. The facility failed to conduct a PASRR Level II for Resident #35 after the PASRR Level I was found to be positive for Mental Illness. The facility failed to ensure that Resident #62's PASRR Level I was coded to match the diagnosis of Schizophrenia and therefore did not conduct a PASRR Level II for Resident #62. This failure could place residents at risk of the facility not meeting the resident's medical, functional, and psychosocial needs. Findings included: Record review on 7/27/23 at 1:19PM of Resident #35's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of, but not limited to, Pseudobulbar Affect (A condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), Other Alzheimer's Disease (Memory loss and loss of ability to carry on a conversation), Generalized Anxiety Disorder, Muscle Weakness, Unspecified Abnormalities of Gait and Mobility (Unusual walking pattern), Other Lack of Coordination, Repeated Falls, Difficulty in Walking, Unsteadiness on Feet, Dementia Unspecified Severity, with Other Behavioral Disturbance, Record review of Resident #35's admitting PASRR I was coded 1 and indicated that Resident #35 had a mental illness. No PASRR II was conducted. Record review of Resident #35's psychiatric notes from the facility's Psychiatric Provider dated 11/9/22, 12/21/22, 1/18/23 and 2/14/23 indicated that nursing staff identified a medical issue of concern that required a mental status examination for routine psychotropic identification and review. Therapeutic issues requiring a timely follow up evaluation to assess effectiveness of psychotropic medication regimen. Record review of rounding Psychiatric Nurse Practitioner's assessments on 11/9/22, 12/21/22, 1/18/23 and 2/14/23 indicated the following on all four occasions: Dementia of Alzheimer's type with late onset and dementia in disease classified elsewhere with behavioral disturbance. Mood disorder due to general medical condition with major depressive-like episode. No adverse effect of psychotropic agents. Unless noted otherwise, a psychotropic gradual dose reduction (GDR) is contraindicated. Monitor patient's behavioral signs and symptoms on each subsequent encounter. Record review of Resident #35's Psychiatric Plans of Action from the rounding Psychiatric Nurse Practitioner for 11/9/22, 12/21/22 and 2/14/23 indicated the following: Continue current medication; any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating an underlying psychiatric disorder. Medication list reviewed. Behavioral intervention for psychiatric signs/symptoms. Transition in care, clinical summary provided. Record Review of Resident #35's Psychiatric Plan of Action from the Psychiatric Provider on 1/18/23 required significant changes due to an increase in behaviors and indicated the following: Continue current medication any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating an underlying psychiatric disorder. Medication list reviewed. Risks and benefits have been considered. Increase medication: Buspirone. Provider does not agree with pharmacist recommendations regarding: Mirtazapine. The continued use is in accordance with relevant current standards of practice and physician documented clinical rationale with explanation that a reduction in dosage may result in exacerbation of the disorder and/or underlying psychiatric condition - Medication in use is in accordance with current standards of practice - Resident is likely to experience a deterioration of condition or psychiatric instability per physician clinical judgement/experience. Current dosage is effective and has resulted in no adverse side effects. Transition in care, clinical summary provided Record Review of Resident #35's Psychiatric Treatment Notes revealed that he had been receiving psychiatric services from the facility's Psychiatric Provider for an identified psychiatric concern, and no PASRR II had been completed for the Resident. On 7/27/23 at 2:08 PM the MDS Manager stated that a PASRR II should have been conducted for Resident #35 and she was unsure why this had not been completed. Record review of Resident #62's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of, but not limited to, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; Major depressive disorder, Generalized anxiety disorder (excessive worry about everyday issues and situations characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), recurrent, mild; and Schizophrenia (delusions, false beliefs, hallucinations, unusual physical behavior, and disorganized thinking and speech), unspecified. Resident #62's PASRR I was coded 0 and indicated that the resident had no serious mental illness and/or intellectual disability or a related condition, and she had an active admitting diagnosis of Schizophrenia. Record review of psychiatric notes from the facility's Psychiatric Provider dated 5/12/23, 5/30/23 and 7/10/23 indicated that nursing staff identified a medical issue of concern that required a mental status examination for routine psychotropic identification and review. Record review of rounding Psychiatric Nurse Practitioner's assessments indicated the following on all three occasions: Psychiatric illness preceded onset of dementia. Senile dementia with depressive features. Cerebral infarction due to occlusion or stenosis of small artery. Paranoid schizophrenia. Severe recurrent major depression without psychotic features. Generalized anxiety disorder. No adverse effect of psychotropic agents. Unless noted otherwise, a psychotropic gradual dose reduction (GDR) is contraindicated. Monitor patient's behavioral signs and symptoms on each subsequent encounter. Record review of the Psychiatric Plans of Action from 5/12/23, 5/30/23 and 7/10/23 indicated the following: Continue current medication any attempted dose reduction would likely impair the patient's function, increase distressed behavior, or cause psychiatric instability by exacerbating an underlying psychiatric disorder. Medication list reviewed. Monitor for recurrence of psychiatric symptoms/signs. Transition in care, clinical summary provided. Record review of psychiatric notes dated 7/12/23 indicated that the nursing staff requested the Psychiatric Provider to address a documented psychiatric issue of concern that required a timely evaluation and medical intervention. Nursing notes are as follows: Hostility. The mood was irritable. Hostility toward caregivers, attempted physical aggression towards staff. Socially inappropriate behavior, and verbal disruptions. Verbal aggression. Record review of the rounding Psychiatric Nurse Practitioner's assessment from 7/12/23 indicated the following: Psychiatric illness preceded onset of dementia. Paranoid schizophrenia, severe, recurrent Senile dementia with depressive features. Cerebral infarction due to occlusion or stenosis of small artery. Major depression without psychotic features. Generalized anxiety disorder. Record review of the subsequent Psychiatric Plan of Action indicated the following: Medication list reviewed. Risks and benefits have been considered. Nurse reports there is a male staff member that this Resident always seems to be concerned of whether he is going into her room. When she sees him, she becomes irritated, aggressive, and checks her surroundings for him. When the staff told her he is not going into her room, she calls them, Liars. Move male staff to a different hall. Duration of the encounter nine minutes. Record Review of Resident #62's Psychiatric Treatment Notes revealed that he had been receiving psychiatric services from the facility's Psychiatric Provider for an identified psychiatric concern, and no PASRR II had been completed for the Resident On 7/27/23 at 2:08 PM the MDS Manager stated that a PASRR II should have been conducted for Resident #62 and she was unsure why this had not been completed.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accident hazards/supervision. The facility failed to use a two-person mechanical lift transfer from the wheelchair to the bed causing Resident #1's foot to get caught between the bed and the Hoyer lift, resulting in an acute nondisplaced fracture of her left distal tibia (ankle). The noncompliance was identified as PNC. The noncompliance started on 05/21/2022 and ended on 05/22/2022. The facility had corrected the noncomplaince before the survey began. This failure could result in residents experiencing accidents, injuries and/or a diminished quality of life. The findings include: Record review of Resident #1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE], with a readmitted [DATE]. Her diagnoses included: history of right hip fracture, chronic pain syndrome, weakness and paralysis following a stroke affecting left non-dominate side, type 2 diabetes mellitus with [CONDITION(S)], protein-calorie malnutrition, seizures, major depressive disorder, [CONDITION(S)], and hypertension. Record review of Resident #1's annual MDS assessment dated [DATE], revealed a BIMS score of 15 (normal cognition). Resident #1 required extensive assistance with two-person physical assistance with bed mobility, dressing, and toileting. Resident #1 required total assistance with two-person physical assistance with transfers. The MDS reflected Resident #1's range of motion was impaired on one side to the upper and lower extremity. She utilized a wheelchair. Record review of Resident #1's Care Plan last reviewed 04/08/2022 revealed: Problem: ADL self-care deficit related to effects of [CONDITION(S)] ([CONDITION(S)] accident) with left [CONDITION(S)]. Prefers staff to assist/complete ADLS for her. Needs encouragement to participant in ADL care. Intervention included: Requires a lift for all transfers with two assist and/or may stand and pivot with two assist. Problem: Uses Hoyer lift for transfers. Intervention reflected, Use at least two people for transfers with Hoyer lift. Problem: Risk of falls related to impaired mobility due to [CONDITION(S)], impaired gait/balance/debility, use of psych med, incontinence, impaired cognition, diabetes mellitus, use of cardiac medications and use of narcotic pain medications as needed. History of falls. Intervention included: Mechanical lift with two staff members to assist with transfers. Review of Resident #1's Bedside Kardex (gives brief overview of resident) dated as of 05/31/2022 for Transferring listed: *Mechanical lift with staff x 2 to assist with transfers *Resident #1 requires a lift for all transfers with 2 assist and/or may stand and pivot with 2 assist. *TRANSFER: The resident requires total assistance with transfers- Hoyer lift transfer. Record review of Nurse's Note dated 05/22/2022 at 10:15 a.m. revealed that when LVN B was administering Resident #1's morning medications, the resident immediately began to complain of pain to her left ankle. Upon assessment of the site there was obvious swelling and bruising noted. The resident stated it may have been caught on something during a transfer. Nurse Practioner was contacted and new order for x-rays obtained, foot elevated, and pain medication was administered. Record review of Event Nurse's Note 12 hour-Bruise dated 05/22/2022 at 10:13 a.m. revealed Event: Resident complained of pain when LVN B administered topical medication. Resident #1 reported her ankle was hurting. The site was assessed with obvious swelling noted. The resident reported her foot got caught on something when she was being transferred to bed the day before. The Nurse Practioner was notified with a new order for x-rays received. Bruise: left ankle and left big toe. Size: 1 inch Color: blue/purple. Physician notified on 05/22/2022 at 9:00 a.m. Responsible party notified 05/22/2022 at 10:58 a.m. Record review of SBAR (situation, background, assessment, and recommendation - communication between nurses and providers) dated 05/23/2022 at 9:15 a.m. documented possible left ankle fracture, symptoms first appeared on 05/21/2022, x-ray obtained. Nurse Practioner notified on 05/23/2022 at 9:10 a.m., and notified responsible party on 05/23/2022 at 9:10 a.m. Order received to transfer Resident #1 to the hospital for further evaluation. Record review of Nurse's Note dated 05/23/2022 at 9:15 a.m. indicated that Resident #1 was transferred to the hospital related to possible left ankle fracture. Needs a CT scan. (diagnostic imaging) Record review of Nurse's Note dated 05/23/2022 at 3:04 p.m. revealed Resident #1 returned from the hospital. She had a splint noted to left lower extremity. Resident complained of pain at a 6 on a scale of 1 to 10. Will medicate per PRN orders. Family notified. Record review of the Provider Investigation Report dated 05/27/2022 revealed the investigation determined that Resident #1's ankle was fractured on 05/21/2022 due to NA not using the Hoyer lift with the proper amount of staff to assist. The NA tried to complete the two-person lift by herself resulting in Resident #1's foot being caught between the lift and the bed causing an acute nondisplaced fracture to the left tibia. Following the investigation the facility was continuing to in-service on safe transfers, and perform competency checks. The NA was terminated for not following the plan of care. Resident Satisfaction Surveys and witness statements from Resident #1 and Resident #6 included in the report. Record Review of Resident #1's x-ray report dated 05/22/2022 at 11:00 a.m. revealed findings of decreased bone mineralization. An acute non-displaced fracture of Resident #1's left distal tibia noted. Interview with the Administrator on 06/01/2022 at 1:50 p.m. revealed he was at the facility on Sunday, 05/22/2022, and was told by nursing about the incident involving Resident #1. He stated the NA was suspended immediately pending the investigation. The Administrator stated when he brought her back in to talk to her on 05/24/2022, she did not think she had done anything wrong. The NA was terminated on 05/27/2022 over the incident involving Resident #1. The NA was a certified nurse aid in another state. The Administrator stated they had reviewed the incident at the QAPI meeting, and had been in-servicing to reiterate two-person assistance with Hoyer lifts. He also stated that PT had conducted an in-service on safe transfers. Interview with the DON on 06/01/2022 revealed the NA had only been employed at the facility for about 6 weeks. The DON stated the NA was certified in another state, so she was hired at the facility as a nurse aide. The DON stated she had reports from other residents the NA could be a little rough with them. The DON stated it was ultimately the charge nurse's responsibility to make sure their staff was performing Hoyer lifts correctly. Observation made on 06/01/2022 at 2:50 p.m. of CNA A and the ADON revealed they were performing a Hoyer transfer with Resident #3 without incident. Interview with ADON on 06/01/2022 at 3:00 p.m. revealed that he thought everyone knew that there is supposed to be two staff with a Hoyer lift. All new staff are oriented and have competency checkoffs before working on the floor. He reported that since the incident they have been pounding it in to staff with in-services and competency check-offs. He is making rounds and assisting staff as needed. Interview with CNA B on 06/01/2022 at 3:08 p.m. revealed that she always has a second person with her for a Hoyer lift. Stated they had been in-serviced a lot since the incident. Interview with LVN C on 06/01/2022 at 3:15 p.m. revealed that they had been in-serviced on proper use of the Hoyer lift. Stated that she will help her staff as needed. Interview with CNA C on 06/01/2022 revealed that she always asks for help when there is a Hoyer lift transfer. She stated that if no one was available at that time, she would wait till someone could help her. Phone interview with the NA on 06/01/2022 at 5:32 p.m. revealed that on Saturday, 05/21/2022, around 11:45 a.m., she assisted another staff member with a Hoyer transfer for Resident #1 from the bed to the wheelchair without incident. The NA stated later that day when the CNA's started making their final rounds of the shift, she checked on Resident #1 around 4:30 p.m., who stated she was ready to get back into bed. The NA stated she let her know that she would be back after they completed rounds. The NA stated after about 10 minutes Resident #1's call light was on. The NA stated the resident was getting a little agitated and wanted to lie down, stating the resident told her, I want to lay down now; you can do it. The NA stated she told her to wait just a few more minutes till they finished up their rounds and she had some help. The NA stated approximately 10 minutes after that, Resident #1 turned on her call light again. The NA stated when she entered Resident #1's room, the resident said, You are going to lay me down now! The NA stated she told the resident she would get the Hoyer lift and be right back. The NA stated she asked the roommate to move to the hall, so she could get the Hoyer lift in the room. The NA stated she strapped up the Hoyer to the sling, and moved Resident #1 so she would be over the bed. The NA stated they had been having problems with the lifts stopping in the middle of the transfer, so she wanted to make sure she had the resident over the bed. The NA stated the resident likes to lay close to the wall, so she gave Resident #1 the lift control, so resident could lower herself to the bed, as she guided her into position on the bed. The NA stated following the transfer she repositioned resident with pillows and made sure she was comfortable. She stated she asked the resident if she was okay and if she needed anything. Resident #1 assured her she was okay. The NA denied the resident getting her foot caught or her complaining of pain. When asked about training, the NA stated she had not been trained on how to use the Hoyer lift at the facility. When asked if she had ever been trained or used a Hoyer lift, NA verbalized it had been about a year ago, but she was familiar with it. The NA stated when she came to work on Sunday, 05/22/2022, LVN B asked her if she laid Resident #1 down the evening before. The NA told her she had, and then LVN B told her, You broke her leg. The NA asked LVN B if she could help her understand because the resident was fine when she left her. The NA stated she was fired, and the Administrator had told her it was neglectful for performing the transfer by herself. The NA stated she did not understand because she transferred another resident, Resident #5, by herself all the time with no problem. Interview with the DON on 06/01/2022 at 5:50 p.m. revealed all new hires went through a three-day orientation. The DON stated the first day they shadowed a CNA; the second day the new hire did a little more with assistance; and the third day they are doing total care with supervision. The DON stated the orientation included competency checkoffs and included Hoyer lift transfers. The DON stated that she had two CNA's that had been with the facility for a long while and knew what to do, so she would put the new hires with them. Interview with LVN A on 06/01/2022 at 6:05 p.m. revealed that she did not work the day when the incident happened, but when she came in on Monday 05/23/2022, she had heard about the incident involving Resident #1. LVN A stated that the x-ray results had not been received yet, so she called radiology and got the report sent over. LVN A stated when the results were received reflecting a fracture, LVN A notified the physician and sent Resident #1 to the emergency department. LVN A stated Resident # 1 returned later the same day with a splint to the left lower leg. Interview with Resident #5 on 06/01/2022 at 6:10 p.m. revealed two staff members used the Hoyer lift when transferring him. Resident #5 was asked about NA performing the lift by herself and Resident #5 stated no, there was always someone else to help. Resident #5 stated the NA was the only one that could get him positioned up in his chair right with the lift. Interview with CNA A on 06/01/2022 at 6:15 p.m. revealed she had worked with the NA and verified she had been trained with the Hoyer lift. CNA stated that NA worked with another CNA for two days, and she worked with her on the third day. DON showed the schedule of the days NA trained with the two experienced CNA's. Interview with CNA D on 06/01/2022 at 6:20 p.m. revealed she had been a CNA for [AGE] years, and that she always has another staff member to help her with a Hoyer lift transfer. She stated, Will never in my life do it by myself. Interview with Resident #1 on 06/01/2022 at 6:25 p.m. revealed that she was ready to go to bed on Saturday 05/21/2022 and the NA transferred her via Hoyer lift from the wheelchair to the bed. Resident #1 stated when the NA lifted her up out of the wheelchair, her left foot got caught and she was yelling, My ankle, my ankle! Resident #1 stated the NA did not stop and just kept moving her to the bed. Resident #1 stated her ankle was okay once she was in bed, and it did not really start hurting till later that night. Resident #1 stated there should be 2 staff performing the transfer. She denied ever being transferred by one staff member prior to this incident. Resident #1 had a splint to her lower left leg. Resident #1 stated she had an upcoming doctor appointment, and did not know if she was going to have to have surgery. Interview with Resident #1's roommate, Resident #6, on 06/01/2022 at 6:30 p.m. revealed that she saw what happened regarding the NA and Resident #1. Resident #6 stated that the NA asked her to leave the room so she could get the lift into the room. Resident #6 stated there were two lifts in the room. Resident #6 reported that when Resident #1 was being lifted, she saw her foot get caught between the two main bars of both lifts, and heard Resident #1 yell out. She also stated the NA was on the phone as well. Phone interview with LVN B on 06/02/2022 at 11:00 a.m. revealed Resident #1 had no complaints of pain on Saturday 05/21/2022. LVN B stated she always rubbed cream on Resident #1's legs in the mornings, but Saturday was her shower day, so she did not put the cream on till that afternoon. LVN B stated there was no bruising or discoloration that day. LVN B stated on Sunday, 05/22/2022, she went in to Resident #1's room that morning to put cream on her legs, and as she entered the room Resident #1 was complaining of pain to her left ankle. LVN B stated when she pulled the covers back to assess the area, the resident's ankle was bruised with swelling noted. LVN B stated she asked Resident #1 what happened, and that was when she found out that NA had transferred the resident to the bed by herself and the resident's foot got caught. LVN B stated she went back to the station to make notifications to the physician and family. She stated she received orders for an x-ray. LVN B stated she did not think she had to worry about staff doing the right thing, as they were all good CNA's. LVN B stated she told her staff to notify her if they needed assistance. Record review of employee file of the NA revealed: Date of hire was 04/18/2022. Date of termination was 05/27/2022. Completed Abuse/Neglect, Preventing Slips, Trips, and Falls, Accident Prevention post tests on 04/19/2022. Employee comments from the Employee Disciplinary Report dated 05/24/2022 reflected, I told [Resident #1] that I would lay her down. I went back three different times before I finally laid her down. There was nobody to help me and I told her that. She still insisted I lay her down. I still do not understand why it took so long for her to say this happened. If it happened then why did she not say something right away. I feel like I did nothing wrong. Record review of the facility's Quality Assurance and Performance Improvement plan dated 05/23/2022 reflected Quality Area: Staff performing Hoyer lift without two persons assist and not following the care plan. Performance Improvement Goal: Staff will be in-serviced on Hoyer lift transfers/Staff will be retrained by therapy on proper Hoyer lift techniques/Staff will be in-serviced on neglect/Staff will have Hoyer lift competency checked off. Record review of in-services included: Safe Transfers Techniques dated 05/03/2022 and 05/23/2022 over proper transfer training provided to promote maximum safety for residents and staff. Neglect and Unknown Injury dated 03/22/2022 that included handouts on how to use the Kardex in Point Click Care. Record review of the facility's Checklist for Mechanical Lift, undated, reflected, .Step 5 Pull the Hoyer lift slowly away from the bed. With the other aide guiding the resident, move the lift to where it is needed Record review of the facility's Safe Patient Handling policy, dated 12/30/2005, reflected, The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment, and interventions to provide a comfortable safe transfer, repositioning, and resident movement

Based on observation, interview and record review it was determined that the facility failed to provide the necessary treatment and services to promote healing prevent infection and prevent new sores from developing for 1 of 3 residents reviewed for treatment, services, promote healing and prevent development of new sores. (Resident # 7) The facility failed to accurately and completely assess Resident # 7's left lower extremity (LLE) which was in an immobilizer at admission. This failure resulted in Resident # 7's LLE developing an unstageable pressure ulcer. This failure affected 1 of 4 residents (Resident #7) identified as having a pressure ulcer for not receiving the required services and treatments. This failure had the potential to affect the other 56 residents who are receiving preventive skin care. Findings include: Review of Resident #7's 4/11/17 Admission Record reflected a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the 4/09/17 Skilled Nursing Note at 03:59 (3:59 a.m.) by LVN #3 documented no [MEDICAL CONDITION]. There was not note of immobilizer. Record review of the 4/09/17 Skilled Nursing Note at 12:17 p.m. by LVN # 6 documented no [MEDICAL CONDITION]. There was not note of immobilizer. Record review of the 4/10/17 Skilled Nursing Note at 00:17 (12:17a.m.) by LVN # 3 documented in Section E. Skin/Skin Conditions: .right heel/toes discolored. Massaged with lotion. 1+ [MEDICAL CONDITION] in left ankle/LLE (left lower extremity). There was not note of immobilizer. Record review of the 4/10/17 Skilled Nursing Note at 12:17 a.m. by RN # 1 documented no [MEDICAL CONDITION]. There was not note of immobilizer. Record review of the 4/10/17 Progress Note at 17:12 (5:12 p.m.) documented by ADON # 2 Noted resident with left foot with [MEDICAL CONDITION] and discoloration at heal and at ankle. Non tender to palpation. Able to palpate pedal pulses. Cold to touch There was not note of immobilizer. Record review of the 4/10/17 Skilled Nursing Note at 19:21 (7:21 p.m.) by RN # 2 documented in Section E Skin/Skin conditions - abnormal turgor. Section H. Cardiovascular - [MEDICAL CONDITION] 3+. There was no note of immobilizer. Record review of the 4/11/17 Skilled Nursing Note at 07:21 (7:21 a.m.) documented by RN #1 in Section E Skin/Skin conditions - abnormal skin color and abnormal turgor. Thin skin, bruises, foot is dark in color. Section H. Cardiovascular - [MEDICAL CONDITION] 4+. Left leg and foot. There was no note of immobilizer. Record review of the 4/11/17 Skilled Nursing Note at 19:40 (7:40 p.m.) by RN #1 documented in Section E Skin/Skin conditions - abnormal turgor. Section H. Cardiovascular - [MEDICAL CONDITION] 3+. LLE (left lower extremity). There was no note of immobilizer. In an observation on 4/11/17 at 12:00 p.m. resident # 7 had an immobilizer on her left lower extremity (LLE). Record review of the 4/11/17 Progress Note at 12:55 p.m. by RN #1 documented Left leg in the sling properly and slightly elevated . In an observation on 4/12/17 at 8:05 a.m. resident # 7 had an immobilizer on her left lower extremity (LLE). In an observation on 4/12/17 at 4:55 p.m. resident # 7 had an immobilizer on her left lower extremity (LLE). Resident denied pain to surveyor. Record review of the 4/12/17 Progress Note at 19:00 (7:00 p.m.) by LVN #3 documented . Left knee immobilizer on. 4+ [MEDICAL CONDITION] in Left foot. Pedal pulse present. Left foot/lower extremity turned outward. Old bruising. Appears metal support inside immobilizer has indented skin and rubbed an open sore size 2.5 inches long X 1 inch wide. Notified wound nurse (LVN Treatment Nurse #1). I cleaned with [MEDICATION NAME] and rinsed with NS (normal saline). Padded Dsg (dressing) applied and I padded distal ends for protection In an observation and interview on 4/13/17 at 8:07 a.m. with LVN #3 in Resident # 7's room, surveyor observed left lower extremity immobilizer was lying on the bedside table. When asked LVN # 3 about the immobilizer being off, she said she had called the resident's physician and mobile x-ray ordered due to the 4+ [MEDICAL CONDITION] and the resident's foot was more noticeably pronated outward than the last time she had seen the resident. Surveyor observed resident's left ankle to be swollen and when nurse lifted the leg, surveyor noticed a foam dressing on posterior left calf. When asked LVN # 3 about the dressing, she said she observed an abrasion to the LLE on her previous night shift. In an interview on 4/13/17 at 2:45 p.m. surveyor met Resident #7's daughters, Family member # 1 and Family member #2 in the lobby. When asked if the family members had visited their resident yet, they said no. When asked family members if either of the them had been notified by the facility of their resident having a change in condition with needing an x-ray or having skin breakdown underneath the left lower leg immobilizer, they both said the facility had not called them. Family member # 2 said, 'I did see the 4+ [MEDICAL CONDITION] to the left ankle, yesterday when I was here, I'm a nurse, so I know what the [MEDICAL CONDITION] was, but no one has contacted either of us to notify of x-ray or breakdown. Record review of the 4/13/17 Skilled Nursing Note at 12:10 p.m. by LVN # 6 documented nothing in Section H. Cardiovascular. In an interview on 4/13/17 at 3:50 p.m. with DON, when asked who and when does the facility notify when a resident had a change in condition, he answered, You should notify the doctor, and family members or legal representative when a resident had a change in condition as soon as possible. Record review of the 4/13/17 Progress Note at 05:53 by LVN # 3 documented 0545 Order received from FNP # 1 for Physician # 1. X-ray left tibia due to increased swelling and pain. Hx (history) of displaced Bicondylar tibia fracture. Portable due to right AKA (above knee amputation) Nursing Progress Note did not address to the physician Resident #7 had skin breakdown. Record review of the 4/14/17 Progress Note at 18:52 (6:52 p.m.) by RN #1 documented, Patient family member stated that the patient told her to tell us to stop trying to make her eat. I told her that we had to try but will not force her. We also discussed the brace and it was said that she did not know why we should keep it on her because all its doing is rubbing her and making sores. So at this time we are going to leave the brace off to avoid more skin irritation per family decision. On 4/17/17 at 10:32 a.m. Resident #7 was in bed awake with CNA just tended to Resident # 7's incontinent care. Left leg was floated on a pillow with no brace. Surveyor summoned another RN Surveyor at 10:32 a.m. and both observed wound on posterior LLE with brownish black looking eschar approximately 6 inches with a round quarter size open red area at top of eschar near bend of knee. During an interview on 4/17/17 at 4:07 p.m. with LVN treatment Nurse #1, when asked, when she knew about Resident # 7's abrasion, she answered It wasn't until today (4/17/17) that I saw Resident #7's abrasion had eschar. When asked if she should have noted a brace/immobilizer on the LLE on the initial assessment, she answered Yes. She continued and said we were not to remove the brace. When asked where is that ordered, she did not answer. When asked did any staff inspect underneath the brace, she answered, No, not until LVN #3 saw it on 4/13/17 and discovered the abrasion. When asked what the facility's policy was on doing skin assessments, she answered, weekly. During an interview on 4-17-17 at 4:40 p.m. with LVN treatment Nurse #1, she said they (staff( were told not to take Resident #7's brace off and DON entered the room at that time and asked what the topic of conversation was and DON interjected, No that was not Resident #7, it was another resident. During an interview on 4/18/17 at LVN Treatment Nurse #1 when asked about the conversation yesterday on 4/17/17 at 8:45 a.m., when you heard Resident #7 was not supposed to have the immobilizer removed, what did you do? LVN Treatment Nurse #1 answered, I never actually physically saw an order. I should have questioned the conversation and double checked for an order to clarify. When asked as nurse, what would you do? She answered, I should have questioned it (the conversation) and called the doctor. When asked who saw the abrasion first, she answered LVN # 3. When asked when she first saw Resident # 7, LVN Treatment Nurse #1 said she saw Resident #7 on the first day of admission on 4/7/17. During an interview on 4/18/17 at 2:00 p.m. with DON, when asked about Resident # 7's immobilizer causing an abrasion, DON confirmed the abrasion and nursing assessments were not thoroughly completed, thus; leading to the abrasion, and then the resident's 3+ - 4+ [MEDICAL CONDITION] then caused a pressure sore. Review of the facility submitted CMS 672 form (Resident census and conditions of residents) dated 4/11/17 confirmed a census of 61 with 60 residents receiving preventive skin care.

Based on observations, interviews, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 3 errors observed out of 54 opportunities for errors during the medication pass observations which resulted in a 5% medication error rate. Four staff were observed (Certified Medication Aides #1, 2, 3) and (Licensed Vocational Nurse #1) passing medications on 2 days (5/23 and 5/24/2011), and on 3 of 3 halls (South, East and West). All of the 3 medication errors were observed during 2 different observation times of CMA #1. 1) (CMA #1) gave 100 Milligrams of [MEDICATION NAME] when the order was for 200 Milligrams of [MEDICATION NAME] for resident (#23). 2) (CMA #1) did not administer resident (#22) a Multivitamin with Minerals as ordered. 3) (CMA #1) did not administer resident (#21) [MEDICATION NAME] 40 Milligrams as ordered. Failure to administer medications as prescribed placed these 3 residents (#21, 22 and 23) at risk for not receiving the therapeutic values required to maintain their health and well-being. These failures placed all 85 residents having their medications administered by facility staff at risk for not receiving medications to reach their most therapeutic levels to maintain their health and well-being. The facility identified that CMA #1 could work anywhere in the building depending on whose shift she was covering. The findings included: 1. Observations on 5/24/11 at 8:15 AM revealed that resident (#21) did not receive [MEDICATION NAME] 40 Milligrams. ([MEDICATION NAME] ([MEDICATION NAME]) can be recommended for patients with [MEDICAL CONDITION], liver disease, or a kidney disorder that are also suffering from fluid retention) Internet Medline May 31, 2011) A review of resident (#21's) admission [DIAGNOSES REDACTED]. A review of the resident's physician orders [REDACTED]. A review of the residents (MAR) for March showed that the resident received [MEDICATION NAME] 40 Milligrams daily from his admission on the March 21st through March 31st. He did not receive [MEDICATION NAME] as ordered during April or May of 2011. The [MEDICATION NAME] order had not been transcribed from March to April or to May of 2011. An interview with Family Nurse Practitioner (FNP #1) on 5/24/11 at 11:05 AM revealed that as far as she could remember, resident (#21) was to have been receiving his [MEDICATION NAME]. An interview and record review of resident (#21) with (LVN #1) and on 5/24/11 at 11:05 AM, revealed that the transfer documentation from the previous facility identified that he was to have [MEDICATION NAME] 40 Milligrams for [MEDICAL CONDITION] and that order had never been discontinued. She agreed that the resident had gone for 2 months without his [MEDICATION NAME]. A review of the resident's nursing assessments since his admission on March 21, 2011 revealed that only 1 time (5/21/11) did a staff person document that his skin had been assessed for swelling. At that time the nurse documented that he had 4+ [MEDICAL CONDITION] to the left and right lower extremities. Observation of and interview with resident (#21) on 5/26/11 at 11:30 AM with (LVN #1), revealed that the resident had 2+ and 3+ [MEDICAL CONDITION] to his Left Foot. He had 2+ [MEDICAL CONDITION] to his Right Foot. Resident (#21) stated, "is that why my feet hurt so much?" 2. Observation on 5/24/2011 at 7:40 AM with (CMA #1) revealed that resident (#23) was administered [MEDICATION NAME] 100 Milligrams. A review of the residents Medication orders and Medication Administration Records dated May 2011 identified that the resident was to receive [MEDICATION NAME] 200 Milligrams every day. An interview with (CMA #1) on 5/24/11 at 8:00 AM revealed that she had given only 1 [MEDICATION NAME] (100 Milligrams) and agreed after review of the physician orders [REDACTED]. ([MEDICATION NAME] is used to treat depression). 3. Observation on 5/24/11 at 7:50 AM revealed that (CMA #1) administered sampled resident (#22) 6 medications. During the review of the resident's medication orders and MAR indicated [REDACTED]. This medication was omitted during the 5/24/11 morning medication pass. An interview with (CMA #1) on 5/24/11 at 7:50 AM, revealed that she had not given resident (#22) his Multivitamin with Minerals that morning but had signed the Administration Sheet as having given it. 4. Interview with the DON on 6/9/11 at 9:11 AM revealed for the most part medication aides work the same hall, however when they are called in to cover for absent staff, they could be assigned anywhere in the facility. 5. Interview with (CMA #1) on 5/24/11 at 7:50 AM revealed that she works all of the 3 halls at any given time. A review of the CMS form 672 (Resident Census and Condition of Residents) identified that the census of the facility was 85 residents.