Every finding on record at Memorial Nursing and Rehabilitation Center

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that meets professional standards of quality and that included measurable objectives and time frames for 3 of 16 (Residents #20, 29, and 31) residents reviewed for care plans.The facility failed to ensure Resident #20's daily use of compression socks had been included in the care- plan. There was no documentation in the care plan of measurable objectives, interventions, or timeframes for how staff would meet this need.The facility failed to ensure Resident #29 and #31's DNR status was included in the resident's care plan.These failures to accurately develop and implement a care plan could result in staff not being aware of critical treatment-related risks and monitoring needs, placing residents at risk for delayed treatment and failure to provide necessary care and services. Findings included: Resident #20Record review of Resident # 20 's face sheet printed [DATE] revealed an [AGE] year-old female. Resident # 20 was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (cognitive impairment that destroys memory), unspecified atrial flutter (a type of abnormal heart rhythm where heart beats too fast) and heart failure(a chronic condition where the heart muscle cannot pump blood and oxygen well enough to meet the body's needs). Record review of Resident # 20's Quarterly MDS, dated [DATE] revealed a BIMS of 9 out of 15 indicating moderate cognitive impairment. Her functionality on the MDS revealed she required supervision and set up assistance for upper and lower body dressing and putting on footwear. Record review of Resident # 20's physician's orders printed by the facility on [DATE], documented Apply compression in AM and remove at bedtime and wash every shift for edema related to HEART FAILURE, UNSPECIFIED. Order start date was 04/ 08/26 with no discontinue date. Record review of the Care Plan dated [DATE] documented Resident # 20 was able to complete ADLs with verbal cues and set up assistance for dressing. The Care plan documented Resident #20 was on diuretic therapy related to edema. The Goal listed revealed Resident will maintain optimal tissue perfusion through the review date. Interventions include administering diuretic medications as ordered. Evaluate arterial leg pulses, evaluate heart rate, evaluate pedal pulses. There was no mention of the compression socks listed in the care plan for any task. Record review of Treatment Administration Record on [DATE] revealed compression socks were documented as being placed on Resident #20 on [DATE] and [DATE] in the am when observations and interviews stated otherwise. In an Observation and Interview on [DATE] at 11:00 am, Resident # 20 was sitting in her recliner in her room. There were no compression socks observed on her legs. Resident # 20 stated that she did not know she had an order for compression socks and that the staff had not told her to put any compression socks on. She stated she had no compression socks that she knew of. She stated she did not know she was supposed to wear compression hose but stated she thought they would help her legs not hurt. She stated she did not remember the last time she had had compression socks on but stated it had been a long time. In an observation and interview on [DATE] at 2:21 pm Resident #20 was observed sitting in the day area with no compression socks on her feet. She stated no one had approached her about putting the compression socks on that day. In an observation on [DATE] at 8:15 am, Resident #20 was eating breakfast in the dining room with no compression socks on her legs. In an observation and interview on [DATE] at 9:30 am, Resident #20 was in her room sitting in her recliner. Resident #20 stated she had no compression socks on and no one ever spoke to her about putting the compression socks on her feet. In an interview on [DATE] at 11:15 am, the Family Member of Resident #20 stated they had been aware Resident #20 was supposed to wear compression socks all the time. The Family Member stated Resident #20 swells up really bad. The Family Member stated they visited Resident #20 on [DATE] and stated, I did not see her compression socks yesterday. The Family Member stated Resident #20 had dementia and could not tell you whether she had the compression socks on or not and would not remember to remind the staff to put them on her. In an observation on [DATE] at 3:00 pm Resident #20 was observed in her recliner with no compression socks on her legs. In an interview on [DATE] at 9:55 am, the DON stated she was aware Resident #20 was ordered compression socks. She stated she was not aware the compression socks had not been included in the care plan. The DON stated the consequences for not putting compression socks on were edema in her legs. She stated the consequences of not having the compression socks care planned would cause poor and inadequate care for the residents. In an interview on [DATE] at 9:09 am, RN A stated she was not aware Resident #20 was supposed to wear compression socks. She stated she and the other RNs supervised the CNAs and made sure correct care was provided to the residents. She stated the consequences for not putting the compression socks on as ordered would be excessive swelling to the legs and could cause blood clots to form. She stated the compression socks should have been included in the care plan. In an interview on [DATE] at 10:37 am the CPC stated compression socks were part of the care plan and should have been documented in Resident #20's care plan. She stated consequences of not documenting compression socks in the care plan were the resident may not get the appropriate care. Resident #29Record review of Resident #29's face sheet printed [DATE] revealed she was an [AGE] year-old female resident admitted [DATE] with diagnosis to include Alzheimer's (a progressive disease that destroys memory and other important mental functions). Record review of Resident #29's quarterly MDS assessment completed [DATE] listed Resident #29 with a BIMS of 4 indicating she was severely cognitively impaired, and she had a functionality from requiring substantial/maximal assistance to setup/clean-up assistance with her activities of daily living. Record review of Resident #29's Order Summary Report printed [DATE] with Active Orders As Of: [DATE] revealed the following order:- DNR (Do Not Resuscitate) Active [DATE]. Record review of Resident #29's care plan with admission date of [DATE] and last revision [DATE] revealed no care plans to address Resident #29's DNR status. During an observation and attempted interview on [DATE] at 8:57 AM Resident #29 was in her room standing at her window dressed well for the day. Resident #29 was confused and anxious with introduction and questions and did not respond appropriately. Resident #31Record review of Resident #31's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interfere with daily functioning), malnutrition (lack of proper nutrition), cardiomyopathy (a disease of the heart muscle when the muscle structure becomes abnormally thick, stiff, thin, or stretched), and malignant neoplasm of the breast (an abnormal, uncontrolled growth of cells originating in the milk ducts or milk-producing glands (lobules) of the breasts). Record review of Resident #31's quarterly MDS assessment completed [DATE] listed Resident #31 with a BIMS of 4 indicating she was severely cognitively impaired, and she had a functionality of being dependent on staff for most of her activities of daily living. Record review of Resident #31's Order Summary Report printed [DATE] with Active Orders As Of: [DATE] revealed the following order:- DNR (Do Not Resuscitate) Active [DATE]. Record review of Resident #31's care plan with admission date of [DATE] and last revision [DATE] revealed no care plans to address Resident #31's DNR status. During an observation and attempted interview on [DATE] at 9:31 AM Resident #31 was observed in the hallway in her wheelchair dressed well for the day. Resident #31 was limited and guarded/agitated with her response to this surveyor and did not answer any questions. During an interview on [DATE] at 9:12 AM RN D reported that a residents DNR should be included in the care plan so the facility would know to review the DNR regularly with the resident to see if the resident's wishes have been changed. RN D reported that if the DNR status was not addressed in the residents care plan then the facility might not address the residents wishes correctly. During an interview on [DATE] at 10:16 AM the DON reported that the DNR did not trigger in their computer system to be include in the care plan but she did felt that the DNR/Code status of a resident needs to be in the resident's computer system/chart somewhere so the staff would be aware to address the code status but not necessarily in the care plan. During an interview on [DATE] at 10:32 AM the CPC reported that the residents DNR/Code status should be addressed in the resident's care plan and that if the DNR/Code status was not addressed in the care plan then the staff might give the wrong care such as doing a full code (starting CPR) on a resident that was a DNR. Record Review of the facility policy dated 2/2025 titled Care Planning revealed:Care Planning is intended to promote continuity of care and communication among residents, and nursing home staff, increase resident safety, and safeguard against possible adverse reactions. Care Plans must be consistent with resident rights, include measurable goals and time frames, be person centered and address the medical, physical, mental and psychosocial needs of the residents.

Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 16 residents (Resident # 20) reviewed for quality of care. The facility failed to follow physician orders and did not apply Compression socks as ordered for Resident # 20. This failure could place residents at risk of staff not being aware of needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings included: Record review of Resident # 20 's face sheet printed 08/12/2026 revealed an [AGE] year-old female. Resident # 20 was admitted on [DATE] with the following diagnoses: unspecified dementia (a decline in mental ability), unspecified atrial flutter (abnormal heart rhythm) and heart failure ( blood does not pump well and leads to swelling in the body). Record review of Resident # 20's Quarterly MDS, dated [DATE] revealed a BIMS of 9 out of 15 indicating moderate cognitive impairment. Her functionality on the MDS revealed she required supervision and set up assistance for upper and lower body dressing and putting on footwear. Record review of Resident #20s Care Plan dated 7/29/26 documented Resident # 20 required reminders and prompting assistance as needed for ADLs. Record review of Resident # 20's physician's orders printed by the facility on 8/12/26, documented Apply compression in AM and remove at bedtime and wash every shift for Edema related to HEART FAILURE, UNSPECIFIED. Order start date was 04/ 08/26 with no discontinue date. Record review of Resident #20's Treatment Administration Record printed by the facility on 8/12/26 at 08:51 am, revealed compression socks were documented as being placed on Resident # 20 on all dates when observations and interviews state otherwise. In an Observation and Interview on 8/11/26 at 11:00 am, Resident # 20 was sitting in her recliner in her room. There were no compression socks observed on her legs. Resident # 20 stated, she did not know she had an order for compression socks and that the staff had not told her to put any compression socks on. She stated she had no compression socks that she knew of. She stated she did not know she was supposed to wear compression hose but stated she thought they would help her legs not hurt. She stated she did not remember the last time she had had compression socks on but stated it had been a long time. In an observation and interview on 8/11/26 at 2:21 pm Resident #20 was observed sitting in the day area with no compression socks on her feet. She stated no one had approached her about putting the compression socks on that day. In an observation on 8/12/26 at 8:15 am, Resident #20 was eating breakfast in the dining room with no compression socks on her legs. In an observation and interview on 8/12/26 at 9:30 am, Resident #20 was in her room sitting in her recliner. Resident #20 stated she had no compression socks on and no one ever spoke to her about putting the compression socks on her feet. In an interview on 8/12/26 at 9:50 am CNA C stated she had been taking care of Resident #20 on 8/11/26 and 8/12/26. She stated she had done a set up for dressing for Resident #20. She stated Resident #20 needed reminders for dressing. CNA C stated she would sometimes look at the physician orders and stated she thought the orders were on the wall kiosk for each resident. CNA C stated she had not been aware Resident #20 had an order for compression socks to be put on daily. She stated she did not put the hose on Resident #20 r on 8/11/26 or 8/12/26. CNA C reviewed the physician orders for Resident #20 and stated the checked box documented that the compression socks were applied. CNA C stated she did not know why it was checked. CNA C stated the consequences of not putting the compression socks on were swelling in Resident #20's legs. In an interview on 8/12/26 at 9:55 am, the DON stated the compression hose were black or brown and should have been in the resident room. She stated she thought Resident #20 had a PRN order for the compression socks and did not need them every day. The DON stated the consequences for not putting compression socks on were edema in her legs. She stated she expected staff to always follow physician orders. She stated staff should not be checking the box if the task had not been completed. In an interview on 8/12/26 at 11:15 am, a Family Member of Resident #20 stated they had been aware Resident #20 was supposed to wear compression socks all the time. They stated Resident #20 swells up really bad. The Family Member stated they visited Resident #20 on 8/11/26 and stated, I did not see her compression socks yesterday. The Family Member stated Resident #20 had dementia and could not tell you whether she had the compression socks on or not. She would not remember to remind the staff to put them on her. In an observation on 8/12/26 at 3:00 pm Resident #20 was observed in her recliner with no compression socks on her legs. In an interview on 8/13/26 at 9:09 am, RN A stated she was not aware Resident #20 was supposed to wear compression socks. She stated she and the other RNs supervised the CNAs and made sure correct care was provided to the residents. She stated the consequences for not putting the compression socks on as ordered would be excessive swelling to the legs and could cause blood clots to form. She stated the compression socks should have been included in the care plan. In an interview on 8/13/26 at 10:37 am the CPC stated compression socks were part of the care plan and should have been documented in Resident #20's care plan. She stated consequences of not documenting compression socks in the care plan were the resident may not get the appropriate care. Record Review of the facility policy titled Physician Orders dated 2/2025, revealed the facility orders for medication and treatments will be consistent with principles of safe and effective order writing. Orders must be recorded on the physician's order sheet in the resident chart.

Based on observation, interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 2 (Resident #1 and #14) of 17 residents reviewed for advanced directives. Resident #1 had a DNR dated [DATE] (signed by the physician) in her record that was missing information in the Two Witness section. Resident #14 had a DNR dated [DATE] (signed by the physician) in her record that was missing information in the Two Witness section. The facility's failure could place residents a risk for not receiving healthcare as per their own or their legal representatives wishes. Findings included: Record review of Resident #1's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include unspecified combined systolic and diastolic congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), dementia (a group of thinking and social symptoms that interferes with daily functioning). Resident #1 was listed as a DNR. Record review of Resident #1's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS score of 03 indicating she was severely cognitively impaired, and she had a functionality of requiring partial/moderate assistance with most of her activities of daily living. Record review of Resident #1's care plan with admission date of [DATE] revealed the following: Focus: -Resident has long/short term memory loss and confusion . Resident/family desire for her to be DNR. 3- 27-25 family desire for her to continue DNR. Date Initiated: [DATE]. Record review of the clinical record for Resident #1 revealed an Order Summary Report with active orders as of [DATE] with the following order: -DNR (Do Not Resuscitate) - Active [DATE]. Record review of the clinical record for Resident #1 revealed a DNR dated [DATE] (signed by the physician) with the following: Section - Two Witnesses - Notary in the State of Texas and County of M - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form. During an observation on [DATE] at 09:18 AM Resident #1 was in her room sleeping in her bed in a scoop mattress with the bed in the lowest position. Resident #1 did not wake to knocking. Resident #1's three FM's present and all three reported good care with no concerns. Record review of Resident #14's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Resident #14 was listed as a DNR. Record review of Resident #14's last MDS was an annual assessment completed [DATE] listing her with a BIMS of 07 indicating she was severely cognitively impaired, and she had a functionality of being dependent on staff for all her activities of daily living. Record review of Resident #14's care plan with admission date of [DATE] revealed she had no care plan to address her code status. Record review of the clinical record for Resident #14 revealed an Order Summary Report with active orders as of [DATE] with the following order: - DNR (Do Not Resuscitate) - Active [DATE]. Record review of the clinical record for Resident #14 revealed a DNR dated [DATE] (signed by the physician) with the following: Section - Two Witnesses - Notary in the State of Texas and County of M - there was a signature for the notary, a printed name for the notary, a date of [DATE] when the notary completed the form but there was no Notary Seal provided in this section. During an observation on [DATE] at 09:38 AM Resident #14 was in her bed sleeping. Resident #14 did not wake to knocking or introduction. Resident #14 appeared in good condition. During an interview on [DATE] at 03:06 PM the DON verified that Resident #1 was a DNR and that if a resident that was a DNR was found without a heartbeat or respirations the staff would not start CPR. The staff would then notify her (the DON), the administrator, physician, and family. The DON reviewed Resident #1's DNR in Resident #1's printed medical record at the nurse station and noted that the notary did not date when they signed the DNR form for Resident #1. The DON stated that the DNR for Resident #1 was not valid. The DON reported that if a DNR was not valid then a family could question why the staff did not do CPR which could result in the residents wishes not being followed. The DON reviewed Resident #14's DNR and noted that the notary seal was in the incorrect section and stated, I still feel it is Ok. The DON reported that she was going to get Resident #14's DNR redone just to be safe. The DON reported that she was going to pull all residents with DNR's and do a full audit to make sure they were all correct. The DON reported that the notary for both DNR's were former employees who no longer worked for the facility. During an interview on [DATE] at 03:19 PM RN A (the nurse responsible for Resident #1 and #14 during this survey) reviewed Resident #14's DNR and noted that the notary did not provide the notary seal in the correct section of the form and stated that it could possibly be an issue, but she did not feel it would affect Resident #14's code status. RN A did report that if a notary did not date their signature such as with Resident #1 then the form was invalid and that was an issue because they would not know what date the DNR code status went into effect. RN A reported that it could affect the resident negatively. Record review of the facility provided policy titled Advanced Care Planning Patient Self - Determination Act dated 01/2025, revealed the following: It is the policy of the facility to honor Advanced Directives which are properly executed in accordance with state law. Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES undated, revealed the following: - The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #25) of 13 residents reviewed for comprehensive care plans. The facility failed to include Resident #25's antidepressant medication in her care plan dated 05/19/25. This failure could lead to residents not receiving needed care and/or receiving improper care/treatment. Findings Included: Record review of Resident #25's admission record dated 06/25/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning and causes disruptive behavior) and anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life). Record review of Resident #25's significant change MDS completed on 04/30/25 revealed a BIMS score of 3 which indicated severely impaired cognition. Resident #25 was coded as receiving antidepressant medication. Record review of Resident #25's care plan with last revision date of 05/19/25 revealed no mention of antidepressant medication. The care plan did note Resident #25 might have feelings of fear or anxiety due to past events and her dementia. She was also noted to have had unplanned/unexpected weight loss due to poor food intake. Record review of Resident #25's order summary dated 06/24/24 revealed the following order with an order start date of 03/20/25: Escitalopram Oxalate Tablet 20 MG give 1 tablet by mouth one time a day for depression related to ANXIETY DISORDER . Record review of Resident #25's MAR from 03/20/25 to 06/25/25 revealed she received Escitalopram Oxalate every day. During an interview on 06/26/25 at 08:52 AM LVN B stated residents could be negatively affected if their antidepressant medication was not in their care plan. He stated, They (residents) don't know what (medication/s) they are taking. During an interview on 06/26/25 at 08:54 AM MDS RN stated she is responsible for completing care plans for residents. She stated she would include antidepressant medication in the care plan if the resident was taking said. She stated, It (antidepressant medication) would be in her (resident's) orders but still need to be care planned because that is the plan of care we follow. During an interview on 06/26/25 at 09:06 PM ADON stated antidepressant medication should be in the care plan. She stated, It depends on what it was prescribed for and when it was prescribed. Sometimes they (residents) come to us having been on it (antidepressant medication) for a long time and sometimes it is newly started and we need to be sure we are monitoring it, calling for decreases (in dose), and make sure that it is not the only thing we are doing to address the depression. During an interview on 06/26/25 at 09:16 AM DON stated residents could be negatively affected if antidepressant medication was not care planned. She stated, It can bleed over into how we are taking care of them and addressing the depression. It can bleed over into weight loss. During an interview on 06/26/25 at 09:34 AM Adm stated MDS RN is responsible for completing care plans. She stated MDS RN took over the position 3 months prior. ADM stated residents could absolutely be negatively affected if their antidepressant medication was not care planned. She stated, We would not know to be monitoring for side effects, we would not know to be trying non-medicinal options to treat the depression, or to monitor how the medication is working, if they (doctors) need to increase or decrease the medication. Record review of facility policy titled Care-Planning and dated 2-2024 revealed the following: . Care-Planning is intended to promote continuity of care and communication among residents, resident representatives, and nursing home staff, increase resident safety, and safeguard against possible adverse events. Care-plans must, be . person-centered, and address the medical, physical, mental and psychosocial needs of the resident. Each resident will have a person-centered care-plan developed and updated through the interdisciplinary team . The comprehensive care-plan will include measurable goals and time frames that will maintain the resident's highest practicable physical, mental, and psychosocial well-being. Problem areas and their causes will be addressed with possible interventions. Each care-plan will reassess the following: Gradual Dose Reduction .

Based on observations, interviews, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication carts (Medication Cart-Hall200/300 and Medication cart 400/500) reviewed for medication storage. The facility failed to ensure that there no lose pills, expired medications, and labels were legible. -2.5 pills found in medication cart for Hall 200/300 -2 bottles of expired medications found in medication cart for Hall 400/500. Findings included: Observation on 05/13/24 at 09:15 AM revealed Medication cart for 200 and 300 Hall. 2.5 pills were found in the bottom of medication cart drawer, 1 pill was identified as Duloxetine and the 2nd was identified as Aspirin, and the 1/2 pill was unidentifiable by MA. Observation on 05/13/24 at 09:39 AM revealed the medication cart for Hall 400 and 500 revealed Resident 86's stool softener with an expiration date of 04/2024 and a bottle of Vitamin D3 had an expiration date of May 2023. MA did confirm that Resident #86 did receive the Vitamin D this morning. During an interview on 05/13/24 at 09:59 AM MA stated that a negative outcome for administering expired medications would be that the medication would not be as effective. MA stated that a negative outcome for having lose pills in the bottom of the medication cart drawers could possibly lead to a missed dose. During an interview on 05/15/24 at 02:09 PM ADON stated that a negative outcome for administering expired medications would be that the medication was not as potent. ADON also stated that lose pills found in the medication cart drawers it could lead to missed doses for residents later. During an interview on 05/15/24 at 02:12 PM LVN stated that a negative outcome for administering expired medication would be that the medication is less effective. LVN stated that the negative outcome for finding lose pills in the medication cart drawers was you don't know who they belong to, and this could cause issues later on. During an interview on 05/15/24 at 02:14 PM DON stated that a negative outcome for administering expired medications was they could have a negative effect on our residents and the medication will not be effective for them. DON stated that a negative outcome for finding lose pills in the medication cart drawers could lead to residents not possibly having the dose that the resident may need and could lead to a missed dose. Record review of facility provided policy titled, Storage of Medications, reviewed 03/2021, revealed the following: Policy Statement: Medications and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. .f. Medications labeled for individual residents are stored separately from the floor stock medications when not in the medication cart. Private pay OTC brought in by family will be properly. Labeled for resident and stored in med cart. .l. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal (section I.E), and reordered from the pharmacy (Section I.C.2), if a current order exists. Record review of facility provided policy titled, The Medication Labels, dated 09/2014, revealed the following: .8. Medication containers have soiled, damaged, incomplete, illegible, confusing, or makeshift labels are returned to the dispensing pharmacy for relabeling or destroyed in accordance with the medication destruction policy.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (the ICP) of 5 staff observed for resident care. -The ICP (Infection Control Preventionist) failed to clean the glucometer machine (an instrument for measuring the concentration of glucose in the blood) between resident use. This deficient practice has the potential to affect residents in the facility receiving diabetic care by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: During an observation on 04/03/23 at 11:57 AM the ICP performed a blood sugar test on Resident #10. The ICP did not clean the glucometer machine (an instrument for measuring the concentration of glucose in the blood) prior to testing Resident #10's blood. The ICP then docked the glucometer machine to transmit the result to the pharmacy. The ICP then removed the glucometer machine from the docking station and tested Resident #20's blood sugar, then the ICP redocked the glucometer machine without cleaning it. During an interview on 04/03/23 at 12:02 PM the ICP reported that she did not clean the glucometer machine between testing Resident #10, Resident #20, and before docking the glucometer machine after testing the last resident. The ICP verified that the glucometer machine did need to be cleaned. The ICP reported that if the glucometer machine is not cleaned properly then cross contamination can result between residents. The ICP verified that it is her responsibility to educate all nursing staff on infection control and prevention. During an interview with 04/05/23 at 09:59 AM the DON reported that when staff complete blood sugar testing they should complete hand hygiene and they should clean the glucometer machine between each residents testing. The DON reported that if staff do not clean the glucometer machine between each resident testing, then staff can spread infection from blood or other sources because you do not know what else is in a resident's room. Record review of the facility provided policy titled Infection Control amended 12-28-2021 revealed the following: Rules: 5. All resident equipment will be sanitized by the staff when used with an approved germicidal before and after use, such as but not limited to -Blood Glucose Monitors. Record review of the facility provided training titled Accu-Check Inform II MNRC Training Checklist undated revealed the following: -Clean with Oxivir 1 Wipes daily, between each patient, and after every use.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #13, #22, and #23) of 16 residents reviewed for advanced directives. Resident #13 had a DNR in her record that was missing the date, printed signature, and license number for the physician who signed the form. Resident #22 had a DNR is her record that was missing the date for when the physician's signed the form and had no signature in the Two Witness section. Resident #23 had a DNR in her record that was missing the date for when the qualified relative signed the form. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #13 Record review of the face sheet dated [DATE] in the clinical record for Resident #13 revealed a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), squamous cell carcinoma of the skin (cancer that occurs in the outermost part of the epidermis-skin), and aneurysm (a ballooning or weakening area of an artery). Under the section Advanced Directives Resident #13 was listed as a DNR. Record review of the clinical record for Resident #13 revealed the last MDS completed was a significant change of condition dated [DATE] with a BIMS of 99 indicating she was unable to complete the interview due to short term memory issues and she had a functionality of requiring one to two-person assistance with all activities. Record review of the clinical record for Resident #13 revealed a care plan with admitted [DATE] with the following: Code Status: DNR Record review of the clinical record for Resident #13 revealed an Order Summary Physician Order Report [DATE] - [DATE] with the following order: Code Status: Do Not Resuscitate. Start date of [DATE] Record review of the clinical record for Resident #13 revealed a DNR dated [DATE] (by Resident #13) with the following: Section-Physician Statement-there is no date of when the physician signed the document, no printed name for the physician, and no license number for the physician. Resident #22 Record review of the face sheet dated [DATE] in the clinical record for Resident #22 revealed a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), dementia (a group of thinking and social symptoms that interferes with daily functioning), and basil cell carcinoma (cancer that begins in the lower part of the epidermis (the outer layer of the skin). Under the section Advanced Directives Resident #22 was listed as a DNR. Record review of the clinical record for Resident #22 revealed the last MDS completed was a quarterly dated [DATE] with a BIMS of 5 indicating she was severely cognitively impaired and she and had a functionality of requiring one to two-person assistance with all activities. Record review of the clinical record for Resident #22 revealed a care plan that did not address her DNR status. Resident #22 opted to become a DNR [DATE] and her care plan was not due to be updated. Record review of the clinical record for Resident #22 revealed an Order Summary Physician Order Report [DATE] - [DATE] with the following order: Code Status: Do Not Resuscitate. Start date of [DATE] Record review of the clinical record for Resident #22 revealed a DNR dated [DATE] (by Resident #22's POA) with the following: Section-Two Witnesses: There was no witness signatures and there was no notary witness signature. Section-Physician Statement-there was no date of when the physician signed the form. Resident #23 Record review of the face sheet dated [DATE] in the clinical record for Resident #23 revealed a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), amnesia (a general term to describe memory loss), and congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should). Under the section Advanced Directives Resident #23 was listed as a DNR. Record review of the clinical record for Resident #23 revealed the last MDS completed was a quarterly dated [DATE] with a BIMS that could not be evaluated due to the resident was rarely/never understood and she and had a functionality of requiring one to two-person assistance with all activities. Record review of the clinical record for Resident #23 revealed a Care Plan Review Form dated [DATE] that listed Resident #23's Code Status as DNR. Record review of the clinical record for Resident #23 revealed an Order Summary Physician Order Report [DATE] - [DATE] with the following order: Code Status: Do Not Resuscitate. Start date of [DATE] Record review of the clinical record for Resident #23 revealed a DNR dated [DATE] (by the physician) with the following: Section-Declaration of the qualified relative of the adult person who is incompetent of otherwise incapable of communication. There was no date of when the qualified relative signed the form. During an interview on [DATE] at 08:39 AM LVN A (the nurse responsible for Resident #23 that shift) reported that if Resident #23 was not breathing and/or did not have a heart rate she was not going to do CPR, that she would verify by stethoscope that the resident was coding, then notify an RN for a second verification, then notify the family and physician. LVN A then reported that each resident had either a red or a green name tag on the door to their room, that if the tag is red then the resident is a DNR and if the name tag is green then the resident is a full code. LVN A verified that Resident #23 had a red name tag on her door that indicated Resident #23 was a DNR. LVN A then reviewed Resident #23's current DNR in Resident #23's chart and reported the DNR form was missing the date of when the responsible party signed the DNR form and therefore the DNR was not valid so Resident #23 was a full code and would require CPR. When asked what the consequences of not having the DNR form completed correctly could be, LVN A reported that resident wishes would not be followed. During an interview on [DATE] at 08:48 AM LVN B (the nurse responsible for Resident #13 and Resident #22 that shift) reported that if either resident was found without a heart rate and/or breathing LVN B would verify with her stethoscope for two minutes that the resident did not have a heart rate or breathing, if they were a DNR LVN B would not start CPR and notify the family and physician, if they were a full code then LVM B would start CPR. LVN B verified that both residents had a red name tag on their doors and were therefore DNR's. LVN B reviewed each residents charts which had DNR stickers on the outside of the chart indicating they were DNR's. LVN B reported that she would not start CPR after verifying that each resident was listed as a DNR. LVN B was asked to review each resident DNR form in their charts and LVN B reported that Resident #13 did not have the correct Physician information to include the date and Resident #22 did not have the correct Physician information to include the date. LVN B reported that neither resident DNR's were valid and therefore both residents would be full codes and require CPR. When asked what the consequences could be if the DNR form was completed correctly, LVN B reported that staff could follow the code status incorrectly. During an interview on [DATE] at 08:55 AM the BOM verified that she was responsible for ensuring the DNR's were completed and in the resident records. The BOM pulled the three original DNR's for Resident #13, #22, and #23 from their records and verified that all three were incomplete. The BOM reported that the DNR status was reviewed with each resident at each care plan conference, but the actual DNR form was not reviewed. The BOM reported that they would start reviewing each DNR form at the care plan conference from this point forward to ensure that they were complete and accurate. During an interview on [DATE] at 09:36 AM the DON verified that Resident #13, #22, and #23's DNR's were not filled out correctly and were not valid DNR's. The DON reported that DNR trainings were completed by herself or a staff preceptor when a staff member was hired. The DON verified that she or the BOM verify that DNR's were complete and accurate and that Resident #13, #22, and #23's DNR's were just missed. The DON reported that all residents are asked at each care plan meeting what they wish their could status to be but that the DNR forms are not reviewed. The DON reported that they will start checking each DNR at the resident's care plan meeting so they can ensure that they are filled out correctly. The DON reported that if a DNR is not filled out correctly then staff will not do CPR when they should, and resident wishes may not be followed. Record review of facility provided policy titled Advanced Care Planning Patient Self-Determination Act, updated [DATE], revealed the following: Documentation: 7. Advanced directives will be reviewed by the admitting person in the business office as well as the admitting nurse in order to ensure the document is complete, singed, and dated by all required parties to include physician. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional 46534 47854

Based on observation, interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for one of 14 (Resident #3) residents reviewed for DNR orders. Resident #3 had an OOH-DNR order that was not completed as it was not signed or dated by a physician. These failures could place residents with DNR orders at risk for receiving, or not receiving, life-saving measures that align with their medical preferences. Findings include: Record review of Resident #3's face sheet, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 03 out of 15 which indicated his cognition was severely impaired. He required total dependence with one-person assistance with bed mobility and personal hygiene, total dependence with two-person assistance with transferring and toilet use, extensive one-person assistance with dressing, and supervision with set-up help with eating. Record review of Resident #3's care plan, dated [DATE], revealed, in part: Code Statue DNR .Family desires to continue DNR . Record review of Resident #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Code Status: DO NOT RESUSCITATE, dated [DATE]. Record review of Resident #3's chart revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated [DATE], which revealed in Section 2A Patient's Statement: I, the undersigned, am capable of making an informed decision regarding the withholding or withdrawing of CPR, including the treatments listed below, and I direct that none of the following resuscitation measures be initiated or continued. Cardiopulmonary resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation . Section 2A revealed Resident #3's signature. There was no printed or typed name for Resident #3 or date in Section 2A, the lines for these were left blank. Section 4 revealed PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no physician signature, physician printed name, license number or date in this section; the lines were left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no physician signature listed on the line that read, Signature of Attending Physician. During an interview on [DATE] at 11:23 AM, SW confirmed she assisted residents with completing DNR orders. She stated that Section 4, Physician's Statement should have been completed for Resident #3's DNR order, and it would have been best for the resident's printed name and date to have been completed as well in Section 2A, Patient's Statement. SW stated if the physician statement section was not completed, the physician may not have been in the loop with what the resident's medical wishes were. SW stated if there was some sort of conflict or question among the resident's family regarding the resident's end-of-life wishes, if the resident did not have his faculties, the physician may not have been able to support the resident's wishes. With the DNR order not being signed by the physician, in an emergent situation, SW stated, depending on who was caring for the resident that day, there could have been question about what the resident's end-of-life wishes were and there could have been the potential for him not having his medical wishes being met (to initiate emergency treatment or not). SW confirmed that she had attended training regarding DNR orders before; she stated that since she was not a lawyer, she was told she could not fill DNR orders out for residents, but she did do the running for them to assist with getting the appropriate signatures. When asked what she would have done if she received an OOH DNR that was not fully completed for a newly admitted resident, she stated she would have had the resident or resident family complete a new one. Record review of facility provided policy titled, Advanced Care Planning Patient Self-Determination Act, dated [DATE], revealed, in part: Policy Statement: [facility name] respects the right of competent individuals or their designated representatives to control decisions related to their medical care in accordance with state law. Competent residents have the right to execute and document advanced directives, such as a Living Will or Health Care Power of Attorney. It is the policy of [facility name] to honor Advanced Directives which are properly executed in accordance with state law. A patient's attending physician has primary responsibility for directing the care of the patient. No request for the rendering, withholding, termination of treatment and cares will be honored by the facility without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Rules: .B. State Law [Facility name] social worker or designee will review the resident's advanced directive. This review will not constitute a representation that such advanced directive complies with requirements of state law. The facility will comply with the requirements of state law governing advanced directives. C. Documentation .3. Advanced Directive are written documents that state choices for health care/or names someone to make those choices. These may include: a. Out of Hospital Do Not Resuscitate Order .G. Request by Resident to Execute and [sic] Advanced Directive Social worker will assist the resident or resident representative in obtaining the appropriate forms and referrals. Record review of facility provided document titled, Frequently Asked Questions about Advanced Care Planning, undated, that was provided to residents upon admission, revealed, in part: .Other Questions about Hospitals and Nursing Facilities and Treatment at the End of Life .What is an Out-of-Hospital Do Not Resuscitate Order (OOHDNR)? This form is for use when you are not in the hospital. It lets you tell health care workers, including Emergency Medical Services (EMS) workers, NOT to do some things if you stop breathing or your heart stops. If you don't have one of these forms filled out, EMS workers will ALWAYS give you CPR or advanced life support even if your advance care planning forms say not to. You should complete this form as well as the Directive to Physicians and Family or Surrogates and the Medical Power of Attorney form if you don't want CPR.

Based on interviews and record review, the facility failed to provide residents the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident for 5 of 5 residents reviewed for resident rights (Residents #1, #2, #3, #4 and #5). The facility stopped essential caregiver visits for all Residents due to having COVID-19 positive residents in the building. The facility's failure to allow essential caregiver visits placed residents at risk of emotional and psychological harm by not receiving visits from family and loved ones. The evidence is as follows: Record review of Resident #1's clinical record documented an admitted [DATE], was [AGE] years of age and had the following Diagnoses: [REDACTED]. Record review of the facility's log of Essential Caregiver visits for Resident #1 documented the following dates when Resident #1 had visits from his Essential Caregiver: 9/27/20, 10/9/20, 10/23/20, 12/21/20, 12/23/20. During an interview on 12/23/2020 at 11:00 a.m., CI-A said back in May or June the facility allowed window visits but then stopped. They resumed the window visits and allowed Essential Caregiver visits in October but stopped those too. He was told by the facility that the State shut the visits down. CI-A said Monday, 12/21/20, was the first time he got to see his dad in 2 ½ months. Record review of Resident #2's clinical record documented an admitted [DATE], was [AGE] years old and had the following Diagnoses: [REDACTED]. Record review of the facility's log of Essential Caregiver visits for Resident #2 revealed there was no documentation that Resident #2 had any Essential Caregiver visits. During an interview on 12/23/20 at 11:22 a.m., CI-B said no one at the facility was on the same page, except that they all say no to essential caregiver visits. She said she just wants to make sure she is allowed to see Resident #2 for 2 hours unsupervised per the Rule without attitude or more fighting. She said they would not allow the hospice nurses in except 1 time every 2 weeks- or if there was a status change. All thru October and November the DON told her they would not allow an Essential Caregiver visit unless the facility was COVID free. She said she was heartbroken and that it should not be a fight to visit Resident #2. They will not even address the fact he could leave for a holiday meal. She said the facility told her it was up to their discretion to follow all these rules or not. Record review of Resident #3's clinical record documented an admitted [DATE], was [AGE] years of age, and had the following Diagnoses: [REDACTED]. Record review of the facility's log of Essential Caregiver visits for Resident #3 documented the following dates when Resident #3 had visits from her Essential Caregiver: 12/22/20. During an interview on 12/23/20 at 1:54 p.m., CI-C stated she got to see Resident #3 yesterday, 12/22/20 for the first time since Resident #3 was admitted to the facility. CI-C said the visit lasted about an hour. She said she did have window visits with Resident #3 but Resident #3 would tell her, I'd love for you to come in and visit with me. I've been here all day by myself. Sometimes Resident #3 would refuse to come to the window because she wanted CI-C to come in to visit and didn't understand why she wouldn't. CI-C said the isolation is the hardest part for Resident #3. Record review of Resident #4's clinical record documented an admitted [DATE], was [AGE] years of age and had the following Diagnoses: [REDACTED]. Record review of the facility's log of Essential Caregiver visits for Resident #4 documented the following dates when Resident #4 had visits from her Essential Caregiver: 9/26/20, 10/5/20, 12/23/20. During an interview on 12/23/2020 at 2:15 p.m., CI-D stated this was the 3rd time this week he has gotten to visit Resident #4. He said it had been over 2 months since he was allowed to visit Resident #4. He was told it was because they had some positive COVID cases and they shut down visitation. Record review of Resident #5's clinical record documented an admitted [DATE], was [AGE] years of age, and had the following Diagnoses: [REDACTED]. Record review of the facility's log of Essential Caregiver visits for Resident #5 documented the following dates when Resident #5 had visits from her Essential Caregiver: 9/25/20, 10/2/20, 10/9/20, 12/23/20. During an interview on 12/23/2020 at 2:39 p.m. CI-E stated he saw Resident #5 this morning for the first time in 1 - 2 months. He was also told the facility had some positive COVID cases and had shut down visitation. During an interview on 12/23/2020 at 3:34 pm DON said they had to stop the Essential Caregiver visits when they had so many positive COVID cases because they didn't have enough staff to continue the visits. DON said they stopped the visits in October and started them again Monday, 12/21/2020. She said they called the families and told them that due to staffing issues they had to stop the visits. She said at one time they had over ½ of the residents in quarantine. The facility had 16 positive staff members since October. DON said all staff are back now so they can continue the Essential Caregiver visits. DON confirmed Resident #2 didn't have any Essential Caregiver visits. During an interview with the ADM on 12/23/2020 at 3:57 pm, ADM said they restricted visitation when they were told by the CDC back in March shutdown/lockdown. Then when there was allowance for window visits they started doing that, doing facetime, began allowing families in for end of life situations, when Residents were actively dying. When Essential Caregiver visits began, they talked with families to get the designations done by the residents or POAs. When they had an outbreak of COVID cases, they limited visitation because of exposure issues. ADM said they can start to allow the Essential Caregiver visits again and that is where they are at this point. He said one resident refuses to do a window visit because she doesn't understand why she can't hug them and see them inside. Some family members are insistent on their visits. Families ask how much longer this will go on. Some think the facility is doing this on purpose. Record review of the facility's Essential Caregiver Visits policy dated 9/23/20 documented the following: Policy Statement: The purpose of the policy is to provide visits between residents and essential designated caregivers while maintaining limited exposure of infection. Rules: The nursing facility must: 1. Provide a designate area for visits. 2. Maintain logs of all visits/caregiver COVID-19 testing. 3. Provide training to caregivers before initial visit on the following: a. Proper personal protective equipment (PPE). b. Usage of infection control measures. c. Hand hygiene. d. Cough and sneeze etiquette 4. Inform all essential caregivers of any applicable policies, procedures, and requirements. 5. Screen caregivers before all visits and provide an identification badge. 6. Maintain all infection control policies and procedures. 7. Provide caregivers with appropriate PPE and hand hygiene essentials. 8. Clean designated area between all visits. 9. Provide caregiver escorts to and from designated areas of visitation. Record Review of Texas Health and Human Services Commission's Provider Letter 20-38 titles COVID-19 Response - Expansion of Reopening Visitation, dated 9/24/2020, documented the following: 1.0 Subject and Purpose As part of the continued reopening of the State of Texas, HHSC has adopted expanded emergency rules to allow for essential caregiver visits, salon services visits, and limited indoor and outdoor visitation in ALFs, ICFs/IID, and NFs. NFs are required to allow closed window visits, end-of-life visits, and visits of persons providing critical assistance, including essential caregivers for residents. NFs are also required to seek a visitation designation to allow additional general visitation. This letter describes the requirements for these visits. 2.0 Essential Caregiver Visits An essential caregiver visit is defined as a personal visit between a resident and an essential caregiver, permitted in all facilities for COVID-19 negative and unknown COVID-19 status residents. NFs must allow essential caregiver visits. A facility does not need an approved general visitation designation from HHSC to allow essential caregiver visits. Up to two essential caregivers can be designated per resident, but each visit is limited to one essential caregiver at a time. Each essential caregiver visit must be by appointment and limited to two hours, unless the facility can only accommodate a visit for a shorter or longer amount of time and adjusts the length accordingly.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #2) whose care plans were reviewed. The facility failed to implement Resident #2's care plan for maintaining a floor mat and a bed alarm as safety precautions. This failure could place residents at risk of injury from falls from their beds which could include abrasions, skin tears, hematomas, and fractures. Findings include: Record review of Resident #2's clinical record documented an admitted [DATE], was [AGE] years old and had the following Diagnoses: [REDACTED]. Resident #2 requires two-person assistance with most activities of daily living. Resident #2 can sometimes understand what is said to him and can sometimes be understood. He has short and long-term memory loss. Record review of Resident #2's Fall Risk assessment dated [DATE] documented a score of 16. Total score of 10 or above represents HIGH RISK. Record review of Resident #2's care plan dated 9/23/20 documented the following: Problem/Need: Potential for Falls/RT weakness/Dementia I am at risk for falls due to dementia and weakness. I use a wheelchair for mobility. I do not have a hx of falls at home but have had falls since admission with no major injuries. I have a floor mat, bed and chair alarms in place for safety. I use bedrails bilaterally in upright position for bed mobility, stabilization and safety. Approach/Intervention 3. Maintain floor mat, bed and chair alarms as a safety precaution. During an observation on 12/23/20 at 10:26 a.m. Resident #2 was in his room, laying in his bed with his eyes closed. There was a fall mat leaning against the wall. There was no fall mat on the floor beside his bed. There was an alarm box on his bedside table that was not plugged into anything. There was a cord sticking up from the side of his bed that was not plugged into anything. During an observation and interview on 12/23/20 at 10:32 am CNA A went into Resident #2's room. When asked what special fall precautions were in place for Resident #2 she said he has a bed alarm for when he is in bed and a chair alarm for when he is in his wheelchair. CNA A looked at the alarm box that was sitting on Resident #2's bedside table and she took the alarm box off of his bedside table and plugged it into the cord that was sticking up out of the side of his bed. When asked if that alarm box should have already been plugged in, she said, Yes it should have been plugged in. The fall mat should be on the floor beside the bed. The fall mat was still leaning against the wall. When asked why they weren't, she said, I guess I just forgot. During another observation on 12/23/20 at 2:11 pm Resident #2 was laying in his bed with his eyes closed. His fall mat was not on the floor beside his bed but was leaning against the wall. During an observation and interview on 12/23/20 at 2:14 pm CNA A was outside Resident #2's room. She was informed that Resident #2's fall mat was leaning against the wall and not on the floor beside his bed. She walked into his room and saw the floor mat leaning against the wall. She said, Oh yeah. She confirmed she forgot again. During an interview on 12/23/20 at 3:34 pm with DON, she was asked about the placement of Resident #2's fall mat and utilizing his bed alarm. She said the fall mat should have been in place if he was lying in bed and the bed alarm should have been plugged in. Record review of the facility's Fall Management policy and procedure dated 12/4/19 documented the following: Procedure: A. Fall Management 5. All high risk status residents will have identifiable interventions in their care plan. B. Immediate interventions by charge nurse 6. Implement any interventions as appropriate for the safety of the resident C. Investigate Fall Circumstances 1. Charge nurse will investigate possible causes or contributing factors such as but not limited to: F. Assistive devices

Based on observations, interviews and record review the facility failed to ensure the resident environment remains as free from accidents hazards as is possible, and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #2) reviewed for accidents and hazards. The facility failed to maintain a floor mat and a bed alarm as safety precautions for Resident #2. This failure could place residents at risk of injury from falls from their beds which could include abrasions, skin tears, hematomas, and fractures. Findings include: Record review of Resident #2's clinical record documented an admitted [DATE], was [AGE] years old and had the following Diagnoses: [REDACTED]. Resident #2 requires two-person assistance with most activities of daily living. Resident #2 can sometimes understand what is said to him and can sometimes be understood. He has short and long-term memory loss. Record review of Resident #2's Fall Risk assessment dated [DATE] documented a score of 16. Total score of 10 or above represents HIGH RISK. Record review of Resident #2's care plan dated 9/23/20 documented the following: Problem/Need: Potential for Falls/RT weakness/Dementia I am at risk for falls due to dementia and weakness. I use a wheelchair for mobility. I do not have a hx of falls at home but have had falls since admission with no major injuries. I have a floor mat, bed and chair alarms in place for safety. I use bedrails bilaterally in upright position for bed mobility, stabilization and safety. Approach/Intervention 3. Maintain floor mat, bed and chair alarms as a safety precaution. During an observation on 12/23/20 at 10:26 a.m. Resident #2 was in his room, laying in his bed with his eyes closed. There was a fall mat leaning against the wall. There was no fall mat on the floor beside his bed. There was an alarm box on his bedside table that was not plugged into anything. There was a cord sticking up from the side of his bed that was not plugged into anything. During an observation and interview on 12/23/20 at 10:32 am CNA A went into Resident #2's room. When asked what special fall precautions were in place for Resident #2 she said he has a bed alarm for when he is in bed and a chair alarm for when he is in his wheelchair. CNA A looked at the alarm box that was sitting on Resident #2's bedside table and she took the alarm box off of his bedside table and plugged it into the cord that was sticking up out of the side of his bed. When asked if that alarm box should have already been plugged in, she said, Yes it should have been plugged in. The fall mat should be on the floor beside the bed. The fall mat was still leaning against the wall. When asked why they weren't, she said, I guess I just forgot. During another observation on 12/23/20 at 2:11 pm Resident #2 was laying in his bed with his eyes closed. His fall mat was not on the floor beside his bed but was leaning against the wall. During an observation and interview on 12/23/20 at 2:14 pm CNA A was outside Resident #2's room. She was informed that Resident #2's fall mat was leaning against the wall and not on the floor beside his bed. She walked into his room and saw the floor mat leaning against the wall. She said, Oh yeah. She confirmed she forgot again. During an interview on 12/23/20 at 3:34 pm with DON, she was asked about the placement of Resident #2's fall mat and utilizing his bed alarm. She said the fall mat should have been in place if he was lying in bed and the bed alarm should have been plugged in. Record review of the facility's Fall Management policy and procedure dated 12/4/19 documented the following: Procedure: A. Fall Management 5. All high risk status residents will have identifiable interventions in their care plan. B. Immediate interventions by charge nurse 6. Implement any interventions as appropriate for the safety of the resident C. Investigate Fall Circumstances 1. Charge nurse will investigate possible causes or contributing factors such as but not limited to: F. Assistive devices

Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bowel and bladder receive appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 Residents (Resident #1 and Resident #2). CNA A, while performing incontinent care on Resident #1, did not perform hand hygiene and did not change gloves after cleaning the Resident and before applying the clean brief. CNA B, while performing incontinent care on Resident #,2 did not perform hand hygiene and did not change gloves after cleaning the Resident and before applying the clean brief. These failures have the potential to affect all residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: During an observation, 12/21/20 at 10:55 AM CNA B, while performing incontinent care for Resident #1, did not change gloves or perform hand hygiene between removing dirty brief and placing clean brief onto resident. After placing resident in a clean brief and incontinence care completed, CNA B changed gloves, however, no hand hygiene was performed between glove change. During an interview, 12/21/20 at 10:57 AM, CNA B stated, the appropriate time to perform hand hygiene or change gloves during incontinence care, is after cleaning the resident, disposing of the dirty brief and after placing a clean brief on the resident and then will change gloves prior to re-dressing resident. During an observation, 12/21/20 at 11:19 AM CNA A, while performing incontinent care for Resident #2, did not change gloves or perform hand hygiene between removing dirty brief and placing clean brief onto resident. After placing resident in a clean brief and incontinence care completed, CNA A changed gloves, however, no hand hygiene was performed between glove change. During an interview, 12/21/20 at 11:22 AM, CNA A stated the appropriate time to perform hand hygiene or change gloves during incontinence care, is after cleaning the resident, disposing of the dirty brief and after placing a clean brief on the resident and then will change gloves prior to re-dressing resident. During an interview, 12/21/20 at 12:16 PM, DON stated, staff are spot checked weekly for incontinence care, hand hygiene and PPE donning and doffing. DON also stated staff are trained to perform hand hygiene and don gloves prior to starting incontinence care, change gloves and perform hand hygiene when going from a dirty to clean area and then doff gloves and perform hand hygiene after completion of incontinence care. Record Review 12/21/20 of Perineal Care, dated 2/2020, states: Procedure: 7. Change gloves between tasks and/or when gloves are visibly soiled. Record Review 12/21/20 of Hand Hygiene, dated 9/2/2020, states: MNRC personnel shall wash their hands or use alcohol-based hand sanitizer to prevent the spread of infection: 3. Before and after wearing gloves a. Gloves are to be changed between tasks on the same resident. Record Review 12/21/20 of Incontinent Care Skills Checkoff, undated, states: *Washes rest of perineal area of perineal area working side to side-wipe and fold technique or using clean wipe with each swipe. *Washes hands and changes glove *Pats dry working towards back (if needed) *Change gloves *Turn resident to side . *Wipes from anus working side to side side-wipe and fold technique or using clean wipe with each swipe . *Change gloves/sanitize or clean hands *Reposition resident on back

Based on observation, interview, and record review, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care, for 2 of 2 Residents (Resident #1 and Resident #2). CNA A, while performing incontinent care on Resident #1, did not perform hand hygiene and did not change gloves after cleaning the Resident and before applying the clean brief. CNA B, while performing incontinent care on Resident #,2 did not perform hand hygiene and did not change gloves after cleaning the Resident and before applying the clean brief. These failures have the potential to affect all residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: During an observation, 12/21/20 at 10:55 AM CNA B, while performing incontinent care for Resident #1, did not change gloves or perform hand hygiene between removing dirty brief and placing clean brief onto resident. After placing resident in a clean brief and incontinence care completed, CNA B changed gloves, however, no hand hygiene was performed between glove change. During an interview, 12/21/20 at 10:57 AM, CNA B stated, the appropriate time to perform hand hygiene or change gloves during incontinence care, is after cleaning the resident, disposing of the dirty brief and after placing a clean brief on the resident and then will change gloves prior to re-dressing resident. During an observation, 12/21/20 at 11:19 AM CNA A, while performing incontinent care for Resident #2, did not change gloves or perform hand hygiene between removing dirty brief and placing clean brief onto resident. After placing resident in a clean brief and incontinence care completed, CNA A changed gloves, however, no hand hygiene was performed between glove change. During an interview, 12/21/20 at 11:22 AM, CNA A stated the appropriate time to perform hand hygiene or change gloves during incontinence care, is after cleaning the resident, disposing of the dirty brief and after placing a clean brief on the resident and then will change gloves prior to re-dressing resident. During an interview, 12/21/20 at 12:16 PM, DON stated, staff are spot checked weekly for incontinence care, hand hygiene and PPE donning and doffing. DON also stated staff are trained to perform hand hygiene and don gloves prior to starting incontinence care, change gloves and perform hand hygiene when going from a dirty to clean area and then doff gloves and perform hand hygiene after completion of incontinence care. Record Review 12/21/20 of Perineal Care, dated 2/2020, states: Procedure: 7. Change gloves between tasks and/or when gloves are visibly soiled. Record Review 12/21/20 of Hand Hygiene, dated 9/2/2020, states: MNRC personnel shall wash their hands or use alcohol-based hand sanitizer to prevent the spread of infection: 3. Before and after wearing gloves a. Gloves are to be changed between tasks on the same resident. Record Review 12/21/20 of Incontinent Care Skills Checkoff, undated, states: *Washes rest of perineal area of perineal area working side to side-wipe and fold technique or using clean wipe with each swipe. *Washes hands and changes glove *Pats dry working towards back (if needed) *Change gloves *Turn resident to side . *Wipes from anus working side to side side-wipe and fold technique or using clean wipe with each swipe . *Change gloves/sanitize or clean hands *Reposition resident on back

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 Residents (Resident #1 and Resident #2). CNA A, while performing incontinent care on Resident #1, did not perform hand hygiene and did not change gloves after cleaning the Resident and before applying the clean brief. CNA B, while performing incontinent care on Resident #,2 did not perform hand hygiene and did not change gloves after cleaning the Resident and before applying the clean brief. These failures have the potential to affect all residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: During an observation, 12/21/20 at 10:55 AM CNA B, while performing incontinent care for Resident #1, did not change gloves or perform hand hygiene between removing dirty brief and placing clean brief onto resident. After placing resident in a clean brief and incontinence care completed, CNA B changed gloves, however, no hand hygiene was performed between glove change. During an interview, 12/21/20 at 10:57 AM, CNA B stated, the appropriate time to perform hand hygiene or change gloves during incontinence care, is after cleaning the resident, disposing of the dirty brief and after placing a clean brief on the resident and then will change gloves prior to re-dressing resident. During an observation, 12/21/20 at 11:19 AM CNA A, while performing incontinent care for Resident #2, did not change gloves or perform hand hygiene between removing dirty brief and placing clean brief onto resident. After placing resident in a clean brief and incontinence care completed, CNA A changed gloves, however, no hand hygiene was performed between glove change. During an interview, 12/21/20 at 11:22 AM, CNA A stated the appropriate time to perform hand hygiene or change gloves during incontinence care, is after cleaning the resident, disposing of the dirty brief and after placing a clean brief on the resident and then will change gloves prior to re-dressing resident. During an interview, 12/21/20 at 12:16 PM, DON stated, staff are spot checked weekly for incontinence care, hand hygiene and PPE donning and doffing. DON also stated staff are trained to perform hand hygiene and don gloves prior to starting incontinence care, change gloves and perform hand hygiene when going from a dirty to clean area and then doff gloves and perform hand hygiene after completion of incontinence care. Record Review 12/21/20 of Perineal Care, dated 2/2020, states: Procedure: 7. Change gloves between tasks and/or when gloves are visibly soiled. Record Review 12/21/20 of Hand Hygiene, dated 9/2/2020, states: MNRC personnel shall wash their hands or use alcohol-based hand sanitizer to prevent the spread of infection: 3. Before and after wearing gloves a. Gloves are to be changed between tasks on the same resident. Record Review 12/21/20 of Incontinent Care Skills Checkoff, undated, states: *Washes rest of perineal area of perineal area working side to side-wipe and fold technique or using clean wipe with each swipe. *Washes hands and changes glove *Pats dry working towards back (if needed) *Change gloves *Turn resident to side . *Wipes from anus working side to side side-wipe and fold technique or using clean wipe with each swipe . *Change gloves/sanitize or clean hands *Reposition resident on back

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 common areas (Recreation area and South Hall) reviewed for infection control. CNA A failed to always wear a face mask in the facility as mandated during the COVID-19 Pandemic while assisting residents in the recreation area. MA B failed to always wear a face mask in the facility as mandated during the COVID-19 Pandemic while in the south hall. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections, particularly COVID-19. Findings include: During an observation on 08/12/20 at 11:20AM, CNA A was assisting residents in the recreation area and her face mask was only covering her mouth and her nose was outside the mask. CNA A was in close proximity to resident's face assisting with resident positioning. During an interview on 08/12/20 at 11:22AM, CNA A said her mask had slipped down. When asked about infection control and PPE training, she said they had one yesterday. CNA A confirmed that she knew she needed to have her mask over her nose and mouth. During an interview on 08/12/20 at 1:25PM, DON stated that staff should be wearing PPE properly, being fully covering their mouth and nose. During an interview on 08/12/20 at 1:55PM, ADM stated staff are required to wear masks properly and masks are always to be worn around residents. When asked about their policy and procedure, he stated that they follow the CDC guidelines. During an observation on 08/12/20 at 3:20PM, MA B was in south hall by medication cart speaking with another staff member with her face mask only covering her mouth and her nose was outside the masks. During an interview on 08/12/20 at 3:32PM, MA B said that it slips off her nose. When asked if she had training on proper wearing of masks, she stated yes. Record review of facility's undated CDC handout titled Sequence for putting on personal protective equipment indicted: 2. MASK OR RESPIRATOR Secure ties or elastic bands at middle of head and neck Fit flexible band to nose bridge Fit snug to face and below chin Fit-check respirator Record review of Executive Order GA 29, dated 7-2-2020, reflected in part: NOW, THEREFORE, I, Greg Abbott, Governor of Texas, by virtue of the power and authority vested in me by the Constitution and laws of the State of Texas, do hereby order the following on a statewide basis effective at 12:01 p.m. on July 3, 2020: Every person in Texas shall wear a face covering over the nose and mouth when inside a commercial entity or other building or space open to the public, or when in an outdoor public space, wherever it is not feasible to maintain six feet of social distancing from another person not in the same household; Record review of Nursing Facility COVID-19 Response Emergency Rule, not dated, reflected in part: (k) All nursing facility staff must wear facemasks while in the facility. (m) If an executive order or other direction is issued by the Governor of Texas, the President of the United States, or another applicable authority, that is more restrictive than this rule or any minimum standard relating to a nursing facility, the nursing facility must comply with the executive order or other direction. Although requested, no policies related to wearing face mask were provided.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 1 resident (Resident #1) reviewed. The facility failed implement their written policies and procedures that prohibit and prevent abuse in that the facility failed to report an allegation of neglect involving Resident #1 to the State Survey Agency within 2 hours of the allegation being made. This failure could affect residents by placing them at risk of not having incidents of abuse, neglect, exploitation, and misappropriation of resident property being reviewed and investigated in a timely manner by the facility and State Survey Agency. The Findings Include: Record review of an undated document provided by the facility titled Reporting Procedure to the Texas Department of Aging and Disability Services included: The following procedure will be followed for any incident that has to be reported to the Department of Aging and Disability Services in Austin, Texas: 1) The facility must report incidents to the Consumer Rights and Service Sections, Department of Aging and Disability State Office Immediately (within 24 hours) upon learning of the incident and send a written investigation report to the Consumer Rights and Services Section no later the 5th working day after the oral report. Record review of Resident #1's clinical records revealed a [AGE] year-old female admitted to the facility 01/19/17. Her [DIAGNOSES REDACTED]. Record review of her Quarterly MDS dated [DATE] revealed a BIMS score is 02 out of 15, indicating severe cognitive impairment. Record review of Resident #1's Quarterly MDS section G dated 06/25/20 revealed she is a one-person assist with locomotion. Record review of Provider Investigation Report revealed that on 07/23/20 CNA A was going help Resident #1 in her wheelchair to her room. CNA A told Resident #1 to lift her feet up. When CNA A started pushing resident, her feet went down, and Resident #1 fell forward out of the wheelchair. It was revealed that on 07/24/20 that Resident #1 had a broken femur. Resident #1 had surgery on 07/27/20 and this is when the allegation was reported to the State Office on 07/29/20. During an interview on 08/12/20 at 12:04PM, CNA A stated that she was going to take Resident #1 to her room from the nurse's station. CNA A stated she asked Resident #1 to put her legs up and when she started to push her, the resident's feet went down, and she fell out of the wheelchair. CNA A stated she got help and put her in her wheelchair. CNA A stated the ADON was present during the incident. During an interview on 08/12/20 at 12:30PM, ADON stated that she heard CNA A tell Resident #1 to pick up her feet and then heard staff say, we need help. ADON stated that CNA A told her what happened. ADON did assessment on Resident #1 and she was not having any pain with movements. ADON stated the following morning, Resident #1was at nurse's station and eating her breakfast when she said her knee was hurting and when ADON touched her left leg, Resident #1 would scream. They called the hospitalist for x-rays and within 10 minutes he saw her. She stated that fall happened on 24th and on the 25th Resident #1 said it hurt and x-ray confirmed her femur was broken. Resident #1 had surgery a few days later. During an interview on 08/12/20 at 1:51PM, ADM stated the protocol on reporting is within 2 hours or 24 hours. When asked about the incident, he said he must have missed this one. He confirmed that it should have been reported within the time frame.

Based on interview and record review, it was determined 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, were reported immediately, but not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) after the allegation was made in accordance with State law for 1 of 1 residents (Resident #1) reviewed. The facility failed to report an allegation of neglect involving Resident #1 to the State Survey Agency within 2 hours of the allegation being made. This failure could affect residents by placing them at risk of not having incidents of abuse, neglect, exploitation, and misappropriation of resident property being reviewed and investigated in a timely manner by the facility and State Survey Agency. The Findings Include: Record review of Resident #1's clinical records revealed a [AGE] year-old female admitted to the facility 01/19/17. Her [DIAGNOSES REDACTED]. Record review of her Quarterly MDS dated [DATE] revealed a BIMS score is 02 out of 15, indicating severe cognitive impairment. Record review of Resident #1's Quarterly MDS section G dated 06/25/20 revealed she is a one-person assist with locomotion. Record review of Provider Investigation Report revealed that on 07/23/20 CNA A was going help Resident #1 in her wheelchair to her room. CNA A told Resident #1 to lift her feet up. When CNA A started pushing resident, her feet went down, and Resident #1 fell forward out of the wheelchair. It was revealed that on 07/24/20 that Resident #1 had a broken femur. Resident #1 had surgery on 07/27/20 and this is when the allegation was reported to the State Office on 07/29/20. During an interview on 08/12/20 at 12:04PM, CNA A stated that she was going to take Resident #1 to her room from the nurse's station. CNA A stated she asked Resident #1 to put her legs up and when she started to push her, the resident's feet went down, and she fell out of the wheelchair. CNA A stated she got help and put her in her wheelchair. CNA A stated the ADON was present during the incident. During an interview on 08/12/20 at 12:30PM, ADON stated that she heard CNA A tell Resident #1 to pick up her feet and then heard staff say, we need help. ADON stated that CNA A told her what happened. ADON did assessment on Resident #1 and she was not having any pain with movements. ADON stated that the following morning, Resident #1was at nurse's station and eating her breakfast when she said her knee was hurting and when ADON touched her left leg, Resident #1 would scream. They called the hospitalist for x-rays and within 10 minutes he saw her. She stated that fall happened on 24th and on the 25th Resident #1 said it hurt and x-ray confirmed her femur was broken. Resident #1 had surgery a few days later. During an interview on 08/12/20 at 1:51PM, ADM stated the protocol on reporting is within 2 hours or 24 hours. When asked about the incident, he said he must have missed this one. He confirmed that it should have been reported within the time frame. Record review of an undated document provided by the facility titled Reporting Procedure to the Texas Department of Aging and Disability Services included: The following procedure will be followed for any incident that has to be reported to the Department of Aging and Disability Services in Austin, Texas: 1) The facility must report incidents to the Consumer Rights and Service Sections, Department of Aging and Disability State Office Immediately (within 24 hours) upon learning of the incident and send a written investigation report to the Consumer Rights and Services Section no later the 5th working day after the oral report.

Based on interview and record review, the facility failed to have a policy regarding the use and storage of foods brought to resident by family and other visitors to ensure safe and sanitary storage, handling, and consumption. The facility failed to have a policy for storage of food brought in by visitors or family. This failure has the potential to affect all residents in the facility by placing them at risk for consuming food that has not been handled in a safe and sanitary manner. Findings include: Record Review of CMS Entrance Conference Worksheet revealed this policy is to be provided by the facility within one hour after the survey has been initiated. The Entrance Conference worksheet was reviewed with the DON on 1-14-2020 at 09:02 AM. During an interview on 01/14/20 at 3:45 PM upon request for policy on food brought into the facility the ADM stated, We do not have a policy on food brought into the facility. The hospital has a policy but that's not what we do here.

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 14 (Residents #1, #5, #7, #8, #11, #13, #14, #16, #19, #21, #29, #30, #33, and #35)of 16 residents reviewed for comprehensive care plans. -The facility failed to care plan the use of bed rails for Residents #1, #5, #7, #8, #11, #13, #14, #16, #19, #21, #29, #30, #33, and #35 This failure could affect all residents in the facility receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Finding include: Resident #1 Record review of Resident #1's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 12-14-2017 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's last MDS was a quarterly dated 9-19-2019 with a BIMS of 5 indicating she is severely cognitively impaired and a functional status of requiring one-person assistance with all activities. Record review of Resident #1's care plan revealed the use of bed rails was not careplanned. During an observation on 01/14/20 at 09:48 AM, Resident #1 was sitting in her wheelchair in her room. Noted were bilateral 1/4 padded bed rails that were in the raised position on her bed. Resident #5 Record review of Resident #5's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 7-6-2017 with [DIAGNOSES REDACTED]. Record review of Resident #5's last MDS was a quarterly dated 10-10-2019 with a BIMS of 15 indicating she is cognitively intact and a functional status of requiring one-person assistance with most activities. Record review of Resident #5's care plan revealed the use of bed rails was not careplanned. During an observation on 01/14/20 at 09:58 AM Resident #5 was up in her wheelchair next to her bed. Noted on her bed was a right side 1/4 bedrail that was up and in place. Resident #7 Record review of Resident #7's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 4-18-2018 with [DIAGNOSES REDACTED]. Record review of Resident #7's last MDS was a quarterly dated 10-24-2019 with a BIMS of 99 indicating Resident #7 was unable to complete the interview due to memory problems and she had a functional status of requiring one-person assistance with most activities. Record review of Resident #7's care plan revealed the use of bedrails was not careplanned. During an observation on 01/14/20 at 09:32 AM Resident #7 was noted sitting up in a rocker holding a baby doll. Observed on her bed were bilateral 1/4 bed rails up and in place. Resident #8 Record review of Resident #8's clinical record revealed an [AGE] year-old male resident admitted to the facility originally on 04/18/2019 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's MDS was a quarterly done on 10/24/2019 with a BIMS of 6 indicating severe cognitive impairment and a functional status of requiring one-person physical assistance with most activities. Record review of Resident #8's care plan revealed the use of bedrails was not careplanned. During an observation on 01/15/2020 at 3:24 PM Resident #8 was not in room. Noted ½ bedrail on right side in lowered position and ¼ bedrail on left side in raised position. Resident #11 Record review of Resident #11's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 05/07/2009 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 11's last MDS was a quarterly dated 10/31/19 with a BIMS of 9 indicating she was moderately cognitively impaired and a functional status of one-person physical assistance with most activities. Record review of Resident #11's care plans revealed the use of bedrails was not careplanned. During an observation on 1/15/2020 at 3:58 PM Resident #11's bed was seen to have ¼ bed rail up on left side. No bed rail was observed on the right side of the bed. Resident #13 Record review of Resident #13's clinical records revealed an [AGE] year-old male admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #13's last MDS was a quarterly dated 10-31-2019 with a BIMS of 7 indicating he is severely cognitively impaired and has a functional status of requiring one-person assistance with some activities. Record review of Resident #13's care plan revealed the use of bedrails was not careplanned. During observation on 01-14-2020 at 9:58 AM Resident #13 was sitting in his wheelchair watching tv. Noted were bilateral ¼ bed rails that were in the raised position on his bed. Resident #14 Record review of Resident #14's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 7-23-2019 with [DIAGNOSES REDACTED]. Record review of Resident #14's last MDS was a quarterly dated 10-31-2019 with a BIMS of 7 indicating she is severely cognitively impaired and a functional status of requiring one or two person assistance with all activities. Record review of Resident #14's care plan revealed the use of bedrails was not careplanned. During an observation on 01/14/20 at 09:41 AM Resident #14 was noted sitting next to her bed in her wheelchair. Resident #14 was noted to have a 1/2 bed rail up in the middle portion of the right side of her bed. When questioned concerning the use of the rails Resident #14 stated, I have my own way of doing things. I don't really need the bed rail at all. Resident #16 Record review of Resident #16's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #16's last MDS was a quarterly review dated 11/7/2019 with a BIMS of 2 indicating she was severely cognitively impaired and a functional status of requiring one-person physical assistance with most activities. Record review of Resident #16's care plan revealed the use of bedrails was not careplanned. During an observation on 01/15/2020 at 4:03 PM Resident #16 was noted in bed sleeping with ½ bedrail on the right side against the wall down and ¼ bedrail on the left side in the raised position. Resident #19 Record review of Resident #19's clinical record revealed an [AGE] year-old male resident admitted [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #19's last MDS was an annual dated 11-14-2019 with a BIMS of 99 indicating he is severely cognitively impaired and a functional status of requiring one-person assistance with all activities. Record review of Resident #19's care plan revealed the use of bedrails was not careplanned. During observation on 01-15-2020 at 3:15 AM Resident #19 was sitting in his wheelchair in his room. Noted were the bilateral ¼ bed rail located on the right side in the raised position on his bed. Resident # 21 Record review of Resident # 21's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 07/26/2018 and readmitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's last MDS was a quarterly dated 11/21/19 with a BIMS of 6 indicating she was severely cognitively impaired and a functional status of requiring one-person physical assistance with all activities. Record review of Resident # 21's care plan revealed the use of bedrails was not careplanned. During an observation on 01/15/2020 at 3:28 PM Resident #21 was lying in bed ½ bed rail on right side against the wall was down. Noted ¼ bed rail on left side was in raised position on her bed. Resident #29 Record review of Resident #29's clinical records revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #29's last MDS was an annual dated 12-05-2019 with a BIMS of 8 indicating he is moderately cognitively impaired and has a functional status of requiring one-person assistance with some activities. Record review of Resident #29's careplan revealed the use of bedrails was not careplanned. During observation on 01-15-2020 at 3:16 PM Resident 29 was not in his room. Noted were bilateral ¼ bed rails that were in the raised position on his bed. Resident #30 Record review of Resident #30's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 11-20-2018 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #30's last MDS was an annual dated 12-5-2019 with a BIMS of 9 indicating she is moderately cognitively impaired and a functional status of requiring one-person assistance with all activities. Record review of Resident #30's care plan revealed the use of bedrails was not careplanned. During an observation on 01/14/20 at 09:38 AM Resident #30 was not in her room. Noted were bilateral 1/4 bed rails that were up and locked in place at the head of her bed. Resident #33 Record review of Resident #33's clinical records revealed an [AGE] year-old female admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #33 last MDS was a quarterly dated 12-12-2019 Resident does not have a BIMS score due to not being able to complete the test. Resident #33 is indicated as being severely cognitively impaired and has a functional status of requiring one-person assistance on all activities. Record review of Resident #33's care plan revealed the use of bedrails was not careplanned. During observation on 01-15-2020 at 3:22 PM Resident 33 was laying in her bed on her left side. Noted were bilateral ¼ bed rails that were in the raised position on her bed. Resident #35 Record review of Resident #35's clinical record revealed an [AGE] year-old female resident admitted originally on 10/12/2015 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 35's last MDS was a quarterly on 12/19/2019 with a BIMS of 3 indicating she was severely cognitively impaired and a functional status of requiring one-person-physical assistance with most activities. Record review of Resident #35's care plan revealed the use of bedrails was not careplanned. During an observation on 01/15/2020 at 3:52 PM 1/2 bedrails were noted on the right side of the bed against the wall in the lowered position. Noted on the left side of the bed were 1/4 bedrails in the raised position. During an interview on 01/15/20 at 01:56 PM when questioned if the facility had consents for the use of bedrails for residents ADON A stated, We don't have a bedrail consent form. We don't have anything (care plans, ongoing monitoring, or physician orders) for bedrails. We've never done anything for bedrails. We only have one resident who doesn't have them up and that's because the Dr ordered them to be down because the resident often crawls out of bed and falls. During an interview on 01/15/20 at 02:00 PM when questioned with the ADON A present concerning the facility's current practice for the use of bed rails the ADM stated, I don't think we have anything. There's not anything that I know of and that's my fault. I know that bed rails are an important issue and one we should be addressing. During an interview on 01/16/20 at 09:23 AM when questioned if a resident with bed rails should have the bed rails include in their care plan ADON A stated, If they are using them then yes. During an interview on 01/15/20 at 04:38 PM when presented with a list of requested policies the ADM stated, I can tell you right now we do not have a policy on bed rails. The facility did not provide a policy for comprehensive care plans.

Based on observation, interview, and record review the facility failed to attempt the use of an alternative prior to using bedrails, failed to assess the residents for risk of entrapment from bed rails, and failed to review the risks and benefits of bed rails with the residents or resident representatives and obtain informed consent prior to installation for 15 (Residents #1, #5, #7, #8, #11, #13, #14, #16, #19, #21, #29, #30, #33, #35, and #186)of 16 residents reviewed for bedrails. The facility failed to attempt the use of an alternative prior to using bedrails, assess the residents for the use of bed rails, inform the residents or their representative of the use of bed rails, and obtain consent for the use of bed rails. This deficient practice could place all residents who use bed rails at risk for injuries such as abrasion, fractures, entrapment, and death from suffocation. Finding include: Resident #1 Record review of Resident #1's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 12-14-2017 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's last MDS was a quarterly dated 9-19-2019 with a BIMS of 5 indicating she is severely cognitively impaired and a functional status of requiring one-person assistance with all activities. Record review of Resident #1's clinical record revealed no orders for bedrails, no consent for bed rails, no ongoing monitoring of bed rails. During an observation on 01/14/20 at 09:48 AM Resident #1 was sitting in her wheelchair in her room. Noted were bilateral 1/4 padded bed rails that were in the raised position on her bed. Resident #5 Record review of Resident #5's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 7-6-2017 with [DIAGNOSES REDACTED]. Record review of Resident #5's last MDS was a quarterly dated 10-10-2019 with a BIMS of 15 indicating she is cognitively intact and a functional status of requiring one-person assistance with most activities. Record review of Resident #5's clinical record revealed no orders for bedrails, no consent for bed rails, no ongoing monitoring of bed rails. During an observation on 01/14/20 at 09:58 AM Resident #5 was up in her wheelchair next to her bed. Noted on her bed was a right side 1/4 bedrail that was up and in place. Resident #5 was unable to respond to questions concerning the bedrail. Resident #7 Record review of Resident #7's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 4-18-2018 with [DIAGNOSES REDACTED]. Record review of Resident #7's last MDS was a quarterly dated 10-24-2019 with a BIMS of 99 indicating Resident #7 was unable to complete the interview due to memory problems and she had a functional status of requiring one-person assistance with most activities. Record review of Resident #7's clinical record revealed no orders for bedrails, no consent for bed rails, no ongoing monitoring of bed rails. During an observation on 01/14/20 at 09:32 AM Resident #7 was noted sitting up in a rocker holding a baby doll. Resident #7 was frequently changing positions but unable to answer any questions. Observed on her bed were bilateral 1/4 bed rails up and in place. Resident #8 Record review of Resident #8's clinical record revealed an [AGE] year-old male resident admitted to the facility originally on 04/18/2019 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's MDS was a quarterly done on 10/24/2019 with a BIMS of 6 indicating severe cognitive impairment and a functional status of requiring one-person physical assistance with most activities. Record review of Resident #8's clinical record revealed no orders for bedrails, no consent for bedrails, no ongoing monitoring of bed rails. During an observation on 01/15/2020 at 3:24 PM Resident #8 was not in room. Noted ½ bedrail on right side in lowered position and ¼ bedrail on left side in raised position. Resident #11 Record review of Resident #11's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 05/07/2009 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 11's last MDS was a quarterly dated 10/31/19 with a BIMS of 9 indicating she was moderately cognitively impaired and a functional status of one-person physical assistance with most activities. Record review of Resident #11's clinical record revealed no orders for bedrails, no consent for bed rails, no ongoing monitoring of bed rails. During an observation on 1/15/2020 at 3:58 PM Resident #11's bed was seen to have ¼ bed rail up on left side. No bed rail was observed on the right side of the bed. Resident #13 Record review of Resident #13's clinical records revealed an [AGE] year-old male admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #13's last MDS was a quarterly dated 10-31-2019 with a BIMS of 7 indicating he is severely cognitively impaired and has a functional status of requiring one-person assistance with some activities. Record review of Resident #13's clinical record revealed no orders for bedrails, no consent for bed rails, and no ongoing monitoring of bed rails. During observation on 01-14-2020 at 9:58 AM Resident #13 was sitting in his wheelchair watching tv. Noted were bilateral ¼ bed rails that were in the raised position on his bed. Resident #14 Record review of Resident #14's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 7-23-2019 with [DIAGNOSES REDACTED]. Record review of Resident #14's last MDS was a quarterly dated 10-31-2019 with a BIMS of 7 indicating she is severely cognitively impaired and a functional status of requiring one-two-person assistance with all activities. Record review of Resident #14's clinical record revealed no orders for bedrails, no consent for bed rails, no ongoing monitoring of bed rails. During an observation on 01/14/20 at 09:41 AM Resident #14 was noted sitting next to her bed in her wheelchair. Resident #14 was noted to have a 1/2 bed rail up in the middle portion of the right side of her bed. When questioned concerning the use of the rails Resident #14 stated, I have my own way of doing things. I don't really need the bed rail at all. Resident #16 Record review of Resident #16's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #16's last MDS was a quarterly review dated 11/7/2019 with a BIMS of 2 indicating she was severely cognitively impaired and a functional status of requiring one-person physical assistance with most activities. Record review of Resident #16's clinical record revealed no orders for bedrails, no consent for bedrails, no ongoing monitoring of bedrails. During an observation on 01/15/2020 at 4:03 PM Resident #16 was noted in bed sleeping with ½ bedrail on the right side against the wall down and ¼ bedrail on the left side in the raised position. Resident #19 Record review of Resident #19's clinical record revealed an [AGE] year-old male resident admitted [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #19's last MDS was an annual dated 11-14-2019 with a BIMS of 99 indicating he is severely cognitively impaired and a functional status of requiring one-person assistance with all activities. Record review of Resident #19's clinical record revealed no orders for bedrails, no consent for bed rails, and no ongoing monitoring of bed rails. During observation on 01-15-2020 at 3:15 AM Resident #19 was sitting in his wheelchair in his room. Noted were the bilateral ¼ bed rail located on the right side in the raised position on his bed. Resident # 21 Record review of Resident # 21's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 07/26/2018 and readmitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's last MDS was a quarterly dated 11/21/19 with a BIMS of 6 indicating she was severely cognitively impaired and a functional status of requiring one-person physical assistance with all activities. Record review of Resident # 21's clinical record revealed no orders for bedrails, no consent for bed rails, no ongoing monitoring of bed rails. During an observation on 01/15/2020 at 3:28 PM Resident #21 was lying in bed ½ bed rail on right side against the wall was down. Noted ¼ bed rail on left side was in raised position on her bed. Resident #29 Record review of Resident #29's clinical records revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #29's last MDS was an annual dated 12-05-2019 with a BIMS of 8 indicating he is moderately cognitively impaired and has a functional status of requiring one-person assistance with some activities. Record review of Resident #29's clinical record revealed no orders for bedrails, no consent for bed rails, and no ongoing monitoring of bed rails. During observation on 01-15-2020 at 3:16 PM Resident 29 was not in his room. Noted were bilateral ¼ bed rails that were in the raised position on his bed. Resident #30 Record review of Resident #30's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 11-20-2018 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #30's last MDS was an annual dated 12-5-2019 with a BIMS of 9 indicating she is moderately cognitively impaired and a functional status of requiring one-person assistance with all activities. Record review of Resident #30's clinical record revealed no orders for bedrails, no consent for bed rails, no ongoing monitoring of bed rails. During an observation on 01/14/20 at 09:38 AM Resident #30 was not in her room. Noted were bilateral 1/4 bed rails that were up and locked in place at the head of her bed. Resident #33 Record review of Resident #33's clinical records revealed an [AGE] year-old female admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #33 last MDS was a quarterly dated 12-12-2019 Resident does not have a BIMS score due to not being able to complete the test. Resident #33 is indicated as being severely cognitively impaired and has a functional status of requiring one-person assistance on all activities. Record review of Resident #33's clinical record revealed no orders for bedrails, no consent for bed rails, and no ongoing monitoring of bed rails. During observation on 01-15-2020 at 3:22 PM Resident 33 was laying in her bed on her left side. Noted were bilateral ¼ bed rails that were in the raised position on her bed. Resident #35 Record review of Resident #35's clinical record revealed an [AGE] year-old female resident admitted originally on 10/12/2015 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 35's last MDS was a quarterly on 12/19/2019 with a BIMS of 3 indicating she was severely cognitively impaired and a functional status of requiring one-person-physical assistance with most activities. Record review of Resident #35's clinical record revealed no orders for bedrails, no consent for bedrails, no ongoing monitoring of bedrails. During an observation on 01/15/2020 at 3:52 PM 1/2 bedrails were noted on the right side of the bed against the wall in the lowered position. Noted on the left side of the bed were 1/4 bedrails in the raised position. Resident #186 Record review of Resident #186's clinical records revealed a [AGE] year-old male admitted [DATE] with [DIAGNOSES REDACTED]. Resident #186 is newly admitted and there is no MDS to review at this time. Record review of Resident #186's clinical record revealed no orders for bedrails, no consent for bed rails, and no ongoing monitoring of bed rails. During observation on 01-15-2020 at 3:15 PM Resident 186 was lying in bed in a supine position in his room. Noted were bilateral ¼ bed rails in the raised position at the top portion of his bed. During an interview on 01/15/20 at 01:56 PM when questioned if the facility had consents for the use of bedrails for residents ADON A stated, We don't have a bedrail consent form. We don't have anything (care plans, ongoing monitoring, or physician orders) for bedrails. We've never done anything for bedrails. We only have one resident who doesn't have them up and that's because the Dr ordered them to be down because the resident often crawls out of bed and falls. During an interview on 01/15/20 at 02:00 PM when questioned with the ADON A present concerning the facilities current practice for the use of bed rails the ADM stated, I don't think we have anything. There's not anything that I know of and that's my fault. I know that's bed rails are an important issue and one we should be addressing. During an interview on 01/15/20 at 04:38 PM when presented with a list of requested policies the ADM stated, I can tell you right now we do not have a policy on bed rails.

Based on observations, interviews and record review, it was determined that for 1 of 8 sampled residents (Resident #1), the facility failed to implement policies and procedures that prohibit neglect when the facility failed to provide goods and services necessary to avoid physical harm. Resident #1, with Kyphosis (hump-backed), while being transported by CNA "A" out the front door of the facility in her wheelchair without footrests, fell forward out of the wheelchair at a depression at the end of the walkway. This failure resulted in Resident #1 sustaining a fractured left humerus (shoulder), and a head injury requiring sutures and an overnight stay in the hospital for observation and had the potential to affect an additional 22 residents at the facility residents at the facility who were wheeled by staff out of the facility to their physician's appointments. The evidence is as follows: 1) Observation on 2/23/12 at 9:35 a.m., of the site where the incident occurred, revealed a concrete walkway at the front entrance of the facility, with a seven foot long break in the curb where the walkway met the asphalt pavement, which created a concrete ramp at the point where the sidewalk ended and the asphalt pavement began. Settling of the asphalt and concrete over time created a depression between the two surfaces, with the concrete and asphalt sloping adjacently downwards at a depth of approximately 1/4 to 1/2 inch where the two surfaces met. 2) Observation during a re-enactment of the incident on 2/23/12 at 2:40 p.m., with surveyor sitting in a wheelchair without footrests, being maneuvered across the ramp on to the asphalt pavement by LVN "H", revealed feet without footrests were significantly caught at the depression once crossing from the concrete to the asphalt pavement. 3) Review of Resident #1's medical record documented the following: - The Record of Admission documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age. - The MDS annual resident assessment dated [DATE], documented a cognitive summary score of 8 out of a possible 15. It documented she had moderate hearing impairment and required use of a hearing appliance. It documented she required extensive one-person assistance with locomotion off the unit, and utilized a wheelchair for mobility. - A nursing progress note dated 1/17/12 at 9:00 a.m., by LVN "B", documented CNA "A" was taking Resident #1 to an appointment at Physician "C's" office. The note documented CNA "A" called LVN "B" to come outside because Resident #1 had fallen out of her wheelchair. It documented once outside, LVN "B" observed Resident #1 laying in a prone position, with her head turned to the right side and a bleeding laceration to the left side of her head. It documented Resident #1 verbalized pain to her head. 4) Review of diagnostic imaging reports dated 1/17/12, documented Resident #1 sustained a displaced [MEDICAL CONDITION] neck and anterior dislocation of the humeral head. Additionally, it documented a [DIAGNOSES REDACTED]. 5) Review of a physician's report dated 1/17/12 by Physician "C", documented Resident #1 was being taken in a wheelchair to his office when she fell forward onto the ground, fracturing her arm and lacerating her forehead. It documented the laceration was repaired. It documented further that Resident #1 was severely hard of hearing. 6) Review of the facility provided document titled "A Framework for a Root Cause Analysis and Action Plan In Response to a Sentinel Event" (no date), documented Resident #1 fell out of her on 1/17/12 at 8:30 a.m., while being transported to a Physician's appointment located across the street from the facility. It documented the following factors contributed to the incident: - Complacency of staff (CNA "A"), regarding the transporting procedure, as well as possibly being in a hurry to get to the appointment on time. - Pushing Resident #1 forward instead of backwards off the ramp. - Resident#1's hearing aides were not in working condition on the morning of the incident, which rendered her unable to hear CNA "A" tell her to hold on to the wheelchair armrests when going on to the pavement (from the concrete sidewalk ramp). - Lack of footrests on Resident #1's wheelchair left her feet dangling with increased risk of her feet getting caught. The top of one foot was later seen to be bruised and swollen, indicating her foot was caught on the pavement buildup at the end of the ramp. - The condition of the sidewalk ramp with a buildup of pavement created an unleveled surface, and was not appropriate for the transport. The document noted the potential existed for the incident to reoccur when other patients were transported to other services within the hospital/facility district, due to staff being used to transporting residents in their wheelchairs to appointments within close proximity to the facility. Also, the document was reported by the Administrator to have been completed on 1/24/12. 7) Review of the Provider Investigation Report dated 2/6/12, documented Resident #1 was alert, oriented, and capable of making informed decisions. It documented further that the laceration sustained by Resident #1 on the left side of her forehead required three sutures. It documented she also sustained a fractured left humerus. 8) Review of the facility provided document titled "Resident Providers" (no date), documented Physician "C" was the primary care physician for 22 residents at the facility, and identified 15 of the 22 residents (to include Resident #1), were wheeled by staff to their scheduled appointments in Physician "C's" office. Additionally, Physician "D" was the primary care physician for 13 residents at the facility, of which 8 residents were identified as wheeled by staff to their appointments at Physician "D's" office. This source identified a total of 23 residents who were wheeled to their appointments in their wheelchairs. 9) During an interview on 2/23/12 at 9:35 a.m., the Administrator said he had not yet scheduled repair of the asphalt at the ramp because the estimate he'd obtained sold asphalt repair mix by the ton, which was more than what would be required to level the surface at the ramp. During a subsequent interview at 1:10 p.m., the Administrator said he had not yet trained staff regarding changes made to prevent a reoccurrence of the incident. Additionally, the Administrator said two new wheelchairs with built in footrests obtained by the facility a week earlier ( 2/20/12), had not yet been utilized, and that he was waiting for two seatbelts to arrive for use with the wheelchairs. Lastly, the Administrator said that only residents whose primary care physicians were Physicians "C" and "D", had the potential to be affected, because all other residents were transported to their appointments by the facility transportation vehicle. 10) During interviews on 2/23/12 at 9:50 a.m., CNAs "E" and "F" acknowledged having frequently transported residents in wheelchairs across the threshold where the incident occurred. Both aides denied difficulty maneuvering wheelchairs across the unleveled surface, but stated due to Resident #1 having Kyphosis and having always sat hunched forward in her wheelchair, the risk was greater for Resident #1 to fall forward out of her wheelchair when being wheeled over an unleveled surface. Additionally, the aides said they were continuing to maneuver residents in their wheelchairs across the ramp, which had not yet been repaired. An interview with LVN "G" at 10:50 a.m., confirmed it was a common occurrence that staff maneuvered residents across the ramp in wheelchairs to physician appointments. 11) During an interview with Resident #1 on 2/23/12 at 10:00 a.m., when asked about the incident said "She (CNA "A"), wheeled me out like she was catching a train....I don't know if she (CNA "A"), hit something or what?" Resident #1 continued, "I flew out (of the wheelchair), like I had wings." Resident #1 then pointed to a 3/4 inch curved healing scar with sutures already removed on her left forehead, and the sling in which her left arm was resting. Resident #1 said she had been wheeled by staff over the ramp on prior occasions without incident, and that she felt the incident occurred due to excessive speed by CNA "A". 12) During an interview with the Maintenance Department head on 2/23/12 at 11:00 a.m., he said the depression at the ramp had been the result of settling in the asphalt and concrete over a period of years. He said the area had not yet been repaired because he was looking around the facility for other areas that were in need of asphalt repair due to the fact the asphalt could only be purchased by the ton. 13) During an interview on 2/23/12 at 12:50 p.m., CNA "A" said she had wheeled residents down the ramp at least fifty times before, all without incident. CNA "A" said Resident #1's feet were not resting on footrests, and got caught on the incline when the ramp ended and the asphalt pavement began, causing her to fall out of the wheelchair. CNA "A" continued, " I was holding on to her (Resident #1) left shoulder with my left hand and, pushing the wheelchair with my right hand. I told her to hang on, but I think she was not wearing her hearing aids and did not hear me." 14) An interview with CNA "G" on 2/23/12 at 12:55 p.m., confirmed Resident #1 was not wearing her hearing aide at the time of the incident. CNA "G" said one of the hearing aides had been corroded, so she had sent it out for repair on the morning of the incident after dressing Resident #1 for the day. 15) During an interview on 2/23/12 at 4:25 p.m., the Administrator said an in-service had been scheduled to educate staff regarding newly implemented safety precautions to prevent a reoccurrence of the incident, on 2/29/12 ( 43 days after the incident). 16) Review of the facility Policy and Procedure titled " Prevention, Identification and Investigation Program Policy" revised 8/15/2000, documented: - The facility shall exert every effort to insure against neglect. - The facility shall intervene to correct situations and settings of neglect as soon as practical, pursuant to TDHS rules and regulations. Note: TDHS is now known as the Texas Department of Aging and Disability Services. - Staff shall be alert to identify any and all activities that may affect overall safety and well-being of the residents. 17) Review of the CMS Form 672, Resident Census and Conditions of Residents, dated 2/23/12, documented the census was 47.

Based on observations, interviews and record review, it was determined that for 1 of 8 sampled residents (Resident #1), the facility failed to implement written policies and procedures that prohibit neglect when the facility failed to 1) prevent an incident of neglect, and 2) immediatly report, 1 of 1 incident of neglect to the state survey agency. Resident #1, with Kyphosis (hump-backed), while being transported by CNA "A" out the front door of the facility in her wheelchair without footrests, fell forward out of the wheelchair at a depression at the end of the walkway. The fall resulted in Resident #1 sustaining a fractured left humerus (shoulder), and a head injury requiring sutures and an overnight stay in the hospital for observation. The facility failed to identify the incident as neglect, and failed to immediatly report the incident until prompted to do so by Resident #1's family. Additionally, the facility failed to implement measures to prevent a reoccurrence of neglect. This failure had the potential to affect an additional 22 residents at the facility residents at the facility who were wheeled by staff out of the facility to their physician's appointments. The evidence is as follows: 1) Review of the facility Policy and Procedure titled " Prevention, Identification and Investigation Program Policy" revised 8/15/2000, documented: - The facility shall exert every effort to insure against neglect. - The facility shall intervene to correct situations and settings of neglect as soon as practical, pursuant to TDHS rules and regulations. Note: TDHS is now known as the Texas Department of Aging and Disability Services (DADS). Additionally, DADS Provider Letter #06-43 dated 1/3/07, which was attached to the facility policy and procedure, documented facilities must report incidents of neglect to state office immediatley (within 24 hours) upon learning of the incident. - Staff shall be alert to identify any and all activities that may affect overall safety and well-being of the residents. 2) Observation on 2/23/12 at 9:35 a.m., of the site where the incident occurred, revealed a concrete walkway at the front entrance of the facility, with a seven foot long break in the curb where the walkway met the asphalt pavement, which created a concrete ramp at the point where the sidewalk ended and the asphalt pavement began. Settling of the asphalt and concrete over time created a depression between the two surfaces, with the concrete and asphalt sloping adjacently downwards at a depth of approximately 1/4 to 1/2 inch where the two surfaces met. 3) Observation during a re-enactment of the incident on 2/23/12 at 2:40 p.m., with surveyor sitting in a wheelchair without footrests, being maneuvered across the ramp on to the asphalt pavement by LVN "H", revealed feet without footrests were significantly caught at the depression once crossing from the concrete to the asphalt pavement. 4) Review of Resident #1's medical record documented the following: - The Record of Admission documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age. - The MDS annual resident assessment dated [DATE], documented a cognitive summary score of 8 out of a possible 15. It documented she had moderate hearing impairment and required use of a hearing appliance. It documented she required extensive one-person assistance with locomotion off the unit, and utilized a wheelchair for mobility. - A nursing progress note dated 1/17/12 at 9:00 a.m., by LVN "B", documented CNA "A" was taking Resident #1 to an appointment at Physician "C's" office. The note documented CNA "A" called LVN "B" to come outside because Resident #1 had fallen out of her wheelchair. It documented once outside, LVN "B" observed Resident #1 laying in a prone position, with her head turned to the right side and a bleeding laceration to the left side of her head. It documented Resident #1 verbalized pain to her head. 5) Review of diagnostic imaging reports dated 1/17/12, documented Resident #1 sustained a displaced [MEDICAL CONDITION] neck and anterior dislocation of the humeral head. Additionally, it documented a [DIAGNOSES REDACTED]. 6) Review of a physician's report dated 1/17/12 by Physician "C", documented Resident #1 was being taken in a wheelchair to his office when she fell forward onto the ground, fracturing her arm and lacerating her forehead. It documented the laceration was repaired. It documented further that Resident #1 was severely hard of hearing. 7) Review of the facility provided document titled "A Framework for a Root Cause Analysis and Action Plan In Response to a Sentinel Event" (no date), documented Resident #1 fell out of her on 1/17/12 at 8:30 a.m., while being transported to a Physician's appointment located across the street from the facility. It documented the following factors contributed to the incident: - Complacency of staff (CNA "A"), regarding the transporting procedure, as well as possibly being in a hurry to get to the appointment on time. - Pushing Resident #1 forward instead of backwards off the ramp. - Resident #1's hearing aides were not in working condition on the morning of the incident, which rendered her unable to hear CNA "A" tell her to hold on to the wheelchair armrests when going on to the pavement (from the concrete sidewalk ramp). - Lack of footrests on Resident #1's wheelchair left her feet dangling with increased risk of her feet getting caught. The top of one foot was later seen to be bruised and swollen, indicating her foot was caught on the pavement buildup at the end of the ramp. - The condition of the sidewalk ramp with a buildup of pavement created an unleveled surface, and was not appropriate for the transport. The document noted the potential existed for the incident to reoccur when other patients were transported to other services within the hospital/facility district, due to staff being used to transporting residents in their wheelchairs to appointments within close proximity to the facility. Also, the document was reported by the Administrator to have been completed on 1/24/12. 8) Review of the Provider Investigation Report dated 2/6/12, documented Resident #1 was alert, oriented, and capable of making informed decisions. It documented further that the laceration sustained by Resident #1 on the left side of her forehead required three sutures. It documented she also sustained a fractured left humerus. 9) Review of the facility provided document titled "Resident Providers" (no date), documented Physician "C" was the primary care physician for 22 residents at the facility, and identified 15 of the 22 residents (to include Resident #1), were wheeled by staff to their scheduled appointments in Physician "C's" office. Additionally, Physician "D" was the primary care physician for 13 residents at the facility, of which 8 residents were identified as wheeled by staff to their appointments at Physician "D's" office.This source identified a total of 23 residents who were wheeled to their appointments in their wheelchairs. 10) During an interview on 2/23/12 at 9:35 a.m., the Administrator said he had not yet scheduled repair of the asphalt at the ramp because the estimate he'd obtained sold asphalt repair mix by the ton, which was more than what would be required to level the surface at the ramp. During a subsequent interview at 1:10 p.m., the Administrator said he identified the incident as an "accident" rather than as neglect. He continued, he did not report the incident to the state survey agency until 2/2/12, when Resident #1's son asked whether or not the incident had been reported to the state survey agency. Additionally, the Administrator said he had not yet trained staff regarding changes to prevent a reoccurrence of the incident, to include, ensuring only wheelchairs with footrests were used and maneuvering the wheelchairs backwards in order to have more control. The Administrator said two new wheelchairs with built in footrests obtained by the facility a week earlier ( 2/20/12), had not yet been utilized, and that he was waiting for two seatbelts to arrive for use with the wheelchairs. Lastly, the Administrator said that only residents whose primary care physicians were Physicians "C" and "D", had the potential to be affected, because all other residents were transported to their appointments by the facility transportation vehicle. 11) During interviews on 2/23/12 at 9:50 a.m., CNAs "E" and "F" acknowledged having frequently transported residents in wheelchairs across the threshold where the incident occurred. Both aides denied difficulty maneuvering wheelchairs across the unleveled surface, but stated due to Resident #1 having Kyphosis and having always sat hunched forward in her wheelchair, the risk was greater for Resident #1 to fall forward out of her wheelchair when being wheeled over an unleveled surface. Additionally, the aides said they were continuing to maneuver residents in their wheelchairs across the ramp, which had not yet been repaired. An interview with LVN "G" at 10:50 a.m., confirmed it was a common occurrence that staff maneuvered residents across the ramp in wheelchairs to physician appointments. 12) During an interview with Resident #1 on 2/23/12 at 10:00 a.m., when asked about the incident said "She (CNA "A"), wheeled me out like she was catching a train....I don't know if she (CNA "A"), hit something or what?" Resident #1 continued, "I flew out (of the wheelchair), like I had wings." Resident #1 then pointed to a 3/4 inch curved healing scar with sutures already removed on her left forehead, and the sling in which her left arm was resting. Resident #1 said she had been wheeled by staff over the ramp on prior occasions without incident, and that she felt the incident occurred due to excessive speed by CNA "A". 13) During an interview with the Maintenance Department head on 2/23/12 at 11:00 a.m., he said the depression at the ramp had been the result of settling in the asphalt and concrete over a period of years. He said the area had not yet been repaired because he was looking around the facility for other areas that were in need of asphalt repair due to the fact the asphalt could only be purchased by the ton. He said he hoped to have the work completed by the end of the month. 14) During an interview on 2/23/12 at 12:50 p.m., CNA "A" said she had wheeled residents down the ramp at least fifty times before, all without incident. CNA "A" said Resident #1's feet were not resting on footrests, and got caught on the incline when the ramp ended and the asphalt pavement began, causing her to fall out of the wheelchair. CNA "A" continued, " I was holding on to her (Resident #1) left shoulder with my left hand and, pushing the wheelchair with my right hand. I told her to hang on, but I think she was not wearing her hearing aids and did not hear me." 15) An interview with CNA "G" on 2/23/12 at 12:55 p.m., confirmed Resident #1 was not wearing her hearing aide at the time of the incident. CNA "G" said one of the hearing aides had been corroded, so she had sent it out for repair on the morning of the incident after dressing Resident #1 for the day. 16) During an interview on 2/23/12 at 4:25 p.m., the Administrator said an in-service had been scheduled to educate staff regarding newly implemented safety precautions to prevent a reoccurrence of the incident, on 2/29/12 ( 43 days after the incident). 17) Review of the CMS Form 672, Resident Census and Conditions of Residents, dated 2/23/12, documented the census was 47.