Every finding on record at Meadow Lake Health Center

Based on interviews and record review, the facility failed to immediately notify the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was an accident involving the resident for 1 of 7 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's physician and representative were notified after Resident #1 had a fall. This failure could result in the family or guardian not being aware of conditions that may require them to make medical decisions. Findings included: Record review of a facility face sheet dated 5/15/25 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included atherosclerotic heart disease (condition caused by the buildup of plaque in the arteries, leading to reduced blood flow and increasing the risk for heart attacks and strokes), atrial flutter (abnormal heart rhythm), hypertension (high blood pressure), and dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities). Record review of a comprehensive MDS assessment dated [DATE] for Resident #1 indicated that he had a BIMS score of 6, indicating he had severely impaired cognition. Resident was occasionally incontinent of urine and always incontinent of bowel. Record review of a comprehensive care plan dated 5/10/25 for Resident #1 indicated he had an actual fall on 5/10/25 which resulted in a bruise on his forehead related to unsteady gait. Interventions included: determine and address causative factors of the fall, provide activities that promote exercise and strength building where possible. Record review of a progress note dated 5/10/25 at 8:00 p.m. and signed by LVN A indicated the following: Resident observed on floor in room beside his bed. Vital signs wnl and neuro checks wnl. Resident assisted from floor to bed per this nurse and one staff member. Resident was dressed in non-skid socks at the time. Prior to fall resident was laying in the bed in his room. Resident observed resting in bed prior to fall. Resident assisted from floor to wheelchair X2 staff. Staff continued to monitor resident. During an interview on 5/15/25 at 10:00 a.m. the DON said Resident #1 had a fall and LVN A did not notify the family, physician, or Hospice. The DON said he had not been made aware of the fall until a family member asked him about the bruise to Resident #1's head. DON said LVN A told him she had forgotten to notify anyone. DON said Resident #1 was admitted for 5 days of respite care and was receiving Hospice services. The DON said LVN A should have notified the physician, family, Hospice and himself of the fall . During an interview on 5/19/25 9:45 a.m. the ADON said when a resident had a fall, staff were to assess, check neuro status, observe skin, and see if they were on blood thinners. The ADON said the NP/physician, DON, ADON, family, and Hospice should all be notified. ADON said LVN A did not notify anyone, and all the above should have been notified . During a phone interview on 5/19/25 at 12:07 p.m. LVN A said she had worked in the facility a little over 3 months. LVN A said she was working on Saturday 5/10/25 when Resident #1 had a fall. LVN A said she was called by the aide and went into the room immediately. Resident #1 was sitting upright on the floor by the bed. LVN A said she assessed him, and his vital signs and neuro checks were good. LVN A said Resident #1 was transferred back to the bed. LVN A said she did not see any open areas, skin tears or bruising. LVN A said the bruise to his forehead did not show up until the next day. LVN A said she had forgotten to call the family. It was a complete oversite on my part. I had gotten busy and just forgot. LVN A said she had received previous training on falls, and reporting, and received more training after this incident. LVN A said she knew the doctor, NP, DON, Administrator, ADON, family and Hospice needed to be notified of any falls or other incidents. LVN A said, it was an oversite on my part, and I'm sorry . During a phone interview on 5/19/25 at 1:21 p.m. CNA B said she had worked in the facility almost 2 years. CNA B said she was working the night Resident #1 had a fall. CNA B said Resident #1 told her he was ready for bed around 6:30-7:00 p.m. CNA B said she put Resident #1 to bed and started to do her charting. CNA B said Resident #1's room was right across from where she was charting. CNA B said she heard a noise in his room and ran in. CNA B said Resident #1 was on the floor trying to get up. CNA B said she told Resident #1 to lay down while she got the nurse. CNA B said the nurse came and assessed Resident #1. CNA B said she could not say what he hit, or if he hit anything when he fell . CNA B said she left that night at 9:45 p.m., and there was no bruising noted on Resident #1. CNA B said when she came back to work the next Monday, Resident #1 had a bruise to his forehead. CNA B said she could not remember what side of his head it was on . Record review of a facility policy titled Falls Prevention and Management Program dated 1/1/2016 and revised 9/23/2019 revealed the following: immediately notify the attending physician and family or guardian of condition changes .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #15) reviewed for care plans. The facility failed to ensure Resident #15's care plan reflected diagnoses of infections and the physician's orders for antibiotic therapy. This failure could place residents at risk of not receiving care and services to meet medical and nursing needs. The findings included: Record review of a face sheet dated 08/20/24 indicated Resident #15 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of subdural hemorrhage (bleeding between the brain and the skull), dementia, diabetes mellitus, and MSSA (methicillin-sensitive-staphylococcus aureus) bacteremia (an infection caused by MSSA entering the bloodstream). Diagnoses of urinary tract infection, pneumonia, and obstructive and reflux uropathy (disorder of the urinary tract that obstructs urine flow) were added to the diagnosis list on 01/24/2024. Record review of an MDS quarterly assessment dated [DATE] indicated Resident #15 had a BIMS score of 7 (severely impaired cognition), was incontinent of bowel and bladder, and required substantial to maximum assistance with bathing and hygiene care. Record review of Resident #15's MDS (Section I: Active Diagnoses) dated 04/05/2024 indicated Resident #15 had diagnoses of pneumonia and a urinary tract infection. Record review of Resident #15's MDS (Section N :High Risk Drug Classes) dated 07/06/2024 indicated Resident #15 was receiving an antibiotic with an indication for use. Record review of laboratory results of urine testing on 02/27/2024, 03/29/2024, and 04/26/2024 indicated Resident #15 tested positive for urinary tract infections on all 3 (three) dates. Record review of Resident #15's physician orders since admission indicated Resident #15 had orders dated 02/27/2024 for the antibiotic Macrobid, 02/28/2024 for the antibiotic Cipro, and 03/30/2024 for the antibiotic Omnicef to treat urinary tract infections. An order dated 05/02/2024 indicated Resident #15 was to receive Keflex (an antibiotic) 3 (three) days a week for prophylactic treatment of urinary tract infections on an ongoing basis. Record review of a Medication Administration Record dated August, 2024 indicated Resident #15 was receiving Keflex 3 (three) days a week on Monday, Wednesday, and Friday. Record review of Resident #15's Care Plan dated 08/20/24 indicated the comprehensive care plan was initiated on 01/31/2024 and had not been updated to include actions/interventions to address Resident #15's diagnoses of pneumonia and urinary tract infections nor antibiotic usage since admission. The care plan did not include any concerns nor interventions to address Resident #15's risk for urinary tract infection, actual urinary tract infections, nor past or current use of ongoing prophylactic use of an antibiotic. During an interview with the DON at 03:30 PM on 08/20/2024, he said care plans were completed on admission and updated at least quarterly and as needed. He said Resident #15's care plan should have addressed each of the infections she had incurred and should have been updated to address Resident #15's current antibiotic therapy. The DON said the failure to address these issues in the care plan was an oversight. The DON said the care plans were individualized to each resident and it was important to keep the care plans updated and accurate to ensure a resident's needs and interventions to meet those needs were communicated. He said everyone on the interdisciplinary care plan team was responsible for ensuring care plans were complete. A review of the facility's policy titled Comprehensive Care Plan indicated the following: Procedures 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, g. Incorporate identified problem areas, h. Incorporate risk factors associated with identified problems, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 2 of 16 Residents (Residents #7 and #10) reviewed for abuse and neglect. 1. The facility failed to report an unwitnessed fall to the state agency when Resident #10 was found on the floor with a laceration to the top of her head by a staff member and was sent to the hospital where she received 2 staples. Resident #10 could not state how she fell . 2. The facility failed to report an injury of unknown origin to the state agency when Resident #7 had pain to her right leg and was found to have a fracture. Resident #7 could not state how the fracture occurred. This failure could place residents at risk for abuse, neglect and serious bodily injury by not reporting incidents as required. The findings included: 1. Record review of Resident #10's face sheet, dated 07/19/23, indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (decline in cognitive ability that affects memory, thinking, and behaviors), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking, and the ability to carry out the simplest tasks), anxiety disorder, major depressive disorder, cognitive communication deficit (difficulty with thinking and how someone uses language), and muscle weakness. Record review of Resident #10's MDS, dated [DATE] revealed she was sometimes understood by others and sometimes made herself understood. Resident #10 had impaired vision, unclear speech, and severely impaired cognition. Resident #10 had continuous inattention and disorganized thinking that did not fluctuate. Resident #10 had impairments to both lower extremities and did not walk. Record review of Resident #10's care plan dated 03/10/23 and last reviewed on 07/14/23 indicated she was at risk for falls related to confusion and interventions included to ensure the call light was in reach and encourage to use it for assistance. Resident #10 had behavior problems due to psychosis and interventions included to anticipate and meet the resident's needs. Record review of Resident #10's nursing progress notes dated 06/05/23 at 12:41 p.m. by LVN A, indicated she was laying on the floor with a laceration to the middle of her head. Resident #10 was unable to express how she fell at this time due to mental orientation. The Nurse Practitioner was notified and received an order to send her to the emergency room for sutures/staples. Record review of an Incident Report dated 06/05/23 at 12:15 p.m. by LVN A, indicated Resident #10 had an unwitnessed fall. LVN B found Resident #10 laying on the floor with a laceration to the middle of her head. Resident #10 was unable to express how she fell at this time due to mental orientation. The Nurse Practitioner was notified and received an order to send her to the emergency room for sutures/staples. Record review of Resident #10's nursing progress notes dated 06/05/23 at 5:44 p.m. by the DON, indicated she returned back to the facility after a laceration repair and had two staples to her scalp. Record review of Resident #10's Emergency Department Records dated 06/05/23, indicated she had a fall and was diagnosed with a laceration to her scalp. She had a laceration repair with staples. The doctor closed the cut on her skin with a special kind of metal staples. During an interview on 07/19/23 at 1:32 PM, LVN A said she was notified on 06/05/23 by an unknown CNA that Resident #10 was laying on the floor of her room. LVN A said she went to Resident #10's room immediately to assess her. LVN A said Resident #10 had blood on the top of her head with a laceration and provided first aid to her. LVN A said LVN A said she notified the physician and DON, and Resident #10 was sent to the Emergency Department. LVN A said when Resident #10 returned back to the facility she had 2 staples in her head. LVN A said Resident #10 was unable to explain how the injury occurred and there were no witnesses. LVN A said she had been trained on abuse, neglect, and exploitation and she reported any allegations to the Administrator, who is the abuse coordinator. During an interview on 07/19/23 at 1:47 PM, the DON said he was notified on 06/05/23 by LVN A Resident #10 had a laceration to her head. The DON said Resident #10 was sent to the Emergency Department and returned back to the facility with 2 staples in her head. The DON said he notified the Administrator, who is the Abuse Coordinator, immediately after Resident #10 had returned. The DON said Resident #10 was unable to explain how the injury occurred and there were no witnesses. The DON said he interviewed staff that had recently worked with her but did not document their statements. The DON said the incident report was the only documentation there was on Resident #10's injury. The DON said he was not sure why the incident was not self-reported to the State as it should have been, but believed the Administrator would have done so. The DON said he did not follow up with the Administrator to see if he had reported it to the State Agency. During an interview on 07/19/23 at 2:24 PM, the Administrator said he had worked at the facility for about 2 months and was the Abuse Coordinator and. The Administrator said he expected all staff to report allegations of abuse, neglect, injuries of unknown origin, and injuries causing serious bodily injury. The Administrator said he was responsible for investigating allegations and reporting it to the State Agency. The Administrator said he was unaware Resident #1 sustained a laceration to her head that required 2 staples to repair it. The Administrator said he did not investigate or report Resident #10's injury to the State Agency and it should have to rule out the possibility of abuse or neglect. The Administrator said he would have investigated and reported Resident #10's injury to the State Agency if he had known. The Administrator said he was not notified of Resident #10's injury or recall the DON telling him about it. 2. Record review of Resident #7's face sheet, dated 07/19/23, indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (decline in cognitive ability that affects memory, thinking, and behaviors), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking, and the ability to carry out the simplest tasks), anxiety disorder, major depressive disorder, and how someone uses language), and age-related osteoporosis. Record review of Resident #7's MDS, dated [DATE] revealed she was rarely understood by others and rarely made herself understood. Resident #7 had impaired vision, unclear speech, short and long-term memory problems and severely impaired decision making. Resident #7 required extensive one-person assistance with dressing, toileting, personal hygiene and was totally dependent on staff with bathing requiring one-person assistance. Resident #7 did not walk. Record review of Resident #7's care plan dated 03/10/23 and last reviewed on 07/14/23 indicated she had an ADL self-care performance deficit related to dementia, poor balance and interventions included one-person staff assistance with bed mobility, dressing, personal hygiene, toileting and a one-two person assistance with transfers. Record review of Resident #7's nursing progress notes dated 06/09/23 at 10:38 a.m. by LVN B, indicated she had pain in her right hip. Resident #7's right hip was swollen and warm to touch. LVN B notified the hospice nurse and physician and received an order for a right hip x-ray. Record review of Resident #7's nursing progress notes dated 06/09/23 at 4:20 p.m. by LVN B, indicated she notified the physician the x-ray results showed the resident had a pathological fracture of the right femur (thigh bone). Record review of Resident #7's x-ray results dated 06/09/23 indicated she had a non-displaced fracture (bone breaks in one place and does not move) with mild angulation (axis of bone is slightly altered pointing off in a different direction) of the femoral neck (upper portion of thigh bone just below the ball part of the ball and socket joint) of indeterminate age. Record review of an Incident Report dated 06/09/23 at 4:25 p.m. by the DON, indicated Resident #7 had an injury of unknown origin. The resident was crying and holding her right leg showing signs of pain. Resident #7 was unable to explain what happened and there were no witnesses. An x-ray was ordered, and the results indicated she had a non-displaced fracture (bone breaks in one place and does not move) with mild angulation (axis of bone is slightly altered pointing off in a different direction) of the femoral neck (upper portion of thigh bone just below the ball part of the ball and socket joint) of indeterminate age. During an interview on 07/19/23 at 1:47 PM, the DON said he was notified on 06/09/23 by LVN B Resident #7 had pain in her right leg and he assessed her. The DON said Resident #7 was holding her right upper leg grimacing in pain and he notified the physician. The DON said he received an ordered for an x-ray of Resident #7's right hip and the results showed she had a right leg fracture. The DON said he called the physician who told him that Resident #7's fracture was pathological (caused by the physical condition or disease) due to her osteoporosis (a condition when bone strength weakens and is susceptible to fracture). The DON said he notified the Administrator, and the both of them had a conference call with the corporate office about Resident #7's fracture and reporting it to the State Agency. The DON said the corporate office determined Resident #7's fracture did not meet the State Agency reporting guidelines because the physician indicated the fracture was pathological. The DON said the facility did not investigate Resident #7's fracture or report it to the State Agency. The DON said a resident with osteoporosis could sustain a fracture during ADL care if a staff member provided them care in a rough manner. The DON said a resident is at risk of abuse or neglect if an injury of unknown is not investigated and reported to the State agency and Resident #7's fracture should have been. During an interview on 07/19/23 at 2:24 PM, the Administrator said on 06/09/23 the DON notified him Resident #7 had a fracture to her right leg. The Administrator said he and the DON had a conference call with the corporate office about Resident #7's fracture and reporting it to the State Agency. The Administrator said the corporate office determined Resident #7's fracture did not meet the State Agency reporting guidelines because the physician indicated the fracture was pathological. The Administrator said he did not investigate Resident #7's fracture or report it to the State Agency. The Administrator said a resident is at risk of abuse or neglect if an injury of unknown is not investigated and reported to the State agency and Resident #7's fracture should have been. Record review of the facility's Abuse, Neglect, Exploitation and Reporting Requirements policy revised on 09/08/22 indicated, .If a covered individual reasonably suspects that a crime has occurred against a resident or person receiving care in the Health Center, the individual must report the suspicion to the Abuse and/or Neglect Coordinating and follow the Federal/State regulations. If the suspected crime involves serious bodily injury, the incident must be reported within 2 hours .or defined by state regulations . Record review of the facility's Fall Prevention and Management Program policy revised on 09/23/19 indicated, .Fall Types: Categorizing fall-related incidents by types helps to analyze fall related events .Unwitnessed fall: A fall that occurs unseen by staff or others .Any injury related to an unwitnessed fall should be reviewed for possible resident abuse .Documentation and Follow-up .3. Complete internal and external notification and reporting requirements, including to applicable licensing agencies .Reporting and Notification .4. Time frame to notify State Agency: Per state regulatory reporting requirements .

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse and neglect are thoroughly investigated and report the results of all investigations to the State Survey Agency, within 5 working days of the incident for 2 of 16 Residents (Residents #7 and #10) reviewed for investigating abuse and neglect. 1. The facility failed to investigate or report the results to the State Survey Agency when Resident #10 was found on the floor with a laceration to the top of her head and was sent to the hospital where she received 2 staples. Resident #10 could not state how she fell . 2. The facility failed to investigate or report the results to the State Survey Agency when Resident #7 had pain to her right leg and was found to have a fracture. Resident #7 could not state how the fracture occurred. This failure could place the residents at risk for abuse and neglect by not reporting the results of investigated incidents as required. The findings included: 1. Record review of Resident #10's face sheet, dated 07/19/23, indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (decline in cognitive ability that affects memory, thinking, and behaviors), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking, and the ability to carry out the simplest tasks), anxiety disorder, major depressive disorder, cognitive communication deficit (difficulty with thinking and how someone uses language), and muscle weakness. Record review of Resident #10's MDS, dated [DATE] revealed she was sometimes understood by others and sometimes made herself understood. Resident #10 had impaired vision, unclear speech, and severely impaired cognition. Resident #10 had continuous inattention and disorganized thinking that did not fluctuate. Resident #10 had impairments to both lower extremities and did not walk. Record review of Resident #10's care plan dated 03/10/23 and last reviewed on 07/14/23 indicated she was at risk for falls related to confusion and interventions included to ensure the call light was in reach and encourage to use it for assistance. Resident #10 had behavior problems due to psychosis and interventions included to anticipate and meet the resident's needs. Record review of Resident #10's nursing progress notes dated 06/05/23 at 12:41 p.m. by LVN A, indicated she was laying on the floor with a laceration to the middle of her head. Resident #10 was unable to express how she fell at this time due to mental orientation. The Nurse Practitioner was notified and received an order to send her to the emergency room for sutures/staples. Record review of an Incident Report dated 06/05/23 at 12:15 p.m. by LVN A, indicated Resident #10 had an unwitnessed fall. LVN B found Resident #10 laying on the floor with a laceration to the middle of her head. Resident #10 was unable to express how she fell at this time due to mental orientation. The Nurse Practitioner was notified and received an order to send her to the emergency room for sutures/staples. Record review of Resident #10's nursing progress notes dated 06/05/23 at 5:44 p.m. by the DON, indicated she returned back to the facility after a laceration repair and had two staples to her scalp. Record review of Resident #10's Emergency Department Records dated 06/05/23, indicated she had a fall and was diagnosed with a laceration to her scalp. She had a laceration repair with staples. The doctor closed the cut on her skin with a special kind of metal staples. During an interview on 07/19/23 at 1:32 PM, LVN A said she was notified on 06/05/23 by an unknown CNA that Resident #10 was laying on the floor of her room. LVN A said she went to Resident #10's room immediately to assess her. LVN A said Resident #10 had blood on the top of her head with a laceration and she provided first aid to her. LVN A said she notified the physician and the DON, and Resident #10 was sent to the Emergency Department. LVN A said when Resident #10 returned back to the facility she had 2 staples in her head. LVN A said Resident #10 was unable to explain how the injury occurred and there were no witnesses. LVN A said she had been trained on abuse, neglect, and exploitation and she reported any allegations to the Administrator, who is the abuse coordinator. During an interview on 07/19/23 at 1:47 PM, the DON said he was notified on 06/05/23 by LVN A Resident #7 had a laceration to her head. The DON said Resident #10 was sent to the Emergency Department and returned back to the facility with 2 staples in her head. The DON said he notified the Administrator, who is the Abuse Coordinator, immediately after Resident #10 had returned. The DON said Resident #10 was unable to explain how the injury occurred and there were no witnesses. The DON said he interviewed staff that had recently worked with her but did not document their statements. The DON said the incident report was the only documentation there was on Resident #10's injury. During an interview on 07/19/23 at 2:24 PM, the Administrator said had worked at the facility for about 2 months and was the Abuse Coordinator. The Administrator said he was responsible for investigating allegations and reporting it to the State Agency. The Administrator said he was unaware Resident #10 sustained a laceration to her head that required 2 staples to repair it. The Administrator said he would have investigated and reported Resident #10's injury to the State Agency if he had known. The Administrator said he was not notified of Resident #10's injury or recall the DON telling him about it. The Administrator said staff members should immediately report allegations of abuse, neglect, injuries of unknown origin, and injuries causing serious bodily injury to him or the DON to rule out the possibility of abuse or neglect. The Administrator said he did not investigate Resident #10's injury to the State Agency and it should have. 2. Record review of Resident #7's face sheet, dated 07/19/23, indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (decline in cognitive ability that affects memory, thinking, and behaviors), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking, and the ability to carry out the simplest tasks), anxiety disorder, major depressive disorder, and how someone uses language), and age-related osteoporosis. Record review of Resident #7's MDS, dated [DATE] revealed she was rarely understood by others and rarely made herself understood. Resident #7 had impaired vision, unclear speech, short and long-term memory problems and severely impaired decision making. Resident #7 required extensive one-person assistance with dressing, toileting, personal hygiene and was totally dependent on staff with bathing requiring one-person assistance. Resident #7 did not walk. Record review of Resident #7's care plan dated 03/10/23 and last reviewed on 07/14/23 indicated she had an ADL self-care performance deficit related to dementia, poor balance and interventions included one-person staff assistance with bed mobility, dressing, personal hygiene, toileting and a one-two person assistance with transfers. Record review of Resident #7's nursing progress notes dated 06/09/23 at 10:38 a.m. by LVN B, indicated she had pain in her right hip. Resident #7's right hip was swollen and warm to touch. LVN B notified the hospice nurse and physician and received an order for a right hip x-ray. Record review of Resident #7's nursing progress notes dated 06/09/23 at 4:20 p.m. by LVN B, indicated she notified the physician the x-ray results showed the resident had a pathological fracture of the right femur (thigh bone). Record review of Resident #7's x-ray results dated 06/09/23 indicated she had a non-displaced fracture (bone breaks in one place and does not move) with mild angulation (axis of bone is slightly altered pointing off in a different direction) of the femoral neck (upper portion of thigh bone just below the ball part of the ball and socket joint) of indeterminate age. Record review of an Incident Report dated 06/09/23 at 4:25 p.m. by the DON, indicated Resident #7 had an injury of unknown origin. The resident was crying and holding her right leg showing signs of pain. Resident #7 was unable to explain what happened and there were no witnesses. An x-ray was order and the results indicated she had a non-displaced fracture (bone breaks in one place and does not move) with mild angulation (axis of bone is slightly altered pointing off in a different direction) of the femoral neck (upper portion of thigh bone just below the ball part of the ball and socket joint) of indeterminate age. During an interview on 07/19/23 at 1:47 PM, the DON said he was notified on 06/09/23 by LVN B Resident #7 had pain in her right leg and he assessed her. The DON said Resident #7 was holding her right upper leg grimacing in pain and he notified the physician. The DON said he received an ordered for an x-ray of Resident #7's right hip and the results showed she had a right leg fracture. The DON said he called the physician who told him that Resident #7's fracture was pathological (caused by the physical condition or disease) due to her osteoporosis (a condition when bone strength weakens and is susceptible to fracture). The DON said the facility did not investigate Resident #7's fracture. The DON said a resident is at risk of abuse or neglect if an injury of unknown is not investigated and Resident #7's fracture should have been investigated. During an interview on 07/19/23 at 2:24 PM, the Administrator said on 06/09/23 the DON notified him Resident #7 had a fracture to her right leg. The Administrator said he and the DON had a conference call with the corporate office to discuss Resident #2's fracture. The Administrator said he did not investigate Resident #7's fracture or report it to the State Agency because they all concluded it did not meet the State Agency guidelines. The Administrator said a resident is at risk of abuse or neglect if an injury of unknown is not investigated and Resident #7's fracture should have been investigated. Record review of the facility's Abuse, Neglect, Exploitation and Reporting Requirements policy revised on 09/08/22 indicated, .If a covered individual reasonably suspects that a crime has occurred against a resident or person receiving care in the Health Center, the individual must report the suspicion to the Abuse and/or Neglect Coordinating and follow the Federal/State regulations. If the suspected crime involves serious bodily injury, the incident must be reported within 2 hours .or defined by state regulations .

Based on interview and record review, the facility failed to ensure the facility's Quality Assessment and Assurance Committee met quarterly, for 1 of 1 facility, reviewed for QAA/QAPI. The facility failed to ensure the QAA/QAPI met for the 2nd quarter (April, May, June) and the 3rd quarter (July, August, September) during 2021, to address identified issues. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months of April 2021 through September 2021 revealed, no documentation to indicate the facility held QAA/QAPI meetings during the 2nd and 3rd quarter period. There were no signature logs for any QAA/QAPI Committee meetings. During an interview on 06/15/2022 at 2:09 PM, the Administrator said she was not the Administrator during the 2nd quarter and could not find any documentation that a meeting was conducted. She said they did not meet during the 3rd quarter because she was distracted. Review of the facility's: Quality Assurance and Performance Improvement - Governance and Leadership Policy (revised March 2020) revealed, Policy Interpretation and Implementation: The Administrator, weather a member of the QAPI committee or not, is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. 7. The committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time and location at least two business days prior to the meeting.

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission, for 1 of 1 resident reviewed for the base line care plans. (Resident # 176) The facility did not complete a baseline care plan within 48 hours of admission for Resident #176. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events. Findings included: A fact sheet dated June 2022, indicated Resident #176 was a [AGE] year-old male who admitted on [DATE] with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the clinical record from 06/04/2022 to 06/13/2022 for resident Resident#176, indicated he did not have a baseline care plan. During an interview on 6/15/22 at 11:02 p.m., the DON said the weekend nurse was responsible for completing the base line care plan, but he missed it. The DON said if the nurse misses it, it would be his responsibility to catch it. He said he should have caught it. The facility's Care Plan - Baseline, Policy Statement (revised December 2016) indicated A baseline care plan to meet the Resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation: 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 4. The Resident and their representative will be provided a summary of the baseline care plan that includes, but is not limited to the following, b. A summary of the resident's medication and dietary instructions.

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission and provide the resident and or the resident representative with a summary of the baseline care plan for 9 of 12 residents reviewed for the base line care plans. (Resident #s 11, 14, 18, 19, 71, 120, 170, 171, and 172) The facility did not complete a baseline care plan within 48 hours of admission for Resident #s 11, 14, 18, 19, 71, 120, 170, 171, and 172. The facility did not provide a written summary of the baseline care plan to Resident #s 11, 14, 18, 19, 71, 120, 170, 171, and 172 or their responsible party. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events. Findings included: 1) A physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated 4/30/21 for Resident #170 did not include initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #170 from 04/30/21 through 05/12/21 did not provide a signed written/oral summary of the baseline care plan. 2) A physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated 5/4/21 for Resident #171 did not include initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #171 from 5/4/21 through 05/12/21 did not provide a signed written/oral summary of the baseline care plan. 3) A physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated 5/8/21 for Resident #172 did not include initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #172 from 5/8/21 through 05/12/21 did not provide a signed written/oral summary of the baseline care plan. 4). Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated 04/14/21 for Resident #11 did not include initial goals or interventions based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #11 from 04/14/21 through 05/12/21 did not provide a signed written/oral summary of the baseline care plan. 5). Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated 04/28/21 for Resident #19 did not include initial goals or interventions based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #19 from 04/28/21 through 05/12/21 did not provide a signed written/oral summary of the baseline care plan. 6). Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated 04/30/21 for Resident #71 did not include initial goals or interventions based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #71 from 04/30/21 through 05/12/21 did not provide a signed written/oral summary of the baseline care plan. 7) A face sheet printed 5/12/21 indicated Resident #14 was an [AGE] year-old male, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated 7/13/20 for Resident #14 did not include initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #14 from 7/13/20 through 05/12/21 did not provide a signed written/oral summary of the baseline care plan. 8) A face sheet printed on 5/12/21 indicated Resident #18 was an [AGE] year-old female, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated10/19/20 for Resident #18 did not include initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #18 from 10/19/20 through 05/12/21 did not provide a signed written/oral summary of the baseline care plan. 9) A face sheet printed on 5/12/21 indicated Resident #120 was a [AGE] year-old female, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan dated 2/22/21 for Resident #120 did not include initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #120 from 2/22/21 through 05/12/21 did not provide a signed written/oral summary of the baseline care plan. During an interview on 5/12/21 at 11:21 am the DON said the charge nurse/admitting nurse on duty at time of admission was responsible for completing the baseline care plan within 48 hours of admission. During an interview on 5/12/21 at 11:37 am LVN A said she was a charge nurse and if a new admission was admitted during her shift then she was responsible for completing the baseline care plans. She said she used the form provided in their system and answer the questions using the resident or resident's family responses. She said she did not ask for signatures, nor provided residents or resident's family a copy. During an interview on 5/12/21 at 12:14 pm the DON said she was not aware the baseline care plans was to include initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the information was on the comprehensive care plans, but not on their baseline care plans. She said they did not print off care plan because it was in the electronic chart. DON said they did not provide resident or family with a copy, but if a resident's family member asked for a copy, she would provide a copy. DON said the baseline care plans are computer generated and back in April 2020 they changed systems and she never reviewed the new baseline care plans nor checked for accuracy. A revised Baseline Care Plan policy dated December 2016 stated A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation: 1) To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2) The Interdisciplinary Team will review the healthcare practitioner's orders (dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a) initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .4) The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a) The initial goals of the resident; b)a summary of the resident's medications and dietary instructions; c) any services and treatments to be administered by the facility and personnel acting on behalf of the facility ; and d) any updated information based on the details of the comprehensive care plan, as necessary.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, based on the comprehensive assessment for 3 of 4 residents reviewed for care. (Resident #s 2, 7, 14, and 171) The facility failed to ensure antibiotic therapy was initiated in a timely manner for Resident #s 171, 14, 7, and 2. This failure could place residents at risk for worsening infections resulting in decline in health, hospitalization , or death. Findings included: 1. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital Discharge Instructions dated 05/04/21 indicated Resident #171 was to receive [MEDICATION(S)] 500 mg twice daily for 5 days with a start date of 05/04/21 and stop date of 05/09/21. A Clinical Admission Evaluation note dated 05/04/21 at 04:15 p.m. indicated Resident #171 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/04/21 at 06:03 p.m. indicated she was to receive [MEDICATION(S)] 500mg twice daily for 5 days for [CONDITION(S)]. The May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 05/12/21 at 01:04 p.m. the DON/IP said Resident #171 should have received an initial dose of the antibiotic on 05/04/21 and not until the next morning. A copy of the pharmacy EKit (emergency medications) Contents list provided by the DON on 05/12/21 at 02:21 p.m. indicated [MEDICATION(S)] 500mg with quantity of 4 available. 2. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital Discharge Instructions dated 04/24/21 indicated Resident #14 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 05/12/21 at 01:03 p.m. the DON/IP said Resident #14 should have received a dose of [MEDICATION(S)]-[MEDICATION(S)] when due. A copy of the pharmacy EKit Contents list provided by the DON on 05/12/21 at 02:21 p.m. indicated [MEDICATION(S)]-[MEDICATION(S)] 400mg-80mg with quantity of 2 available. 3. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital Discharge Summary dated 11/23/20 indicated Resident #7 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 11/23/20 at 10:36 p.m. indicated Resident #7 arrived at the facility. The November 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 05/12/21 at 12:58 p.m. the DON/IP said she was not sure if [MEDICATION(S)] 100mg was in the EKit. She said Resident #7 should have received the initial dose prior to 07:00 pm the next day. 4. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital emergency room (ER) Discharge Instructions dated 08/19/20 indicated Resident #7 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The August 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 05/12/21 at 12:58 p.m. the DON/IP said Resident #7 should have received the second dose on the same day. A copy of the pharmacy EKit (emergency medications) Contents list provided by the DON on 05/12/21 at 02:21 p.m. indicated [MEDICATION(S)] 100mg with quantity of 6 available. During an interview on 05/12/21 at 01:10 p.m. the DON said all nurses had access to the Ekit. She said when the Ekit was opened a slip was filled out as to which medication was given to which resident and put in the Ekit, the Ekit was resealed, and the pharmacy was notified of a replacement needed. She said as far as she knew the pharmacy always had the same amount of medication in the Ekit. 5. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A laboratory report dated 06/07/20 indicated Resident #2 had a [CONDITION(S)] and the culture with sensitivity indicated which antibiotics were appropriate. A hand-written note on the report indicated it had been scanned to the physician with the initials of the DON and former DON. Nurse notes for 06/07/20 through 06/09/20 had no indication Resident #2's physician was contacted to follow up with the laboratory report. An order dated 06/10/20 indicated Resident #2 was to receive [MEDICATION(S)] 875mg-125mg twice daily for 7 days for [CONDITION(S)]. The June 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 05/12/21 at 12:58 p.m. the DON/IP said Resident #2's laboratory report should have been followed up and an antibiotic ordered and administered on 06/07/20 not 3 days later. She said the initials on the lab report were hers and the former ADON. She said she should have ensured it followed up. An Antibiotic Stewardship-Orders for Antibiotics policy revised 12/2016 indicated .Policy Interpretation and Implementation: 5. If a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders 7. When a culture and sensitivity (C&S) is ordered, it will be completed, and: a. lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued 10. Before a nurse removes an antibiotic from the emergency supply of medication, he or she will check for the right drug, right strength, allergy information and the use of [MEDICATION(S)], along with the following: b. The pharmacy removal slip for the dose(s) removed will be completed; and c. The use will be reported to the infection preventionist.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 3 residents observed for medication pass. (Resident #14) LVN A did not administer all of Resident #14's medications during medication pass. This failure could place residents at risk of not receiving necessary medications, not receiving the intended therapeutic benefits of their medications, and a decline in health. Findings included: Physician orders for May 2021 indicated Resident #14 was an [AGE] year-old male, admitted on [DATE] with diagnoses including abnormal heart rhythm in the heart's upper chambers, decreased pumping of the heart muscle, and high blood pressure. During an observation on 05/11/21 at 07:30 a.m. LVN A administered medications to Resident #14. Resident #14's blood pressure (BP) and heart rate (Pulse) were checked prior to medication administration. The blood pressure was 121/59 and the heart rate was 70. LVN A did not administer [MEDICATION(S)] 25mg or [MEDICATION(S)] 30mg. Medication reconciliation indicated an order dated 04/13/21 indicated Resident #14 was to receive [MEDICATION(S)] 30mg for high blood pressure with parameters to hold the medication if the top number of the blood pressure was less than 100, the bottom number of the blood pressure was less than 60, or the heart rate was less than 60 and [MEDICATION(S)] 25mg for high blood pressure. There was no indication to hold the [MEDICATION(S)] for any set parameters. The May 2021 MAR for Resident #14 indicated a code of 4 was vitals outside of parameters and Resident #14's [MEDICATION(S)] was not administered: * the 08:00 a.m. dose on 05/02, the BP was 98/65 and the pulse was 66; * the 08:00 a.m. dose on 05/08, the BP was 82/58 and the pulse was 72; * the 08:00 a.m. dose on 05/09, the BP was 73/51 and the pulse was 70; * the 08:00 a.m. dose on 05/11, the BP was 121/59 and the pulse was 70. During an interview and record review on 05/12/21 at 01:27 p.m. LVN A said she held Resident #14's blood pressure medications on 05/11/21 due to the lower blood pressure number was 59. LVN A said she had held the medication previously when his blood pressure was low. LVN A said she should have checked the order and either given the medication or notified the physician of her holding it to clarify if they wanted it to be given. During an interview on 05/12/21 01:28 p.m. the DON said medications were to be given unless there was a parameter to hold. She said the physician was to be notified and determine if he wanted the medication held when the BP or pulse was low. A Medication Administration policy was requested and not provided.

Based on interview and record review the facility failed to ensure the right to formulate an advance directive was provided for 1 of 8 residents reviewed for advanced directives with an Out of Hospital-Do Not Resuscitate (OOH-DNR). (Resident #11) -The facility did not have a valid OOH-DNR form for Resident #11. This failure could place residents at risk of lifesaving procedures performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 04/20/21 indicated the resident had a code status of DNR. An OOH-DNR dated 04/19/21 indicated Resident #11 had no physician printed name, license number, or date the physician signed the form documented. During an interview on 05/12/21 at 01:20 p.m. LVN A said the SW usually did the DNR forms. She said the DNR should be complete. She said a resident would be considered a full code with an incomplete DNR form. During an interview on 05/12/21 at 01:23 p.m. the DON said the SW was responsible for the DNR forms. She said an OOH-DNR should have the complete information of the physician otherwise it was not active. She said Resident #11 would be considered a full code. She said Resident #11 could have all lifesaving procedures conducted to save her life. A Filling out the Out-of-Hospital Do-Not-Resuscitate Form accessed on 05/12/21 at http://dshs.texas.gov/emstraumasystems/dnr.shtm#form indicated: * Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. The SW was attempted notification but was not available. A DNR policy was requested and not provided.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 13 residents reviewed for accuracy of MDS assessments. (Resident #10). The facility did not accurately code Resident #10's MDSs for an anticoagulant medication. This failure could place the residents at risk of not receiving adequate care and services to meet their needs. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of revised care plan dated 3/25/21 indicated Resident #10 was on anticoagulant therapy ([MEDICATION(S)] and Aspirin). Goal: Resident will be free from discomfort or adverse reactions related to anticoagulant. Interventions: administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness Q-shift. Record Review of admission MDS dated [DATE] for Resident #10 indicated in Section N0410 Medication Received - Indicate the number of days the resident received the following medications by pharmacological classification during the last 7 days. Information entered indicated Resident #10 received seven anticoagulant for seven days and not zero. During an interview on 5/12/21 at 11:22am DON said the anticoagulant Resident #10 was taking was [MEDICATION(S)] and Aspirin. Surveyor explained [MEDICATION(S)] and aspirin were not anticoagulant and DON said she thought anything that increase the risk for bleeding was considered an anticoagulant. During an interview on 5/12/21 at 2:20pm DON said a license nurse enters and generates the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . DON said she was not aware how the MDS coded the medications on the MDS but expect for them to go by the MDS guidelines She said the current MDS staff was an interim and had only been with them a week. During an interview on 5/12/21 at 2:29pm Interim MDS Coordinator said she had been there for 6 days. She said the medications [MEDICATION(S)] and Aspirin are not considered anticoagulants on the MDS. Interim MDS Coordinator said Resident #10 MDS was incorrect because he was not receiving anticoagulants. She said she went by the MDS RAI manual.

Based on observation, interview, and record review, the facility failed to make the most recent survey results available for examination in a place readily accessible to residents and the public in the facility. The facility did not make available the most recent survey results. The facility failed to post a notice of the availability of such reports in areas of the facility. This failure could affect residents, resident family members, resident representatives, and members of the public by placing them at risk of a lack of awareness of facility survey and investigation results. Findings included: During a group meeting on 5/11/21 at 9:30 a.m. 4 of 4 residents said they did not know where the latest survey inspection reports were located. All four of the residents said they were not aware the inspection report was available for public view. (Resident #s 10, 170, 171, and 172). During an observation on 5/11/21 at 11:32 a.m. in the front lobby a white binder located on shelf along the wall outside the therapy entrance was a white binder with a cover page titled State Survey Activity- current 2567 and plan of correction indicated there were no results from investigations done since the last inspection on 02/08/19 (missing the following: 9/26/19; 2/18/20; 4/15/20; 7/02/20; 7/13/20; 2/18/20; 4/15/20; 7/13/20-; and 9/03/20). The book only included 2019, 2018 and 2017 full book survey. During an interview on 5/11/21 at 3:21 p.m. Administrator said she only added survey results that were cited, and not incidents or non-cited visits. She said she did not know she was to add all visits. Administrator said there was no sign available indicating location of survey book. Administrator asked a receptionist in the lobby if they knew where the state survey book was located, and receptionist was not aware what the state survey book was or where to locate a state survey book. The administrator said she was the one who was responsible for updated the survey book.

Based on interview and record review, the facility failed to ensure medications were administered accurately for 6 of 6 residents reviewed for pharmacy services. (Resident #s 1, 2, 3, 4, 5, and 6) The facility did not administer medications as ordered for Resident #s 1, 2, 3, 4, 5, and 6. This failure could place residents at risk of not receiving the full therapeutic benefit of their medications. Findings included: 1. A face sheet dated 02/18/20 indicated Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A baseline care plan dated 02/10/20 indicated Resident #1 was ordered medications by her physician. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had severely impaired cognition, made her needs known, and understood others. She required extensive assistance with ADLs. She was incontinent of bowel and bladder. She received antipsychotic, anticoagulant (blood thinner), opioid, and antidepressant medications since admission. Physician orders [REDACTED]. *[MEDICATION NAME] 5mg-325mg (pain) ordered 0[DATE] and scheduled twice a day at 8:00 a.m. and 8:00 p.m., *[MEDICATION NAME] 100mg (constipation) ordered 02/07/20 and scheduled twice a day at 8:00 a.m. and 8:00 p.m.; *[MEDICATION NAME] 50mg (high blood pressure) ordered 02/07/20 scheduled twice a day at 8:00 a.m. and 8:00 p.m.; *[MEDICATION NAME] 3ml nebulizer (shortness of breath) ordered 02/07/20 and scheduled three times a day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. A Medication Administration Record [REDACTED] *[MEDICATION NAME] 5mg-325mg - administered at 11:00 a.m. (3 hours after scheduled dose), *[MEDICATION NAME] 100mg - administered at 12:14 p.m. (4 hours and 14 minutes after scheduled dose), *[MEDICATION NAME] 50mg - administered at 12:14 p.m. (3 hours and 14 minutes after scheduled dose), and *[MEDICATION NAME] 3ml nebulizer - administered at 1:00 p.m. (missed 8 a.m. dose). During an interview on 02/18/20 at 4:27 p.m., Resident #1's daughter said she visited her mother daily and was at the facility on 02/15/20. She said the facility does not have enough staff most days, she said on 02/15/20 her mother's medications were administered several hours late. She said her mother had pneumonia and she had a breathing treatment scheduled at 8:00 a.m., she said at 11:00 a.m., Resident #1 still had not received her breathing treatment, pain pill, or any other medications. Resident #1's daughter said about 11:00 a.m., she asked RN A about Resident #1 getting her pain pill and breathing treatment. She said around 11:45 a.m., RN A administered Resident #1's pain pill. She said about 45 minutes later, RN A administered Resident #1's breathing treatment and the rest of her morning medications. Resident #1's daughter said she texted the ADON and DON on the morning of 02/15/20 regarding her mother's late medications. She said the ADON did not respond at all and the DON said she was on vacation. She said the administrator called her and told her that a CNA did not show up to work and the MA had to go to the pod (unit of the nursing facility separate from other units and the nursing station) while the nurse administered medications. She said it was very frustrating because her mother's medications should have been administered when they were scheduled. 2. A face sheet dated 02/18/20 indicated Resident #2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 0[DATE] indicated Resident #2 would have pain control and staff should monitor for increased pain and administer medications. An MDS dated [DATE] indicated Resident #2 was cognitively intact, made her needs known, and understood others. She required assistance with ADLs. She was occasionally incontinent of bowel and bladder. Physician orders [REDACTED]. *[MEDICATION NAME] 200mg (arthritis) ordered 0[DATE] and scheduled twice a day at 8:00 a.m. and 5:00 p.m.; *[MEDICATION NAME] 3.125mg (heart failure and hypertension) ordered 0[DATE] and scheduled twice a day at 9:00 a.m. and 5:00 p.m.; A MAR indicated [REDACTED] *[MEDICATION NAME] 200mg- administered at 2:46 p.m. (6 hours and 46 minutes after the scheduled time, and *[MEDICATION NAME] 3.125mg - administered at 2:41 p.m. (5 hours and 41 minutes after scheduled time). During an interview on 02/18/20 at 4:16 p.m., Resident #2 said her morning medications were administered several hours late on 02/15/20. She said she knew the staff was very busy because they did not have enough staff working that day. Resident #2 said she finally did receive her morning medications, but it was the middle of the afternoon before she received them. The website www.drugs.com accessed 2/18/20 indicated the following: * take [MEDICATION NAME] exactly as prescribed by your doctor. Follow all directions on your prescription label. Skip the missed dose if it is almost time for your next scheduled dose. Do not take extra medicine to make up the missed dose. *Take [MEDICATION NAME] exactly as prescribed by your doctor. Follow all directions on your prescription label and read all medication guides or instruction sheets. Your doctor may occasionally change your dose. [MEDICATION NAME] works best if you take it with food, at the same time every day. Take the medicine as soon as you can but skip the missed dose if it is almost time for your next dose. 3. A face sheet dated 02/18/20 indicated Resident #3 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A baseline care plan dated [DATE] indicated Resident #3 was ordered medications by his physician. An MDS dated [DATE] indicated Resident #3 had severely impaired cognition, made his needs known, and understood others. He required limited assistance with ADLs. He was continent of bowel and occasionally incontinent of bladder. He received an anticoagulant (blood thinner) since his admission. Physician orders [REDACTED]. *Losartan 50 mg (high blood pressure) ordered [DATE] and scheduled twice a day; A MAR indicated [REDACTED] *Losartan 50 mg - administered at 10:28 a.m. (3 hours and 28 minutes after the scheduled time). During an interview on 02/18/20 at 5:23 p.m., Resident #3 said sometimes he had problems getting his medications on time. He said he could not remember the exact days, but staff were late administering his medications. The website www.drugs.com accessed 2/18/2020 indicated the following: * take losartan exactly as prescribed by your doctor. Follow all directions on your prescription label. Your doctor may occasionally change your dose to make sure you get the best results. Do not take this medicine in larger or smaller amounts or for longer than recommended. 4. A face sheet dated 02/18/20 indicated Resident #4 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #4 had severely impaired cognition, made his needs known, and understood others. He required limited assistance with ADLs. He was incontinent of bowel and bladder. A care plan dated 02/09/20 indicated Resident #4 had [MEDICAL CONDITION] and staff should administer medication as ordered. The care plan also indicated Resident #4 received [MEDICAL CONDITION] medications. Physician orders [REDACTED]. *[MEDICATION NAME] 100mg (constipation) ordered 10/01/19 and scheduled twice a day at 8:00 a.m. and 8:00 p.m.; *[MEDICATION NAME] 5 mg (anxiety) ordered 08/16/19 and scheduled three times a day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. A MAR indicated [REDACTED] *[MEDICATION NAME] 100mg (constipation) - administered at 1:02 p.m. (5 hours and 2 minutes after scheduled dose), and *[MEDICATION NAME] 5 mg (anxiety) - administered at 2:00 p.m. (missed 8 a.m. dose) During an interview on 02/18/20 at 11:25 a.m., Resident #4's daughter said she had concerns about the lack of staffing at the facility, especially on the weekends. She said the weekends were terrible due to the lack of staffing. She said they paid $[AGE]00.00 a month for Resident #4's stay at the facility and it was frustrating because the shortage of staffing caused care and medications to be provided late. The website www.drugs.com accessed 2/18/2020 indicated the following: *[MEDICATION NAME] ([MEDICATION NAME]) is an anti-anxiety medicine that affects chemicals in the brain that may be unbalanced in people with anxiety. Take [MEDICATION NAME] exactly as it was prescribed for you. Follow all directions on your prescription label. Your doctor may occasionally change your dose to make sure you get the best results. Do not take this medicine in larger or smaller amounts or for longer than recommended. Skip the missed dose if it is almost time for your next scheduled dose. Do not take extra medicine to make up the missed dose. 5. A face sheet dated 02/18/20 indicated Resident #5 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 0[DATE] indicated Resident #5 would have pain control and staff should monitor for increased pain and give medications. An MDS dated [DATE] indicated Resident #5 had severely impaired cognition, she made her needs known, and understood others. She required extensive assistance with ADLs. She was incontinent of bowel and bladder. She received antianxiety and opioid medication since admission. Physician orders [REDACTED]. *[MEDICATION NAME] 50mg (pain) ordered [DATE] and scheduled twice a day at 8:00 a.m. and 8:00 p.m.; *[MEDICATION NAME] 0.5mg (anxiety) ordered [DATE] and scheduled twice a day at 8:00 a.m. and 8:00 p.m. A MAR indicated [REDACTED] *[MEDICATION NAME] 50mg - 8:00 a.m. dose not administered (no reason given), *[MEDICATION NAME] 0.5mg - 8:00 a.m. dose not administered (no reason given). 6. A face sheet dated 02/18/20 indicated Resident #6 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 12/31/19 indicated Resident #6 had impaired cognition and received medication to improve cognition and manage anxiety. He required the use of [MEDICAL CONDITION] medication. An MDS dated [DATE] indicated Resident #6 had severely impaired cognition, made his needs known, and understood others. He required extensive assistance with ADLs. He was incontinent of bowel and bladder. He received an antipsychotic since his last admission. Physician orders [REDACTED]. *[MEDICATION NAME] mcg nasal spray (allergy symptoms) ordered 08/30/18 and scheduled twice a day; *[MEDICATION NAME] 0.2mg/hr. [MEDICATION NAME] 24-hour patch (chest pain) ordered 09/04/18 and scheduled once a day and remove at 8:00 p.m.; A MAR indicated [REDACTED] *[MEDICATION NAME] mcg nasal spray - administered at 12:52 p.m. (3 hours and 52 minutes after the scheduled time), and *[MEDICATION NAME] 0.2mg/hr. [MEDICATION NAME] 24-hour patch - patch applied at 12:55 p.m. (3 hours and 55 minutes after the scheduled time). The website www.drugs.com accessed 2/18/2020 indicated the following: *[MEDICATION NAME] Patch is used to prevent chest pain or pressure. During an interview on 0[DATE] at 6:43 p.m., RN A said she worked on Saturdays and Sundays from 6:00 a.m. to 2:00 p.m. RN A said when she arrived at the facility on 02/15/20, she went to one of the resident pods and noticed there was no CNA on the pod. She said she found out the CNA scheduled to work did not show up and did not call in. RN A said she called the ADON and did not get a response. She said she called the DON and the DON said she was on vacation and was out of state. RN A said she called the administrator and the administrator told her to sit in the pod until the MA arrived at 8:00 a.m. She said the nursing station was located away from all the resident pods and she could not start administering medications because she was monitoring the residents on the pod. RN A said MA B came in at 8:00 a.m. and MA B took over the pod. RN A said she had many interruptions that day. She said she had to answer the phone and she dealt with residents and resident's family members that were upset because medications were administered late. RN A said she was unfamiliar with the computer charting system because she had only worked at the facility a few weeks. RN A said she was supposed to only work until 2:00 p.m. but she was still administering medications at 4:00 p.m. She said she eventually administered all the resident's medications. RN A said the facility had staffing issues on weekends because staff would not show up on time or not at all. During an interview on 02/18/20 at 4:02 p.m., MA B said she worked 8:00 a.m. to 8:00 p.m. She said when she arrived at the facility on 02/15/20, she was told that she would not be administering medications but instead she was assigned to a resident pod. She said one of the CNAs that was scheduled to work did not show up to work and she worked as a CNA and RN A administered medications. She said several resident family members were upset because medications were administered late. She said she sometimes pulled from the medication cart to work on a resident pod when scheduled staff did not show up to work and the nurse would have to administer medications. During an interview on 02/18/20 at 5:01 p.m., the administrator said she was aware of the staffing issue and the late medication administration on 02/15/20. The administrator said one of the CNAs that was scheduled to work 6:00 a.m. to 2:00 p.m. did not show up for work and RN A stayed on the pod until MA B arrived to work at 8:00 a.m. She said MA B worked on the pod and RN A administered medications. She said she was contacted by a resident's family member about medications being administered late on 02/15/20. She said RN A was new to the facility, had difficulty with the computer charting system, and it took her a while to get the medications administered to residents. The administrator said she came to the facility on [DATE] because a CNA called in. She said she had MA B administer medications and RN A sat in the pod with the residents until a CNA was available to take over the pod. She said they were having a job fair and hoping to hire more staff. She said the DON was currently on vacation, they did not have an ADON, and they had no staff that was able to cover the shift. The administering medications policy dated October 2010 indicated the purpose of the procedure was to provide guidelines for the safe administration of medications. The policy did not include timeframes for medication administration.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent injury for 2 of 2 residents reviewed for accidents. (Residents #10 and 16) The facility did not provide adequate supervision for Resident #10 during toileting, which led to a fall with injury. The facility did not provide adequate supervision and assistive devices for Resident #16 during transfer. This failure could place residents dependent for toileting and transfers at risk for injury, hospitalization , pain and decreased quality of life. Findings included: 1. Physician orders [REDACTED].#16 was a [AGE] year old female, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #16's mental status was slightly impaired. She required extensive assistance of two persons with transfers and was total dependent of two persons assist while bathing and was always incontinent. A care plan dated dated 07/30/19 indicated Resident #16 was non-weight bearing. A physician visit form dated 07/30/19 for Resident #16 indicated physical therapy - non-weight bearing A physician after visit summary order dated 09/04/19 indicated continue non-weight bearing to bilateral lower extremities. Return to clinic in 5 weeks. An interdisciplinary note dated 09/05/19 indicated Resident #16's current ADL status was non-weight bearing, total assist for transfers with support of full mechanical lift, and total assist with bathing resident not to assist. During an observation on 09/05/19 at 10:37 AM, CNA B extended her hand to Resident #16 to help her sit up in bed to transfer her to the wheelchair. Resident #16 grabbed CNA B's hand and pulled herself up in bed and sat at the side of the bed with feet dangling. CNA B brought the wheelchair close to the bed, she rolled the Hoyer sling up and put it aside. Resident #16 grabbed both arms of the wheelchair, stood up and pivoted and sat in the wheelchair. CNA B placed her hand on her back to assist, a gait-belt was not used. During an interview on 09/05/19 at 10:50 AM, CNA B said she does not know why the Hoyer slingwas is in Resident #16's room, she said she stands for me all the time. An incident report dated 07/18/19 at 10:25 AM indicated Resident #16 was in the shower and she had fallen on the floor. Resident #16 was oriented and there were two staff with her. She was sent to the ER for evaluation. A written statement dated 07/18/19 indicated CNA C said she was getting Resident #16 in the shower. She had completed the shower and was trying to get her to sit to stand. The ADON came to help her. CNA C documented Resident #16 slipped out of the chair and ran to get some help. CNA C was not available for interview during the survey, she was on leave for a death in the family. During an interview on 09/06/19 at 10:40 AM, LVN M said she went to the shower room on 07/18/19 because the call light was on. She found Resident #16 sitting on the shower chair and CNA C was attempting to place the Hoyer sling underneath Resident #16. She went to assist with the Hoyer lift transfer. A written statement dated 07/18/19 completed by LVN M indicated she was rounding and entered Resident #16's room where she was sitting on the shower chair being dried. She said she asked if she could assist with the transfer, because she was intermittently screaming aloud. As LVN M grabbed the lift and began to push it under her chair CNA C was about to put the sling under Resident #16 and she slid to the floor on her right side. She did not hit her head. During an interview on 09/05/19 at 2:30 PM, the Physical Therapist indicated Resident #16 was partial weight bearing when she was admitted , she fell in the shower and her pelvic fractures were worsened. She is non-weight bearing. The Physical Therapist said she had a new physician order [REDACTED]. An x-ray report dated 07/18/19 indicated Resident #16 had a displaced right pubic fracture. A physical therapy note dated 07/31/19 indicated, Resident #16 exhibits exacerbation of decrease in functional mobility and increased need for assistance from others. Resident #16's current history includes she is a [AGE] year-old female that fell at an assisted living facility, fractured her right superior and inferior pubic rami. She was receiving therapy when she sustained a fall from the shower chair. Due to poor bone quality, Resident #16 is strict non-weight bearing to her bilateral lower extremities. During an interview on 09/06/19 at 10:49 AM, DON U said the staff should never remove the Hoyer sling when showering a resident. During an interview on 09/06/19 at 10:50 AM, the RN nurse consultant said Resident #16 had been non-weight bearing since admission. 2. Physician orders [REDACTED].#10 was an [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #10 was severely impaired cognitively, incontinent, and she was totally dependent with two persons assist for toileting. A care plan dated 06/25/19 indicated Resident #10 was to have extensive assist for toileting with staff support of 1-2, and she was frequently incontinent. She was at risk for falls as evidenced by fall risk assessment score, mental status alert with confusion and a history of falls. A fall risk assessment dated [DATE] indicated Resident #10's level of consciousness is disoriented at all times, she was chair bound and required assist with toileting. Resident #10 was legally blind, has problems with balance, walking, and gait. Her total score was 19 (a score of 10 of more indicates high risk for falls). A nursing note dated 08/14/19 at 6:58 AM, completed by RN J documented Resident #10 was found lying on her back on the right side of her bed, in front of her chair. The note indicated her left leg was extended and her right leg was bent up with her foot planted on the floor and her knee pointing toward the ceiling. Resident #10 had a shirt on, her brief was removed, and she had feces on her hands and under her fingernails. RN J documented a head to toe assessment was done and no injuries were found. The note indicates a fall mat was in place and the bed remained in low position. A nursing note dated 08/21/19 at 1:33 PM, completed by DON U indicated Resident #10 had fallen in the bathroom and was found on the floor on her back. DON U asked Resident #10 what happened, she indicated I fell , I lost balance. The note documented her injuries as a laceration above the left eye, left lateral wrist, and left knee swelling with abrasions. The note indicates EMS was contacted. DON U documented she asked CNA G what happened, and she indicated she put Resident #10 on the commode and was standing outside her door to give her privacy and she heard the resident fall. CNA G indicated she notified her nurse. A nursing note dated 08/21/19 at 6:45 PM, completed by LVN H documented Resident #10 to the facility at 6:35 PM via her sons work truck from the ER. LVN H indicated she called the ER for a verbal report and was informed the resident had no broken bones and the X-ray and CT scan were all clear. The note indicated Resident #10 had a laceration to the left forehead just above the eye. LVN H document the ER nurse was unable to tell her (LVN H) how many sutures Resident #10 had but said the area was covered with gauze dressings and her head was wrapped in kerlix to keep the resident from picking at the incision site. Further documentation indicated Resident #10 had a skin tear to the left hand and wrist that was closed with dermabond, the left knee had an abrasion, and there was bruising noted to the left eye, hand and leg. During an observation on 09/03/19 at 9:45 AM, Resident #10 was up in her wheelchair, self-propelling around the common area. During an interview on 09/03/19 at 10:23 AM, LVN [NAME] said you should never leave a resident alone in the bathroom. During an interview on 09/03/19 at 11:33 AM, CNA [NAME] said this is her 3rd day working at the facility, she said she only provided incontinent care for Resident #10. During an interview on 09/03/19 at 11:33 AM, DON U stated CNA G worked night shift and was not available by phone. During an interview on 09/03/19 at 11: 35 AM, DON U said CNA G came and got her and said Resident #10 had fallen. She said CNA G should not have left Resident #10 alone in the bathroom. DON U said she spoke with CNA G immediately after the incident regarding leaving a dementia resident alone in the bathroom. A written statement on 08/21/19 completed by CNA G indicated she took Resident #10 to the bathroom around 1:10 PM. She documented she got the resident on the commode and stepped out into the hallway to give her some privacy. CNA G indicated while she was in the hallway she heard Resident #10 calling for help, when she went in the resident was on the floor. During an interview on 09/05/19 at 10:15 AM, CNA B said she has worked all 3 halls, and has taken care of Resident #10, she said she was not working the day she fell in the bathroom. She said the whole left side of her face was bruised. CNA B said Resident #10 is incontinent, she said she had never taken her to the bathroom, she said the resident cannot tell staff when she needs to go. CNA B said she does not know why they took her to the bathroom, she said Resident #10 rarely refuses care. An in-service dated 08/21/19 given by DON U called providing care to our residents, specifically peri-care do not do the following: *When assisting resident to the bathroom/commode, please do not leave them unattended or step outside of the restroom/bedroom to allow for privacy When they are altered cognitively. This is a safety issue and they should always be within your line of vision and close enough to assist promptly. A safe lifting and movement of Residents policy revised date (MONTH) (YEAR) indicated In order to protect the safety and well-being of staff and residents, and to promote care .2. Manual lifting of residents shall be eliminated when feasible .4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. A lifting machine, using a mechanical policy revised date (MONTH) (YEAR) indicated . safe lifting using a mechanical lifting device . 1. At least two nursing assistants are needed to safely move a resident with a mechanical lift .2 .b. transferring a resident from bed to chair

Based on observation, interview and record review, the facility failed to ensure the governing body appointed an administrator who was responsible for the management of one licensed nursing facility. The facility did not have an administrator managing one facility. This failure could place residents at risk for not being managed in a manner to use its resources effectively and efficiently and of not having the proper care and services provided. Findings included: During an observation on 9/5/19 at 9:00 a.m. the campus included a nursing facility, assisted living and independent living center. A job offer letter dated (MONTH) 29, 2019 indicated the administrator was offered a position as Executive Director/Administrator. A Job Description signed by the administrator on 04/01/19 indicated the following: Position title: Executive Director/Administrator .General Summary: The Executive Director/Administrator is responsible for the overall administration of the community .Essential Functions: .2. Assures compliance with federal, state, and local standards for retirement, nursing, and assisted living operations . During an interview on 09/06/19 at 11:05 a.m. the administrator said he was the executive director/administrator for the licensed nursing facility, licensed assisted living, and independent living center. He said he was hired by the company to oversee all the operations of the campus.

Based on record review and interview, the facility failed to ensure the facility assessment determined what resources were necessary to provided competent care for the facility. The facility assessment did not contain information for the current DON and did not have information regarding the level and competency of staff needed to meet the needs of each resident. This failure could place residents at risk of inadequate care or treatment. Findings included: The facility assessment dated [DATE] did not include information regarding the level and competency of staff needed to meet the needs of each resident. The assessment also listed the previous DON information and not the current DON. During an interview on 09/06/19 at 9:17 a.m., the administrator said he was not aware the information regarding the level and competency was required for the facility assessment. He said the DON information listed was a mistake and it should reflect the current DON.

Based on interview and record review, the facility failed to ensure the quality assessment and assurance committee (QAA) consisted of the required members (including the Medical Director) for 3 of 5 QAA meetings reviewed. The facility failed to have a Medical Director or his designee present for three QAA committee meetings. This failure could place residents at risk for quality deficiencies being unidentified with no appropriate guidance developed or implemented. Findings included: The QAPI attendance records sign in sheets dated 6/27/19, 7/16/19 and on 8/20/19 did not have the Medical Director nor a designee signature of attendance indicating they did not attend. During an interview on 9/4/19 at 3:32 p.m., administrator N said he was the QAPI coordinator and they met according to their QAPI policy which is monthly on the 3rd Tuesday. He said he started as the administrator on 4/10/19 and he was not aware who the QAPI coordinator was when he was hired. He said he could not locate any previous QA information, and was not aware if they were having meetings. Administrator N said the only previous QA information he could locate was for the 11/15/18 and 3/28/19 meetings, he said they were not meeting monthly as the QAPI policy instructs. Administrator N said in the medical director's contract he was supposed to meet with them monthly for QA meetings, he said he was responsible for notifying the medical director of the QA meetings. Administrator N said he did not notify the medical director of the 6/27/19, 7/16/19 and 8/20/19 QA meetings, he said he was still working on developing a proper QA process, but he should have notified him. Administrator N said the DON, medical director or a designee, and the administrator were required to attend all QA meetings. A QAPI meetings form noted meetings were held on 11/15/18, 3/28/19, 6/27/19, 7/16/19 and on 8/20/19, not monthly as the policy indicates. A Quality Assurance and Performance Improvement (QAPI) Plan revised on (MONTH) 2014 stated- in section Implementation: 2) This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality related activities of all departments, services, or committees. An Undated Medical Director Contract stated on page #2 on line #7 Meeting monthly with nursing and other professional staff to discuss clinical and administrative issues, specific resident and client care issues, the need for education or training of professional staff or the need for consultants for professional staff, and to identify area in which policies should be developed.

Based on observation, interview, and record review, the facility failed to follow physician orders [REDACTED]. (Residents #76 and 225). Residents #76 and 225 did not receive daily weights as indicated in their written plan of care. This failure could place residents at risk for potential weight loss or weight gain. Findings included: 1. A physician order [REDACTED].#76 was to be weighed daily. A physician order [REDACTED].#76 admitted on [DATE] with [DIAGNOSES REDACTED]. The daily weight order had been deleted. Physician orders [REDACTED].#76 was to receive Two Cal HN oral liquid supplement 4 oz. by mouth four times a day and orders dated 08/23/19 indicated the resident was to receive [MEDICATION NAME] 15 mg tablet by mouth every day for anorexia. The most recent care plan dated 08/14/19 did not address daily weight, appetite stimulants or nutritional supplements for Resident #76. The resident vital stats documented in the clinical record indicated Resident 76#'s weights were as follows: *08/14/19 110.8 lbs., *08/15/19 110.8 lbs., *08/16/19 109.4 lbs., *08/17/19 110.4 lbs., *08/18/19 111.3 lbs., *08/19/19 109.0 lbs., *08/26/19 105.6 lbs., *08/31/19 104.1 lbs., *09/01/19 103.8 lbs., *09/02/19 105.6 lbs., and *09/04/19 101.4 lbs. There were no documented weights for 8/20/19, 8/21/19, 8/22/19, 8/23/19, 8/24/19, 8/25/19, 8/27/19, 8/28/19, 8/29/19, 8/30/19, and 9/3/19. During an observation on 09/05/19 at 10:05 AM, a handwritten note attached to the wall at the nurses' station titled Daily Weights listed residents to be weighed daily. Resident #s 76 and 225 names were on the list for daily weights. During an interview on 09/05/19 at 10:25 AM, DON U said the physician order [REDACTED].#76 was an error. She said their policy is to weigh residents daily for the first 3 days after admission and then weekly for four weeks. She provided weight documentation indicating the resident was weighed daily on 08/14/19, 08/15/19, 08/16/19, 08/17/19, 08/18/19, 08/19/19 and then again on 08/26/19, 08/31/19, 09/01/19, 09/02/19, and 09/04/19. During an interview on 09/05/19 at 11:15 AM, LVN F said DON U had prepared the handwritten daily weights list attached to the nurses' station wall. During an interview on 09/05/19 at 11:18 AM, DON U said she had made the handwritten list posted at the nurses' station indicating Resident #s 76 and 225 were to receive daily weights. 2. A physician order [REDACTED].#225 was a [AGE] year old male, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders also indicated he was to have daily weights. The most recent care plan dated 08/29/19 did not address daily weights for Resident #225. The resident vital stats documented in the clinical record indicated Resident #225's weights were as follows: *8/29/19 211 lbs., *8/31/19 209.6 lbs., *9/1/19 210.4 lbs., *9/2/19 211 lbs., *9/3/19 210.40 lbs., and *9/4/19 211 lbs. There were no documented weights for 8/30/19. During an interview on 9/5/19 at 12:20 PM, DON U said Resident #225 was to have daily weights and provided weights for 8/29/19, 8/31/19, 9/1/19, 9/2/19, 9/3/19 and on 9/4/19. She said she did not have a daily weight for 8/30/19. She said she had issues in the past with weekend staff, she said they are to write it down and slide it under her door. DON U said the staff who worked on 8/30/19 did not turn in anything for Resident #225. During an interview on 9/6/19 at 12:22 PM, DON U said she still could not find a weight for 8/30/19 on Resident #225.

Based on interview and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and needs of the residents in accordance with the comprehensive assessment for 3 of 3 residents reviewed for activities. (Resident #s 2, 5, and 10). The facility did not provide ongoing activities for long term residents. This failure could place residents at risk of diminished social interactions and a decreased of quality of life. Findings included: During an observation on 09/04/19 at 9:30 a.m., the AD along with Resident #s 2, 5, and 10 said the Pledge of [MEDICATION NAME] as an activity which lasted about 1 minute. During a group interview on 09/04/19 at 09:48 a.m., Resident #5 said there are not a lot of activities. Resident #s 2, 5, and 10 said they would like to have more entertainment activities. All three residents said they watch a lot of television because there was nothing to do. During an interview on 09/04/19 at 11:45 a.m., the Ombudsman indicated the long-term residents complained to her about there not being enough activities. She said she spoke with DON U and the corporate nurse about the issue and said they agreed there were not enough activities. During an interview on 09/06/19 at 10:54 a.m., the AD said she started a couple of months ago and realized the activities were insufficient for the long-term care residents. She said she did not realize activities of daily living such as grooming were not an activity. She said not all of the residents were long-term care, most were there just for rehabilitation. The (MONTH) 2019 activity calendar had the following: *every Sunday (1st, 8th, 15th, 22nd and 29th)-8:00 breakfast, 11:00 church service, and 2:00 family and friends visit; *every Monday (2nd, 9th, 16, 23, and 30th)-8:00 breakfast; 10:00 pledge, singing, exercise; 12:00 lunch; 3:00 hand massage; (10:30 Resident Council meeting the second Monday); *every Tuesday (3rd, 10th, 17th, and 24th)-8:00 breakfast; 10:00 pledge, singing, exercise; 12:00 lunch; 1:00 1 on 1 bible study; 3:00 pretty nails; *every Wednesday (4th, 11th, 18th, and 25th)-8:00 breakfast; 10:00 pledge, singing, exercise; 12:00 lunch; 3:00 sing a long; *every Thursday (5th, 12th, 19th, and 26th)-8:00 breakfast; 10:00 pledge, singing, exercise; 12:00 lunch; 3:00 story time; *every Friday (6th, 13th, 19th, and 27th)-8:00 breakfast; 10:00 pledge, singing, exercise; 12:00 lunch; 3:00 ice cream treats; and *every Saturday (7th, 14th, 20th, and 28th)-8:00 breakfast; 9:00 personal grooming; 12:00 lunch; 3:00 games. A Group Programs and Activities Calendar Policy revised (MONTH) (YEAR) indicated Policy Interpretation and Implementation:9. Calendar development and changes are discussed with the Resident Council to keep them informed. The Activity Director/Coordinator periodically reviews the current types of activity programs in terms of the current facility population and changes are made based on this analysis with input from the Resident Council and the interdisciplinary team An Activity Director job description dated (MONTH) (YEAR) indicated Essential Functions: 1. Plans, organizes, implements activities for residents. a. Activities are planned, organized, and implemented to meet the physical, emotional, spiritual, recreational and educational needs of the residents

Based on observation, interview, and record review, the facility failed to ensure CNAs demonstrated competency in techniques to care for 2 of 3 residents reviewed for incontinent care (Resident #s 78 and 16) and 1 of 1 residents reviewed for transfers (Resident #16). CNA A did not use correct technique when providing incontinent care for Resident #78. CNA B did not wash or sanitize her hands while providing incontinent care and a transfer for Resident #16. CNA B did not use the mechanical lift as ordered for transfer for Resident #16. This failure could place residents who required assistance with incontinent care at risk for discomfort, skin breakdown, cross contamination, and infections and residents who require assistance with transfers at risk for injuries. Findings included: 1 .During an observation on 09/05/19 at 02:40 PM, CNA A provided incontinent care for Resident # 78. CNA A wore gloves into the room and did not wash her hands. She uncovered the resident. She opened the bedside table and removed a clean brief, unfolded it, and placed it on the bed. She left a package of incontinent wipes in the drawer and opened the lid. She pulled 3 wipes from the package and turned around to the resident. Holding 3 wipes in her right hand she undid the resident's brief with her left hand. She used one wipe and wiped across the resident's lower abdomen, took another wipe and cleansed the left groin, took another wipe and cleansed the right groin. Those wipes were placed on the soiled brief. Using the same soiled gloves, she reached into the drawer and removed a wipe from the package and wiped the resident's scrotal area. Using the same soiled gloves, she took another wipe from the package and cleansed the other side of the scrotal area and wiped the resident's penis with a downward motion. Without changing her gloves, she got another wipe from the package and cleansed the tip of the resident's penis without retracting the foreskin. She helped the resident turn on his right side and took wipes from the package and cleaned the resident's left buttock. She took more wipes from the package and removed a medium amount of bowel movement from the resident's anal area. Using the same soiled gloves, she got more wipes from the package and cleaned the resident's anal area 2 more times. She took more wipes from the package and cleansed the resident's buttocks. She rolled the brief and placed it in the trash can. Using the same soiled gloves, she took the clean brief and placed it under the resident. CNA A then removed her gloves and donned fresh gloves without washing or sanitizing her hands. She turned the resident on his back and affixed the tabs. During an interview on 09/05/19 at 02:45 PM, CNA A said she performed the incontinent care the way she always did and would not have done anything differently. The physician orders [REDACTED].#78 was an [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] for Resident #78 indicated the resident required extensive assistance with assist of 1-2 staff with bed mobility, transfers, dressing, toileting and personal hygiene and he was always incontinent of bowel and bladder. A care plan dated 08/09/19 indicated Resident #78 had a self-care deficit related to disease processes and required assistance with ADLs. The care plan indicated the resident was incontinent of bowel and bladder due to his cognitive status and was at risk for skin breakdown due to incontinence, fragile skin, and physical impairment. A Perineal Care policy, revised 02/2018, indicated 8. For a male resident: . b. Wash perineal area starting with the urethra and working outward . d. Retract foreskin of the uncircumcised male. e. Wash and rinse urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum and inner thighs .j. Reposition foreskin of uncircumcised male m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. 2. During an observation on 09/05/19 at 10:30 AM, CNA B wearing gloves, removed the front of Resident #16's soiled brief and assisted her to turn onto her left side. CNA B lowered the brief from Resident #16. Wearing the same soiled gloves, she opened the top drawer of the night stand and took out a container of wipes. She cleaned Resident #16's buttocks. She removed the soiled brief from under Resident #16 and using the same soiled gloves, placed a clean brief under her. She then instructed Resident #16 to turn on her back. Wearing the same soiled gloves, CNA B pulled several wipes out of the container and cleaned the perineal area with the clean brief under Resident #16., CNA B pulled up the brief and secured the tabs. CNA B never changed her gloves throughout the entire procedure. CNA B discarded the soiled items into the resident's trash can that did not have a liner., she emptied the soiled items into a plastic bag and did not sanitize the trash can or place a plastic liner inside. During an observation on 09/05/19 at 10:37 AM, after CNA B completed incontinent care on Resident #16, wearing the same soiled gloves she wore during incontinent care, she extended her hand and the resident grabbed her with both her hands and the CNA pulled to assist the resident to sit on the side of the bed. Resident #16 became dizzy and asked to sit for a minute. The CNA pulled the wheelchair close to the bed, locked the wheels, rolled up the Hoyer sling in the wheelchair and put it in the corner. Still wearing the same soiled gloves, the CNA put her hand on the resident's back to assist her to get into the wheelchair, no gait belt was used during the transfer. The resident pivoted and sat in the wheelchair. During an interview on 09/05/19 at 10:40 AM, when CNA B was asked if she would do anything different during the incontinent care, she shook her head to indicate no and started talking about when Resident #16 gets a shower it was different. During an interview on 09/05/19 at 10:47 AM, CNA B said she did not know why the Hoyer sling was in the wheelchair. CNA B said Resident #16 stands for her all the time so she never uses it. The physician orders [REDACTED].#16 was a [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #16 required total assistance of 2 staff with mobility, transfers, and ADLs and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 07/30/19 indicated Resident #16 had limited mobility with need for assist with ADLs and self-care deficits related to pubis fractures. The care plan indicated the resident was at risk for skin breakdown due to incontinence, cognitive impairment, and physical impairment. During an interview on 09/05/19 at 02:30 PM, the director of Physical Therapy (PT) said when Resident #16 admitted she was partial weight bearing, then she had the fall in the shower and it worsened the pelvic fracture she admitted with. She said she had been non-weight bearing since the fall and the new physician order [REDACTED]. During an interview on 09/06/19 at 11:05 AM, DON U did not respond with her expectations regarding incontinent care, she just stated she had a lot of inservices to do. During an interview on 09/06/19 at 11:20 AM, the administrator said they did not have a policy or procedure for transferring residents. A Handwashing/Hand Hygiene policy, revised 08/2015, indicated .Use an alcohol-based hand rub .; or, alternatively, soap and water for the following situations: .b. Before and after direct contact with residents; . h. Before moving from a contaminated body site to a clean body site during resident care; .j. After contact with blood or bodily fluids; . m. After removing gloves; . Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves . after removal 5. Perform hand hygiene.