Every finding on record at Oakwood Manor Nursing Home

Based on interviews and record reviews, 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 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting allegations of abuse. The facility failed to ensure MA A reported an allegation of abuse to the Abuse Coordinator immediately when Resident #1 told them on 3/12/26 that CNA B was rough during care The facility failed to ensure MA E and CNA B reported an allegation of abuse, made by Resident #1, to the Administrator immediately when they learned of the allegation on 03/18/26. MA E reported the allegation to CNA B and CNA B then reported the allegation to LVN D. These failures could place residents at risk of further incidents of abuse, neglect, exploitation, and a decreased quality of life.Findings included: Record review of Resident #1's face sheet dated 03/21/26 indicated she was [AGE] years old, admitted on [DATE] and her diagnoses included metabolic encephalopathy (brain dysfunction), Alzheimer's (type of dementia that affects memory, thinking and behavior), anxiety (uncontrollable worry), wedge compression fractures of the T11-T12 vertebra (spinal injuries), wedge compression fracture of the first lumbar vertebra (spinal injury), pain, and bipolar disorder (mental health condition). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. She had intact cognitive function (BIMS-14). Record review of Resident #1's care plan dated 07/07/25 indicated she had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's. Interventions included to administer medications as ordered and keep the resident's routine consistent. Record review of Resident #1's care plan dated 03/19/26 indicated Resident #1 had verbal behavior symptoms directed toward others and alleged staff attacked her then reported she loved the same staff. Interventions included to allow time for the resident to express themselves and feelings and psychiatric consultation as indicated. Record review of the facility investigation dated 03/24/26, completed by the Administrator indicated an incident occurred on 03/07/26. The facility became aware of the incident on 03/18/26 at 4:40 p.m. and reported to HHS on 03/18/26 at 5:52 a.m. The allegation was noted as abuse. The APs were identified as CNA B and CNA C. CNA B and CNA C were suspended on 03/18/26. The allegation of abuse was not confirmed. Resident #1 was assessed on 03/18/26 with no injuries. The report indicated on 03/18/26 at approximately 4:40 p.m., Resident #1 reported to LVN D (typo-error; should read MA B) that about a week ago, CNA B and CNA C were giving her a bed bath, twisted her leg, and jumped on the bed. Resident #1 was being treated for a UTI. Resident #1 said she reported to her (family member). Family Member H indicated Resident #1 never reported any incident with staff and her leg pain was chronic. The allegation of abuse was not confirmed. Abuse and Neglect training (included reporting) began on 03/18/26 and included MA A, CNA B, and CNA C. Record review of CNA B's undated statement indicated On March 7th 2026 Saturday 6 [AM]-7 [AM] in the morning Resident #1 was the last bed bath [CNA C] and I had to do. [CNA C] and I never have done [Resident #1's] bath before, so we decided to do it together. We started her bed bath and bathed her like we normally do our bed baths. There was no complaints the whole time we were giving her her a bed bath. Monday (03/09/26) came and I worked on the same hall and there was still wasn't any complaint. [CNA C] and I worked Sunday (03/08/26) morning and everything was fine. [Resident #1] never said anything even after giving her tray or just going in her room to take care of her roommate. Four days had gone by that I didn't work and when I came to work Thursday March 12th, 2026 [MA A] told me that [Resident #1] was saying all this stuff about me and [CNA C]. I was off for four days after that and worked Tuesday March 17th, 2026 and today March 18th, 2026. When [MA E] told me a different story of what [Resident #1] said. The whole time [CNA C] and I gave [Resident #1] a bath was normal. She was a little cold but we told her we were trying to hurry. [MA E] that told me [Resident #1] complained to her that we got her wet when we gave her a bath. Record review of CNA C's statement dated 03/18/26 indicated On Saturday March 7th 2026 [CNA B] and I came to work and started on bath. [Resident #1] was the last bath given before breakfast trays were served. We had never done her bath before so we decided to do her bath together. We got her soap, lotion, deodorant, and clean clothes out to begin her bath. During her bath she didn't complain about any pain but complained she was wet. We did her bath like we would do any other resident here. After this event happened, nothing was told to me or [CNA B] until four days after it happened. I was not notified of any of this until March 18th almost two weeks after this happened. In between her bath and today [Resident #1] has never told me a complaint from her bath . Record review of MA E's undated statement indicated On March 18th [Resident #1] told me that [CNA B] was rough when giving her bath and she could (not) remember the other aides name, and she said that her legs were hurting really bad because they were jumping up and down on her legs. I then let [CNA B] know and she reported it to [LVN D] she told me this around 4:30 to 5:00 PM. There was no statement in the investigation from MA A for available for review. Record review of MA A's statement obtained by the facility on 03/31/26 indicated Resident #1 reported that CNA B was rough with her. She was unsure what day this occurred or which nurse she told. She did not remember the date. Record review of CNA B's time card indicated she worked 03/07/26, 03/08/26, 03/12/26, 03/17/26 and 03/18/26. Record review of CNA C's time card indicated she worked 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/13/26, 03/14/26, 03/15/26, and 03/16/26. During an interview on 03/31/26 at 8:55 a.m., the Administrator said she was the abuse coordinator. She said allegations of abuse were reportable to her or her designees immediately and to HHSC within 2 hours. She said she was informed of Resident #1's allegations on 03/18/26 at approximately 4:40 p.m. She said it was determined the allegations came from 03/07/26 when CNA B and CNA C gave her a bed bath. Resident #1 said they hurt her leg and jumped on her bed. She said Resident #1 was being treated for a UTI and her diagnoses included bipolar and hallucinations. She said Resident #1 would receive continued psychiatric services after treatment for the UTI was completed. She said Resident #1 never made any previous allegations against staff. She said Resident #1 indicated she never had any issues and stated she really liked CNA B and CNA C. She said CNA B and CNA C were suspended immediately pending the investigation. The allegation was not substantiated and they returned to work. She said the risk of not reporting allegation immediately placed residents at risk of further abuse. During an interview on 03/31/26 at 10:09 a.m., Resident #1 said CNA A and CNA B were rough when they gave her bath, twisted her leg and jumped on the bed. She said she did not remember exactly what day it was, but she did not want them in her room or to give her care or a bath. She said she was hurt. She said she believed it was done on purpose but did not know if it was abuse. She said she was not afraid of any of the staff. She said she told someone about the incident but could not remember the name of the staff or what date. During an interview on 03/31/26 at 10:17 a.m., LVN D said on 03/18/26 CNA B came to her and reported someone had told her Resident #1 said CNA B had attacked her and put too much water on her. She said she had to report the allegation to the Administrator. She said she called and texted the Administrator and then told the ADON because she could not reach the Administrator. She said CNA B was not allowed to continue any resident care and had to write a statement. She said CNA B was suspended immediately and left the facility. She said MA A did not report any allegations of staff being rough or abusive on 03/12/26. She said the risks of not reporting immediately could be continued abuse. During an interview on 03/31/26 at 10:46 a.m., CNA B said she had not provided Resident #1 a bath previously and asked CNA C to assist on 03/07/26. She said Resident #1 complained she was getting wet and they explained they would get her dry and dressed and then changed her sheets. She said Resident #1 was normally a bed bath because she did not get up for showers. She said she came to work on the 03/17/26, and she was not made aware of any issues or complaints. She said she returned to work on 03/18/26 and MA E told her Resident #1 said she was jumping on her bed and legs. She said she told LVN D immediately and LVN D said she had to report to the Administrator immediately. She said she wrote a statement and went home. She said she did not hurt Resident #1 and did not jump on her bed. She said staff being rough could be abuse. She said the risk of not reporting immediately could be further abuse. She said she was previously trained on abuse and reporting and was retrained upon her return to work after the investigation. During an interview on 03/31/26 at 11:01 a.m., CNA C said she was not aware of any allegations until she was called on 03/18/26 to make a statement. She said she and CNA B provided Resident #1 a bed bath on 03/07/26. She denied she or CNA B hurt Resident #1 or jumped on the bed or her legs. She said staff being rough could be abuse. She said the risk of not reporting immediately could be further abuse. She said she was previously trained on abuse and reporting and was retrained upon her return to work after the investigation. During an interview on 03/31/26 at 11:36 a.m. MA A said Resident #1 said on 03/12/26 (she could not recall the exact time) that CNA A was rough with her during care. She said she told Resident #1 that she did not think CNA A would be rough. She said Resident #1 did not say she was hurt or complain of pain. She said she went on the give medications to the next resident. She said she believed she told LVN D or whoever the nurse was on duty on 03/12/26 of Resident #1's allegation of staff being rough but she could not recall who she told. She said staff being rough could be abuse. She said abuse was reportable immediately to the nurse, DON, ADON, or Administrator. She said she did not report immediately to the Administrator. She said the risk of not reporting immediately could be further abuse. She said she was previously trained on abuse and reporting ad was retrained upon her return to work after the investigation. During an interview on 03/31/26 at 12:25, the ADON said MA A did not report to her on 3/12/26 the allegation CNA B was rough with Resident #1. She would have reported any allegation to the Administrator immediately. She said staff being rough could be abuse. She said she assessed Resident #1 on 03/18/26 and there were no injuries. During an interview on 03/31/26 at 1:03 p.m., TX LVN F said MA A did not report to her on 3/12/26 the allegation CNA B was rough with Resident #1. She would have reported any allegation to the Administrator immediately. She said staff being rough could be abuse. During and Interview on 03/31/26 LVN G said MA A did not report to her on 3/12/26 the allegation CNA B was rough with Resident #1. She would have reported any allegation to the Administrator immediately. During a clarification interview on 04/01/26 at 11:46 a.m., MA E said she was taking Resident #1's BP on 03/18/26 at approximately 4:30 -5:00 p.m. and Resident #1 reported CNA B and another CNA were rough during care. She said Resident #1 could not remember the second CNA's name. She said Resident #1 said her legs were hurting because the aides were jumping up and down on her legs. She said she told CNA B what Resident #1 said and CNA B reported to LVN D immediately. She said she did not report the allegation to the LVN D or the Administrator immediately. She said she should have reported immediately and had no excuses. She said residents were at risk of abuse if allegations were not reported immediately to the charge nurse or Administrator. Record review of the facility's Abuse Protocol dated 04/2019 indicated . 8. Any person observing an incident of Patient Abuse or suspecting Patient Abuse must immediately report such incidents to the Charge Nurse. The following information should be reported to the Charge Nurse: a. The name of the Patient involved; b. The date and time that the incident occurred; c. Where the incident took place; d. The name(s) of the person(s) committing the incident, if known; e. The name(s) of any witnesses to the incident; f. The type of abuse that was committed (i.e., verbal, physical, sexual, etc.); and g. Other information that may be requested by the Charge Nurse. 9. The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical or sexual abuse.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for one of two resident's (Resident #1) reviewed for respiratory care. The facility failed to obtain physician orders for Resident #1's continuous oxygen. The facility failed to ensure Resident #1's nasal cannula was changed when it was touching the carpet on the floor, and it was placed back on Resident #1. These failures could place residents at risk for respiratory infections, an incorrect amount of oxygen, and the risk of lung infections.Findings included: Record review of Resident #1's face sheet, dated 01/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hypertension (high blood pressure), dehydration, and right femur fracture (thigh bone fracture). Record review of Resident #1's Comprehensive MDS assessment, dated 01/12/26, reflected Resident #1 had a BIMS of 03, which indicated he had severe cognitive impairment. The MDS did not reflect Resident #1 was on oxygen therapy while at the facility. Record review of Resident #1's Comprehensive Care Plan, date initiated 01/06/26, reflected there was no indication of Resident #1's need for oxygen therapy. Record review of Resident #1's Physician's Order summary report, dated 01/14/26, reflected no physician order for oxygen use. Record review of Resident #1's physician order summary report, dated 01/15/26, and after state surveyor intervention reflected Oxygen: Oxygen at 2 L per nasal cannula every shift. Active 01/15/2026. During observations on 01/14/26 at 01:15 p.m., 02:15 p.m., and 03:00 p.m. indicated Resident #1 was lying in bed. The oxygen nasal cannula had a date of 1/11/26. The oxygen nasal cannula was off, thrown over to the opposite side of his bedside table, and the two prongs that inserted into the resident's nostrils were touching the carpeted floor. The oxygen concentrator and the humidifier were on and set at 2 L. The resident was not interview able. During an observation on 01/15/26 at 08:09 a.m. Resident #1 was lying in bed. The oxygen nasal cannula was on and had the label dated 1/11/26. The oxygen concentrator and humidifier were on. The oxygen concentrator was set at 2 L. During an interview with LVN A on 01/15/26 at 09:38 a.m. LVN A had been Resident #1's nurse on 01/14/26 and 01/15/26. LVN A stated Resident #1 could have been admitted with oxygen or his oxygen decreased overnight and it was placed on the resident urgently. She stated, I don't know.on our click offs we check off oxygen for an order of oxygen. If there was an order, it would be in the electronic health record. A nurse might have received a verbal order and forgot to enter it into the electronic health record. She stated it could have been any nurse that missed the oxygen order. LVN A stated they have in-serviced on oxygen protocols. LVN A stated an example of what could have happened, was if the resident had COPD (Chronic Obstructive Pulmonary Disease) and the oxygen was set too high, the resident could have been over oxygenated. LVN A stated that if a nasal cannula was found on the ground, it should be replaced to prevent infection due to germs being on the floor. During an interview with the DON on 01/15/26 at 10:11 a.m. she indicated oxygen should be administered according to physician orders. The DON stated the nurses were responsible to ensure orders were completed and the settings were correct for oxygen administration. She stated oxygen was a medication and was used for sustaining life. She stated if the nasal cannula was touching the floor it needed to be changed because that would be an infection control issue. The DON stated respiratory trainings were completed annually and as needed. The DON stated she had started an oxygen administration audit and related in-services. Record review of LVN A's certificate of completion, dated 09/09/2025, reflected LVN A had successfully completed training in oxygen delivery modalities, pulse oximetry, and nebulized delivery of medications. The check-off lists were included and had the same date. Record review of the facility's policy, Special Needs, dated 2025, reflected To address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This policy pertains to the following needs: parental fluids, respiratory care, prosthesis, and dialysis. b. RNs and LPNs will participate in the management of medical conditions by following physician orders, assessment of residents, and reporting changes in condition to the resident's physician Record review of the facility's policy, Infection Prevention and Control Program, dated November 7, 2024, reflected The facility has established and maintains 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 as per accepted national standards and guidelines.10. Equipment protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs for 1 of 4 halls (hall 300) reviewed for controlled medications and 1 of 19 residents rooms reviewed for unsecured medication, and 1 of 1 medication rooms reviewed for expired medications. The facility failed to ensure controlled medications were counted on 12/14/25 between the night and day shift for the 300 hall med cart. The facility failed to ensure controlled medications were counted on 12/15/25 between the day and night shift for the 300 hall med cart. The facility failed to ensure no loose pills were left on the floor of Resident #98's room. The facility failed to ensure the expired fast acting dairy relief lactase supplement (dairy relief) was not in the medication storage room from current supply. This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion. Findings included: 1. Record review of the controlled counting sheet for between shifts, indicated the sheet contained shifts without documentation for300 hall med cart. The sheet was missing nursing signatures for 12/14/25 at 10:00 p.m. and 12/15/25 at 6:00 a.m. During an interview on 12/16/25 at 8:59 a.m., LVN B said she did not count the cart with the 10 p.m.-6 a.m. nurse, and that LVN C had a very bad night. She stated one of the residents was dying and she let the 10 p.m.-6 a.m. nurse leave without counting. She said she had been trained to count all narcotics when coming on her shift and when she was leaving the facility. She said they counted to prevent missing medications and drug diversion. During an interview on 12/16/25 at 2:00 p.m., LVN B said she could not remember if she counted Sunday morning. She said she normally counted unless there was an emergency with her family. She said she had been trained on counting controlled medications and the reason for counting was to prevent drug diversion. 2. Record review of a face sheet dated 12/15/25 indicated Resident #98 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hemiplegia affecting the right side (paralysis affecting one entire side of the body resulting from brain or spinal cord damage), liver transplant status (major surgery replacing a diseased liver with a healthy one from a donor), and history of cerebral infarct (death of brain tissue from a lack of blood flow). Record review of the admission MDS dated [DATE] indicated Resident #98 had a BIMS score of 13 indicating she had intact cognition with diagnoses of stroke, hemiplegia and liver transplant status. Record review of the care plan dated 11/25/25 indicated Resident #98 required pain medication therapy related to administration of pain medication. Record of physician's orders dated 12/15/25 indicated Resident #98 was prescribed baclofen 10 mg three times a day related to spasmodic torticollis (a painful neurological disorder causing involuntary neck contractions sometimes caused by a problem with the brain) with a started date of 11/06/25. During an observation and interview on 12/14/25 at 9:00 a.m., Resident #98 was lying in bed, and under Resident #98's bedside table was a small white pill on the floor. In an interview Resident #98 said she must have dropped her baclofen pill when she was trying to take her pills this morning. She said the nurse hands her a cup with her pills and she takes the pills out of the cup and lines them up on her napkin on her bedside table and checks them and then takes the pills. She said MA D gave her medications this morning and she lined them up on her bedside table and must have dropped the baclofen. She said the MA watched her take her pills but went back to her medication cart for a moment but came back to watch her finish. Resident #98 said she must have dropped the pill between that time. During an interview and observation on 12/14/25 at 9:24 a.m., MA D said she gave medication to Resident #98 this morning. She said the white pill under Resident #98's bedside table on the window side of her bed was her baclofen. She said the pill could have been dropped last night. She said she gave Resident #98 her pills this morning but Resident #98 takes all her pills out of the medicine cup and lines them up on her bedside table on a napkin and takes them one at a time, taking a long time to take them sometimes up to an hour. MA D said she watched Resident #98 take all her pills this morning. She said she did walk back to her medication cart at the door and check something while Resident #98 was taking her pills and Resident #98 may have dropped the pill at that time when she was not looking. She said she did not see the pill on the floor until surveyor intervention. MA D said it was the facility policy to give the resident their pills and stand and watch the resident take all the pills before they turned and left the room. She said she had been educated to give a resident all the prescribed pills for a medication pass and stand and watch the resident until all pills were consumed and not leave the resident until the medication pass was completed. The risk of a resident dropping some of their prescribed medication on the floor was the medication may not be as beneficial to the resident if she did not receive all of them. During an interview on 12/15/25 at 1:00 p.m., the DON said the charge nurse or MA that was providing medication to a resident was responsible for ensuring that resident received all medications given on each medication pass. She said the charge nurse or MA giving medication were to stay with the resident until the medications prescribed were all taken and not leave a resident with any medication. The DON said the charge nurses and MAs were all educated on medication administration protocol. She said Resident #98 possibly dropped the medication or knocked them to the floor when MA D went back to her medication cart. She said the risk was that a resident may not receive their medication as prescribed. The DON said her expectation was all medications were given by the MA and charge nurses as prescribed and none left with the resident or on the resident's table. She said the MAs and charge nurses were expected stay and watch the resident take all medication given. During an interview on 12/15/25 at 4:00 p.m., the Administrator said the nurse or MA giving medication to a resident was responsible for ensuring the resident took all medications provided and no medications were dropped on the floor. She said all nurses and MAs had been educated on administration of medication properly. The Administrator said the medication on the floor was possibly overlooked, she said it was possibly dropped by the resident when the MA went back to her medication cart. She said the resident risk of medication dropped on the floor was not following physician orders. The Administrator said her expectation was all medication administered properly and timely. Record review of a facility policy titled, Medication Administration, revised 2025, indicated, . Medications are administered by licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.18. observe resident consumption of medication. Record review of a facility in-service titled, Medication Administration dated 11/11/12/25 and signed by MA D, indicated,. 2. The 7 rights of Medication Administration. 1. Right person. Before medication prep identify correct patient and their readiness to receive medications. e. ensure that resident swallow medications before walking away and drinks all of the liquid medication/supplement due. F. If a pill drops anywhere, discard in a manner which it cannot be accessed by other residents and prepare the dose again. During an observation of the medication storage room on 12/14/2025 at 10:35 a.m., revealed a box of fast acting dairy relief lactase enzyme supplement (dairy relief) 32 chewable t tablets with an expiration date of 08/25 was in the medication storage room with current supply. During an interview on 12/14/25 at 11:15 a.m., the Interim DON for 12/14/2025 said only non- expired medications should be in the facility for use. She said nursing staff were responsible for ensuring expired medications were removed from current use medications and properly discarded of. During an interview 12/16/25 at 10:50 a.m., the Administrator said the unit manager, charge nurses and the DON were responsible for ensuring expired medications were removed and properly discarded. She said her expectation was not to have expired medication in the facility. She said the potential risk was that the expired medications may not be as effective, and it could potentially be a sanitation issue. Record review of facility policy titled Medication Storage dated 12/1/2025 indicated in part: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 treatment cart and 1 of 1 medication storage rooms reviewed for storage of drugs and biologicals. The facility failed to ensure the treatment cart was locked and secured when the Wound Care Nurse left the treatment cart unlocked and unattended on [DATE] at 7:45 a.m. The facility failed to ensure the treatment cart #1 was locked and secured when the Wound Care Nurse left the treatment cart unlocked and unattended on [DATE] at 9:42 a.m. The facility failed to ensure Hall200's medication aides' medication cart was free of loose pills at the bottom of the medication cart on [DATE] at 12:00 p.m. The facility failed to ensure medication carts were free of loose pills at the bottom of the medication cart. These failures could place residents at risk of medication misuse or drug diversion. The findings included: 1. During an observation and interview on [DATE] at 7:45 a.m. revealed the treatment cart was left unlocked and unattended in front of the nurse's station, facing out into the main pathway. The Wound Care Nurse said the cart should not have been left unlocked and unattended. 2. During an observation and interview on [DATE] at 9:42 a.m. on hall 400 the Wound Care Nurse left the treatment cart (drawers facing outward) unattended and unlocked (cart lock button was not pushed in indicating the cart was unlocked). Staff and residents had passed by the treatment cart that was left unlocked by the Wound Care Nurse. She had begun wound care in room [ROOM NUMBER], forgot needed supplies and went back to the treatment cart to retrieve supplies. She did not unlock the lock when she went back to retrieve supplies, nor did she lock the cart after the supplies were retrieved. During an interview on [DATE] at 9:50 a.m. with the Wound Care Nurse she said she did not lock the cart when she left the treatment cart the first time and when she went back to retrieve supplies. She said she should have locked the treatment cart to avoid anyone getting ahead to items that they should not have access to. She said she had been educated on the importance of locking the medication cart. During an interview on [DATE] at 11:10 a.m., the interim DON for [DATE], said the treatment cart should be locked when not in use by the nurse. She said the wound care nurse was responsible for ensuring her cart was locked. The DON said she makes rounds and checks the carts. During an interview [DATE] at 10:50 a.m., the Administrator said the treatment cart should be locked when not within the sight of the nurse assigned to the cart. She said the nurse that was assigned the cart was responsible for ensuring the cart was locked after use. 3. During an observation on [DATE] at 12:00 p.m. revealed Hall 200's medication aides' med cart had a total of 23 loose pills at the bottom of the medication cart: 2 large round white pills 2 white capsules 1 green round pill 1 white square pill 13 small white round pills 1 round orange pill 1 oval white pill 1 crushed orange/ tan pill 1 round orange pill During an interview on [DATE] at 12:10 p.m., the Interim DON for [DATE] said carts should be cleaned at the end of each shift ensuring there are no loose pills anywhere in the cart. During an interview [DATE] at 10:50 a.m., the Administrator said her expectation was for all carts to be locked, tidy, no expired medication, unlabeled meds, or things that did not belong in it. Record review of facility policy titled Medication Storage dated [DATE] indicated in part: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection control 1 of 4 halls (hall 400) observed for infection control. The facility failed to ensure the Wound Care Nurse wore personal protective equipment (gown) while doing wound care. The facility failed to ensure the Wound Care Nurse performed hand hygiene between glove changes while doing wound care. The facility failed to ensure the Wound Care Nurse sanitized the wound cleanser bottle before putting it back in the treatment cart. These failures could place residents at risk of cross-contamination and development of infections.The findings included: During an observation on 12/14/2025 at 8:45 a.m. revealed the Wound Care Nurse began and ended Resident #74 (on enhanced barrier precautions for wound care.) wound care without personal protective equipment (gown) on. The Wound Care Nurse removed Resident #74's soiled dressings then she changed her gloves and put on new ones without using hand hygiene. At 9:00 a.m. the Wound Care Nurse took the wound cleanser bottle out of Resident #74's room that she used and placed it back in the treatment cart without sanitizing it. During interview on 12/14/2025 at 9:42 a.m. with the Wound Care Nurse said she should have had the personal protective equipment (gown) on. She said wearing personal protective equipment (gown) protected the resident and herself from cross contamination. She said she had been trained and in-serviced on personal protective equipment (gown and gloves) and cross contamination. She said she should have used hand hygiene between glove changes when she did Resident #74's wound care. The Wound Care Nurse said she should have sanitized the wound cleanser bottle before putting the bottle back into the treatment cart. She said she was responsible for wearing personal protective equipment (gown and gloves) during wound care, sanitizing her hands between glove changes, and sanitizing the wound cleanser bottle before putting it back in the treatment cart. She said the associated risk is cross contamination to residents in the facility. During an interview on 12/14/2025 at 12:15 a.m. with the Interim DON, she said it was her expectation for staff to wear personal protective equipment (gown) during wound care and on residents that were on enhanced barrier precautions, sanitizing their hands between glove changes, and sanitizing the wound cleanser bottle before putting it back in the treatment cart. She said the Wound Care Nurse had been in- serviced and trained on enhanced barrier precautions and wearing personal protective equipment during wound care. During an interview on 12/16/2025 at 2:45 p.m. with the Administrator, she said herself and the Infection Preventionist were responsible for all infection control training. She said the Wound Care Nurse was responsible for proper infection control and hand hygiene during wound care. The Administrator said the Wound Care Nurse was educated on infection control. She said the potential associated risk was the spread of infection. She said her expectation was for all staff to follow infection control polices. Record review of facility policy tilted Infection Prevention and Control Program revision dated: 12/01/2025 indicated in part: Policy:This facility has established and maintains 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 as per accepted national standards and guidelines. Definitions: Staff includes all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions.Policy Explanation and Compliance Guidelines:1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases.2. All staff are responsible for following all policies and procedures related to the program.3. Surveillance:a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards.b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee.c. The RNs and LPNs participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections.4. Standard Precautions:a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.c. All staff shall use personal protective equipment (PPE) according to the established facility policy governing the use of PPE.d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.e. Environmental cleaning and disinfection shall be performed according to the facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department.5. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.b. Single-use disposable equipment is an alternative to sterilizing reusable medical instruments. Single-use devices must be discarded after use and are never used for more than one resident. c. Reusable items potentially contaminated with infectious materials shall be placed in an impervious clear plastic bag. Label bag as CONTAMINATED and place in the soiled utility room for pickup and processing.d. The central supply clerk will decontaminate equipment with a germicidal detergent prior to storing for reuse.

Based on interview and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents reviewed for resident rights. (Resident #67) The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #67. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Record review of a face sheet dated [DATE] indicated Resident #67 was an [AGE] year-old male admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), dementia (loss of cognitive functioning), and atrial fibrillation (a type of irregular heartbeat). Record review of an undated OOH-DNR indicated it was signed by Resident #67 but there was no and was signed by his physician but had no date. Record review of an undated care plan indicted Resident #67 requested code status of no CPR with an intervention of Make sure that code status is signed by [Resident #67] or responsible party and in the active medical record. During a record review and interview on [DATE] at 11:42 a.m., LVN A acknowledged Resident #67's OOH-DNR had no date for when Resident #67 signed his section and no date for when the physician signed his section. LVN A said without the dates the OOH-DNR was incomplete so it would not be valid and Resident #67 was a full code which meant they would have to perform CPR on him. LVN A said the SW handled the OOH-DNRs. During a record review and interview on [DATE] at 11:48 a.m., the SW acknowledged Resident #67's OOH-DNR had no date for when Resident #67 signed his section and no date for when the physician signed his section. The SW said he was the one who notarized Resident #67's signature and he was the one who would help the families and residents with their OOH-DNRs. The SW said with the dates missing the form was not valid and Resident #67 was a full code. During a record review and interview on [DATE] at 11:50 a.m., the DON acknowledged Resident #67's OOH-DNR had no date for when Resident #67 signed his section and no date for when the physician signed his section. The DON said without the dates the OOH-DNR was incomplete so it would not be valid and Resident #67 was a full code which meant they would have to perform CPR. Record review of an Advanced Directives policy revised [DATE] provided by the Corporate Nurse had no indication of the OOH-DNR requiring the information to be completed. Record review of the Frequently Asked Questions about OOH-DNR accessed on [DATE] at https://www.dshs.texas.gov/dshs-ems-trauma-systems/out-hospital-do-not-resuscitate-program: Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The patient is pregnant There are unnatural or suspicious circumstances surrounding the death. The form is not signed twice by all who need to sign it or is filled out incorrectly . Filling out the Out-of-Hospital Do-Not-Resuscitate Form indicated: Declarations: A. This box is for patients who are competent. The patient should sign his/her name, date the document, and prints or types his/her name D. This box is used when a physician has evidenced that a patient has issued a previous directive to physician or observes a person issuing an OOH-DNR by non-written communication. The physician must check the appropriate box in this section, sign and date the form, print or type his/her name and provide his/her license number

Based on observation, interview, and record review, the facility failed to complete a significant change MDS assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition a significant change of condition for 1 of 19 residents reviewed for assessments. (Resident # 53) The facility failed to complete a Significant Change MDS for Resident #53 within 14 days after the resident was admitted to hospice services. This failure could place residents who experienced a significant change in their condition requiring an MDS assessment at risk of not receiving needed services. Findings Included: Record review of a face sheet dated 09/24/24 indicated Resident #53 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), dementia (loss of cognitive functioning), anxiety disorder (persistent and excessive worry that interferes with daily activities), and hypertension (a condition in which the force of the blood against the artery walls is too high). They also indicated Resident #53's referral to hospice on 08/19/24. Record review of a physician telephone order dated 08/19/24 indicated Resident #53 was admitted on hospice services. Record review of the EMR from 08/19/24 through 09/24/24 indicated Resident #53 did not have a significant change MDS for admission to hospice within the required 14-day time frame. Record review of the current care plan reviewed on 09/24/24 indicated Resident #53 required hospice as evidenced by terminal illness of chronic obstructive pulmonary disease. During an observation and interview on 09/23/24 at 09:52 a.m. Resident #53 was in bed finishing her breakfast. She was clean, neat, and had no odors. Resident #53's RP said they asked for Resident #53 to be placed on hospice services on 08/19/24. The RP said hospice was at the facility the same day to admit Resident #53. During an interview on 09/24/24 at 11:40 a.m., LVN A said Resident #53 had a referral to hospice dated 08/19/24 and had orders from hospice to admit on 08/19/24. During a record review and interview on 09/24/24 at 11:55 a.m., the MDS Nurse acknowledged a quarterly MDS dated [DATE]. She said she had not done a significant change MDS for the admission to hospice. She said she was supposed to do a significant change MDS within 14 days after the admission to hospice. During an interview on 09/24/24 at 12:18 p.m., the DON and the Corporate Nurse said they did not know when a significant change MDS was to be done after admission to hospice. They said they thought the Corporate MDS Nurse was responsible for reviewing if a MDS was due. During an interview on 09/25/24 at 09:18 a.m., the DON said for MDS accuracy and submissions they followed the RAI guidelines. Record review of the MDS RAI manual dated October 2023 indicated 03. Significant Change in Status Assessment (SCSA) (A0310A = 04): .Assessment Management Requirements and Tips for Significant Change in Status Assessments: An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing

Based on interview and record review, the facility failed to accurately submit a PL1 (PASRR Level 1 Screening) screening when a resident admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 1 of 6 residents reviewed for PASRR screenings. (Resident #333) The facility failed to submit a new PL1 screening when Resident #333 was diagnosed on [DATE] with Major Depressive Disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily living) during his stay. This failure could place residents at risk of not receiving specialized services. Findings included: Record review of Resident #333's face sheet dated 09/24/24 was an [AGE] year-old-male admitted [DATE] with diagnoses of seizures (uncontrolled jerking, loss of consciousness and other symptoms caused by abnormal electrical activity in the brain), anxiety disorder (mental health disorder with feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life). Record review of Resident #333's PL1 form dated 02/24/24, indicated he was negative for mental illness, intellectual disability, and developmental disability and negative for dementia as the primary diagnosis. There was no PASRR Level II Screening or Form 1012 (Mental Illness/Dementia Resident Review) found in the clinical record from the resident's admission on 2/27/24 to 09/24/24. Record review of Resident #333's care plan created on 02/28/24 indicated Resident #333 had a history of seizures and psychotropic medication for depression and anxiety with a goal to monitor for effectiveness of psychotropic medication. Record review of Resident #333's annual MDS dated [DATE] indicated not PASRR positive and had a BIMS score of 14 indicating intact cognition. The assessment indicated a mood interview of feeling down depressed or hopeless present for 2-6 days. Record review of Resident #333's Follow up physician visit, dated 03/12/24 indicated diagnoses of seizure and major depressive disorder. Record review of Resident #333's Psychiatric Initial Assessment, dated 03/15/24 indicated a diagnosis of major depressive disorder, recurrent, moderate. Record review of Resident #333's quarterly MDS dated [DATE] with a BIMS score of 15 indicated intact cognition. The assessment indicated a mood interview of feeling down depressed or hopeless present for 2-6 days with diagnoses of convulsions (medical condition that causes the body's muscles to contract and relax rapidly and repeatedly) and depression other than bipolar (many types of depression including major depressive disorder). During an observation and interview on 09/24/24 at 10:20 a.m., Resident #333 as lying in bed and said he was treated well and would report any concerns to the nurse. During an interview on 09/24/24 at 3:00 p.m., the MDS nurse said she was responsible for all PASRR forms in the facility. She said Resident #333's PL1 was negative but should have had a positive PL1. The MDS nurse said Resident #333's PL1 was overlooked. She said at the time Resident #333's PL1 was completed she was new and was unaware the diagnosis of major depressive disorder was a PASRR positive diagnosis. The MDS nurse said she was educated on PASRR forms, she had watched a couple of webinars on PASRR forms completion. She said the MR was her back up and made sure all residents had a PL1 form. The MDS nurse said the risk of a PL1 form being incorrect was a resident could miss out on deserved services. During an interview on 09/24/24 at 3:05 p.m., the MR said the MDS nurse was responsible for PL1 forms. She said she was responsible for receiving the PL1 form from the referring entities and making sure it was filled out and uploaded into the facilities computer system. The MR said she was not responsible for checking PL1 forms for accuracy. During an interview on 09/24/24 at 3:30 p.m., the DON said the MDS nurse was responsible for all PASRR forms in the facility and was educated on completing PASRR forms correctly and timely. She said Resident #333 's PL1 form was overlooked. The DON said the risk of PASRR forms completed incorrectly was a resident could miss out on services if deemed PASRR positive. She said the Regional Care Coordinator double checked PASRR forms for accuracy. She said at the time of Resident #333's PL1 form the MDS nurse was just inputting the PL1 forms as received from the referring entity and did not double check the resident's diagnoses. The DON said Resident #333 needed a positive PL1 sent in. She said the risk was a resident could miss out on services if deemed PASRR positive. The DON said her expectation was all PASRR forms completed correctly and timely. She said the facility followed the RAI for their PASRR policy. During an interview on 09/25/24 at 10:38 a.m., the Administrator said the MDS nurse was responsible for all PASRR forms in the facility and was educated on correctly and timely completing PASRR forms. She said the DON and Regional Care Coordinator were the MDS nurse's back up. She said Resident #333 's PL1 was overlooked. The Administrator said the risk of PASRR forms completed incorrectly was a resident could miss out on deserved services. The Administrator said her expectation was a PL1 form completed on admission and with a new diagnosis be correct and timely. During an interview on 09/25/24 at 10:51 a.m., the Regional Care Coordinator said the MDS nurse was responsible for completing the PL1 and PASRR forms in the facility. She said the IDT (inter-disciplinary team) reviewed the admission paperwork and on receiving a new diagnosis the IDT team would review the new PL1 and resident information and decide if a new positive PL1 needed to be completed and uploaded. She said the MDS nurse was educated on completion PL1s accurately and timely. She said the risk of a PL1 form completed incorrectly was if the resident should be positive the resident could get more assistance depending on needs. Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 19 residents reviewed for care plans. (Resident #6) The facility did not have a care plan to address Resident #6's Post Traumatic Stress Disorder (PTSD). This failure could place residents at risk of not having their individual needs met and not receiving needed services. Findings included: Record review of a face sheet dated 09/25/24 indicated Resident #6 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record review of an annual MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 14 indicating her cognition was intact and she had a diagnosis of PTSD. Record review of a care plan dated 07/25/19 to present indicated Resident #6 had no care plan addressing her PTSD. During an observation and interview on 09/24/24 at 09:10 a.m., Resident #6 was sitting up in bed in her room. She said she felt safe at the facility and was doing alright. She said she got anxiety and irritation at times but had learned to work through those episodes. During an interview on 09/25/24 at 09:35 a.m. the ADON said she was responsible for writing care plans for Resident #6, but she did not realize she had a diagnosis of PTSD. She said she should have a care plan to address her PTSD. She said a possible negative outcome of not addressing her PTSD could be staff being unaware of the diagnosis and without precautions could trigger anxiety and distress for the resident. During an interview on 09/25/24 at 10:22 a.m., the DON said the nursing department was responsible for writing and updating care plans. She said all care plans were reviewed quarterly, but Resident #6's PTSD diagnosis was missed. She said not having a care plan to address her PTSD could result in staff not giving needed emotional support. During an interview on 09/25/24 at 1:40 p.m., the Administrator said her expectation was for care plans to address all diagnosis of residents and all care needed by the resident. Record review of a Care Plans-Comprehensive policy revised September 2010 indicated An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS.

Based on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for the facility for 2 of 7 residents (Resident #24 and Resident #27) reviewed for infection control procedures. The facility failed to ensure LVN B used enhanced barrier precautions (a set of infection control guidelines used to prevent spread of infections) while she administered medication to Resident #24 through a gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach). The facility failed to ensure LVN B used enhanced barrier precautions while she performed tracheostomy care (surgical opening into the neck for breathing) to Resident #27. These failures could place residents at risk for exposure to infections and communicable diseases. Findings included: 1. Record review of Resident #24's admission sheet dated 09/25/24 indicated she was admitted on [DATE] and was [AGE] years old with diagnoses of dysphagia (difficulty in swallowing). Record review of Resident #24's physician's orders dated September 2024 indicated her orders included NPO (nothing by mouth), was to receive gastric feedings and medications via a gastrostomy tube. The orders included Enhanced Barrier Precautions with a start date of 04/25/24. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #24 had severely impaired cognition. She required a feeding tube (g-tube). Record review of a care plan dated 09/25/24 indicated Resident #24 had a feeding tube (g-tube) and interventions included Enhanced Barrier Precautions implemented. During an observation on 09/24/24 at 8:32 a.m., LVN B prepared medications for Resident #24 and the resident's room had a sign which indicated EBP was required for residents who have indwelling medical device such as feeding tube. LVN B entered the room, washed her hands, donned gloves and checked placement of Resident #24 gastric tube. LVN B then administered medications per gastric tube without wearing an isolation gown. 2. Record review of Resident #27's admission sheet dated 09/25/24 indicated he was admitted on [DATE] and was [AGE] years old with diagnoses of tracheostomy, aphasia (difficulty in speaking) and dysphagia (difficulty in swallowing). Record review of Resident #27's physician's orders dated September 2024 indicated his orders included NPO (nothing by mouth), was to receive tracheostomy care with dressing change and change the inner cannula of the tracheostomy daily. The orders included EBP with start date of 04/25/24. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #27 was severely impaired with his cognition. He required a trache. Record review of a care plan dated 09/24/24 indicated Resident #27 had a feeding tube (g-tube), tracheostomy, and interventions included EBP implemented. During an observation on 09/24/24 at 10:45 a.m., LVN B walked into Resident #27's room to perform tracheostomy care. Bedside the door was a sign which indicated EBP for residents who have tracheostomy. LVN B donned gloves after she washed her hands. She then removed the soiled dressing then cleaned around the tracheostomy. LVN B completed the care to the tracheostomy; however, she did not use an isolation gown while providing care to the resident. During an interview on 09/24/24 at 2:00 p.m., LVN B said she was trained on EBP and just forgot to put on a gown when she provided care to Resident #24 and #27. She said she should have worn a gown. During an interview on 09/24/24 at 2:05 p.m., the DON said her expectation was for staff to wear gowns and gloves when providing close contact care to residents who required EBP to prevent spread of infections. She said nurses should wear gowns and gloves when administering medications via a resident's g-tube and when providing tracheostomy care. During an interview on 09/24/24 at 3:30 p.m., the Administrator said her expectation was for the staff to follow policy on EBP and wear PPE as required. During an interview and record review on 09/25/24 at 9:00 a.m., with the ADON and the UM, the ADON said she was the ICP nurse. The ADON said EBP was put in place to prevent the spread of infections. The UM said she was the backup ICP nurse and assisted the ADON with training the staff and ensuring the staff implemented the EBP. The ADON said she was responsible for ensuring the staff wore PPE while providing care as needed. The UM said they made rounds- daily and re-educated staff as needed. The ADON provided the last completed training forms for EBP dated 05/31/24 and 06/03/24. The ADON said the staff were to wear gowns and gloves while providing close contact resident care. She said the PPE was located in the rooms for each resident on EBP. Record review of the Enhanced Barrier Precautions dated March 2024 indicated Policy: Enhanced Barrier Precautions (EBP is an infection control intervention to reduce transmission of multidrug resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. EBP is indicated for residents with . Chronic wounds . and or indwelling medical devices . tracheostomy tubes . feeding tubes . 13. Gowns and gloves used for each resident during high-contact resident care activities .

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 1 of 2 residents reviewed for smoking safety evaluations. The facility did not ensure the quarterly smoking evaluations were completed for Residents #59. This failure could place residents at risk of injury and contribute to avoidable accidents. Findings included: Record review of the face sheet dated 09/25/24 indicated Resident #59 was admitted on [DATE], was [AGE] years old with diagnoses of nicotine dependence, chronic obstructive pulmonary disease, diabetes and peripheral vascular disease (blood flow reduce to limbs). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #59 used tobacco. Record review of the care plan dated 09/25/24 indicated Resident #59 was a smoker and interventions included assist resident to smoking area and keep matches/lighters at the Nurses Station. Record review of the smoking evaluation form dated 01/30/24 indicated Resident #59 was a safe smoker with direct supervision and no other evaluations were in the clinical record after that date. During an observation on 09/24/24 at 10:30 a.m., Resident #59 was smoking with supervision. During an interview on 09/25/24 at 9:50 a.m., the DON said she was responsible for ensuring smoking evaluations were completed and Resident #59's smoking evaluation was missed in April and July. She said she just missed his quarterly evaluations. She said the negative outcome could be more interventions might have been needed, smoking status could have changed, and the smoking evaluation for Resident #59 was not completed quarterly. She said the resident had to be supervised, that was the facility's policy and resident could drop his cigarette and need help. During an interview on 09/25/24 at 1:30 p.m., the Administrator said her expectation was for the smoking evaluations to be completed on all residents who smoke annually and quarterly. Record review of Resident Smoking Policy dated 01/04/24 signed by Resident #59 indicated To maintain safety for residents who smoke. 11. A smoking evaluation will be completed for residents who smoke on admission, quarterly and significant change of condition.

Based on interview and record review the facility failed to implement the ongoing system of surveillance to identify possible communicable diseases and infections before they can spread to other persons in the facility for 12 of 12 employees reviewed for annual tuberculosis (TB) screening. The facility required TB screening annually but did not have documentation of the annual TB screening done for the ADM, AD, ADON, BOM, DM, HS, MD, PT, ST, LVN D, LVN E, and CNA F. This failure could place residents, staff, and visitors at risk of being exposed of being exposed to a communicable disease and the facility not being aware of TB to report to the health department. Findings included: Record review of the facility Employee Tuberculosis Screening Nursing Policy and Procedure revised March 2019 indicated Policy: The Facility must screen all employees before providing services in the facility and annually, according to CDC guidelines. The facility must require all persons providing services under an outside resource contract to provide evidence of current tuberculosis screening prior to providing services in the facility. The facility must document or keep a copy of the evidence provided. Procedure: .All employees will be evaluated annually, and after any suspected exposure to a documented case of active tuberculosis. Record review of employee files indicated the following: * ADM hire date was 05/16/16 with the last TB screening dated 05/17/16; * ADON hire date was 02/17/20 with the last TB screening dated 05/13/22; * BOM hire date was 09/26/19 with the last TB screening dated 09/26/19; * DM hire date was 06/11/12 there was no TB screening in the file; * HS hire date was 04/01/10 there was no TB screening in the file; * MD hire date was 04/11/22 with the last TB screening dated 04/13/22; * PT hire date was 11/15/21 with the last TB screening dated 11/15/21; * ST hire date was 01/31/22 with the last TB screening dated 01/31/22; * LVN D hire date was 08/12/19 with the last TB screening dated 08/12/19; * LVN E hire date was 08/12/19 there was no TB screening in the file; and * CNA F hire date was 02/18/22 with the last TB screening dated 02/18/22. There were TB Screening questionnaires in the medical portion of the employee files with no dates or names on them. During an interview on 07/26/23 at 03:40 PM, the DON said the IP was out and was not available. She said the TB screening was to be done upon hire and annually at the facility. She acknowledged TB Screening questionnaires in the employee files had no names or dates on them. She said she would look in the IP's office to try and locate anything showing documentation of TB Screening. During an interview on 07/26/23 at 04:18 PM, the DON said she located a folder with some TB Screening questionnaires. She acknowledged some of the forms had names and dates, but most did not have a date. She said she would look one more time. During an interview on 07/26/23 at 05:06 PM, the DON said she was not able to locate any TB screening documentation for the employees listed above.

Based on observation, interview, and record review the facility failed to ensure food was provided that accommodated food preference for 4 of 23 residents reviewed for food choices (Resident #7, #43, #66 and #75) in that: Residents #7, #43, #66, and #75 preferred fried eggs and did not receive fried eggs. This failure could place residents at risk for poor oral intake, weight loss, and poor quality of life. Findings included: 1. Record review of an admission face sheet for Resident #7 indicated she was admitted [DATE] with diagnoses of high blood pressure and pain. Record review of the physician orders dated July 2023 indicated Resident #7 had a diet order for Low concentrated sweet, no salt on tray and no fried foods. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7 had moderately impaired cognition with BIMS score of 12, could understand, and usually could make needs known. Record review of the care plan with print date of 07/26/23 indicated Resident #7 wanted to lose weight. Approaches included and not limited to: Serve diet per order - monitor intake. Discourage foods not within diet limits, to monitor/discuss preferences During an interview on 07/25/23 at 2:50 p.m. Resident #7 said the residents ' request for fried eggs was not a new problem. She said several residents requested fried eggs. She said one of the other residents turned in a list to the kitchen of all the residents who wanted eggs back in April 2023. 2. Record review of an admission face sheet for Resident #43 indicated she was admitted on [DATE] was [AGE] years old with diagnoses of fractured femur (leg), eating disorder and anxiety. Record review of the physician orders dated Resident #43 indicated her diet order was LCS diet, NSOT and no fried food. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #43 was cognitively intact with BIMS score of 15. During a group interview on 07/25/23 at 12:49 p.m., Resident #43 said she did not like scrambled eggs. She said she asked for a fried egg, but she did not get them. 3. Record review of an admission face sheet indicated Resident #66 admitted on [DATE] was [AGE] years old with diagnoses included anorexia (an eating disorder), respiratory failure, and depression. Record review of the physician orders dated July 2023 indicated Resident #66 had an order for regular diet. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #7 had moderately impaired cognition with a BIMS score of 09. Resident #7 usually understood and usually could make needs known. Record review of the care plan with print date 07/25/23 indicated Resident #66 had approaches which included monitor for weight loss and encourage intake within dietary limits. Resident #66 was at risk for unintended weight related to chemotherapy and approaches included but not limited to update food preferences, liberalized diet, and diet as ordered. During a group interview on 07/25/23 at 12:49 p.m., Resident #66 said she turned in a list with 13 names on it to the kitchen of residents who wanted fried eggs. She said, we never got fried eggs. During an interview on 07/25/23 at 2:45 p.m., Resident #66 said she knew other residents wanted fried eggs, like she wanted them. She said she went from room to room and asked the residents and made a list. She said she did not keep a copy. She said she knocked on the kitchen door and gave the list to the kitchen staff described her as a young little lady. 4. Record review of an admission face sheet indicated Resident #75 was admitted on [DATE] was [AGE] years with diagnoses of chronic pain, anxiety and vitamin deficiency. Record review of the physician orders dated July 2023 indicated Resident #75 was on LCS diet. Record review of the quarterly MDS assessment dated [DATE] indicated Resident was cognitively intact with BIMS score of 14. Record review of the care plan dated 12/22/22 indicated Resident #75 was at risk for impaired nutritional status related to multiple food preferences or complaints. Approaches included to monitor for signs or symptoms of dehydration, aspiration, or diet intolerance. During an observation on 07/25/23 at 7:45 a.m., no eggs were on Resident #75 ' s breakfast tray. During an interview on 7/24/23 at 2:00 pm, Resident #75 said she does not eat scrambled eggs. She said she liked fried eggs. She said she spoke with the dietary manager last month, but it did not help. She said she got fried eggs for 3 weeks last month (June), but then no more fried eggs. Record review of the menus for the week of 07/24/23 indicated eggs of choices for breakfast every day of the week. During an interview on 07/24/23 at 8:25 a.m., the dietary manager said we do not fry eggs because we do not have enough staff to cook fried eggs. DM said we serve scrambled eggs. During an interview on 07/26/23 at 8:30 a.m., the dietary manager denied she received a list back in April of 2023 but said she had heard there was a list. She said she did not question residents or dietary staff. She said in June 2023 the kitchen was giving one resident fried egg 3 times a week. The dietary manager said she did not think it was right to just give one resident fried egg and she told the administrator. She said they (DM and administrator) talked about her coming in early to cook the fried eggs because she did not have enough staff to fry eggs right now. During an interview on 07/26/23 at 11:00 a.m., the Administrator said she was unaware of a list provided to the dietary department and unaware the residents wanted fried eggs. Record review of the last 3 months of resident council meetings did not include request for fried eggs. Record review of the week at a glance dated 07/30/23 indicated egg of choice for breakfast every day.

Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 23 residents reviewed for oxygen therapy. (Resident #38 and Resident #71) The facility did not obtain orders for Resident #38's oxygen. The resident received oxygen via nasal cannula connected to a portable oxygen concentrator. The facility did not ensure humidifier bottles contained liquids for Resident #s 38 and 71. The humidifier bottles for each concentrator were empty. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: 1. Record review of the physician orders dated July 2023 indicated Resident #38, admitted [DATE], was [AGE] years old with diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture which can contribute to lung disease). There was no documentation to indicate the resident had oxygen ordered. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #38 was cognitively intact, had diagnoses of cerebral palsy. The assessment did not indicate the resident received oxygen. Record review of a care plan updated 10/14/20 through current date indicated Resident #38 was unable to maintain adequate oxygen saturation levels. Beginning 07/26/23, interventions were initiated to include oxygen use for Resident #38. During observation and interviews on 07/24/23 at 9:03 a.m., Resident #38 was lying in bed watching television. Oxygen via nasal cannula at 3 L/min portable concentrator was in use. An empty humidifier bottle was dangling from the concentrator. Resident #38 said she wore oxygen continuously due to shortness of breath. LVN G made entrance to Resident #38's room and made observation and acknowledged the humidifier bottle was empty and needed to be refilled. She said the strap used to anchor the humidifier bottle was not secure and she would change out humidifier bottle and repair the anchor. She added the night shift was responsible for changing tubing, humidifier containers, and cannulas every Sunday and as needed. She added all nursing staff were responsible as well. LVN G said a possible negative outcome for not having humidified oxygen could be dry nasal passages. During an interview on 07/25/23 at 9:47 a.m., LVN G said she could not locate orders for Resident 38's oxygen in the electronic records. She said the resident was discharged from hospice services on 07/21/23 and the oxygen orders apparently were not transferred to new orders. During an interview on 07/25/23 at 10:00 a.m., DON acknowledged there were no orders for oxygen, or changing humidifier bottle in Resident #38's electronic record. She said there should have been physician orders for the oxygen. The DON said her expectations were to have orders entered correctly. She said added possible negative outcomes for not having humidified oxygen were nostrils becoming dry, or infections. 2. Record review of the physician orders dated July 2023 indicated Resident #71, admitted [DATE], was [AGE] years old with diagnoses of acute respiratory failure, with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Orders included oxygen at 2 L/min per nasal cannula. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #71 was alert and had a BIMs of 3 out of a total score of 15 (test used to determine cognitive function of a resident with BIMs score of 3 indicating the resident had severe cognitive impairment. Record review of the care plans dated 11/11/22 to present indicated Resident #71 did not have oxygen concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During observation and interviews on 07/24/23 at 9:03 a.m., Resident #71 was lying in bed with oxygen infusing 2 L/min per nasal cannula via concentrator at bedside. Resident #71 was non-interviewable. During observation and interview on 07/24/23 at 9:20 a.m., Resident #71 was lying in bed. Oxygen via nasal cannula at 2 /L per minute per portable concentrator was in use. An empty humidifier bottle was attached to the concentrator. LVN A made observations to Resident #71's room and acknowledged the humidifier bottle was empty and needed to be refilled. She said the night shift was responsible for changing tubing, humidifier containers, and cannula's every Sunday and as needed. She said she would immediately change out the humidifier bottle. LVN A said a possible negative outcome for not using humidified oxygen could be dry nasal passages or irritation. Record review of a Protocol for Oxygen Administration policy dated as reviewed March 2019 indicated: Patients with oxygen therapy will have their plan of care updated to reflect their oxygen use.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 23 residents (Resident #55) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for Resident #55 with the pruning shears and the shears were not stored securely. This failure could place residents at risk for injury due to the lack of supervision provided by the facility. Findings include: Record review of the face sheet for Resident #55 indicated he was admitted on [DATE], was [AGE] years old with diagnoses of PTSD (a disorder that develops in some people who have experienced shocking, scary or dangerous event), heart failure, high blood pressure and anxiety. Record review of physician orders dated July 2023 indicated Resident #55 had orders for morphine 15 mg immediate release tablet (1 1/2 tab) tablet every four hours and alprazolam 0.5mg 1 tablet as needed every 4 hours. Record review of the quarterly MDS assessment dated [DATE] for Resident #55 indicated BIMS (brief interview for mental status) was 13 which indicated moderately impaired cognition. He required minimal assistance of one staff member for transfer and grooming. Record review of the care plan with print date of 07/25/23 indicated Resident #55 was at risk for additional falls and risk for drowsiness when he received pain medications. The care plans did not address the resident using pruning shears outside. During a confidential interview, the person said Resident #55 had pruning shears and he pruned the bushes outside. During an interview on 07/25/23 at 945 a.m., Resident #55 was in his room and reached into his walker and pulled out the pruning shears. The shears were approximately 2-inch curved blade and approximately 6-inch handle. Resident #55 said he got them awhile back and could not remember the day or the month. He said he spoke with the maintenance supervisor about storing them in his office when he was not pruning the bushes, but nothing was decided. Resident #55 said he had just been keeping the shears in his walker when he was not using them. He denied any staff asked him to turn in the shears. He said he just goes outside and prunes the bushes unsupervised. During an interview 07/25/23 at 9:55 a.m., the DON said she was not aware that a resident had pruning shears. The DON said we should have care planned and provided outside gardening activity with supervision for Resident #55. During an interview on 07/25/23 at 9:57 a.m., the Maintenance Director denied talking to any resident about using pruning shears. He said we were responsible for pruning bushes and the residents could get hurt if not supervised. During an interview 07/25/23 at 10:00 a.m., the administrator said she was unaware Resident #55 had pruning shears and did not know he was keeping them in his room. She said tools should be kept secure and if it was an activity of gardening, it would need to be care planned and supervised. She said the facility did not have a policy for pruning shears.

41057 Based on interview, and record review, the facility failed to ensure individuals identified with MD or ID are evaluated for 3 of 6 residents reviewed for PASRR. (Residents # 55, #73 and #89) The facility did not have an accurate PASRR level 1 screening for Residents #55, #73 and #89 who identified with having a mental health diagnosis therefore they had no further evaluation. This failure could place residents who have a diagnosis of mental disorder or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1. Record review of a face sheet indicated Resident #55 admitted [DATE], was a [AGE] year-old male, with diagnoses of PTSD (post-traumatic stress disorder -a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with symptoms including flashbacks, nightmares and severe anxiety), anxiety (intense, excessive, and persistent worry and fear about everyday situations) and depression (a common and serious medical illness that negatively affects how you think and act.). Record review of PASRR level 1 screening completed by the transferring facility dated 03/27/23 indicated Resident #55 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. Record review of a care plan initiated 03/29/23 indicated Resident #55 was currently taking psychotropic medication for depression and anxiety and required monitoring for side effects, behaviors and mood problems. Record review of a quarterly MDS dated [DATE] indicated Resident #55 had a BIMS score of 10 indicating he had moderately impaired cognition, had diagnoses of PTSD, depression and anxiety and received medication for anxiety and depression 7 of 7 days. Record Review of physician orders dated July 2023 indicated Resident #55 had a diagnosis of PTSD. The orders indicated Resident #55 was prescribed duloxetine (an antidepressant medication) 20 mg daily for depression with a start date of 3/28/23, trazadone (an antidepressant medication)100 mg at bedtime for depression with a start dated of 04/04/23 and alprazolam (an antianxiety medication) 0.5 mg every 6 hours as needed for anxiety with a start date of 06/13/23. 2. Record review of a face sheet indicated Resident #73 admitted [DATE], was an 83- year-old male, had a diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration and makes it difficult to carry out day-to-day task) Record review of PASRR level 1 (PL1) screening completed by the transferring facility dated 05/24/23 indicated Resident #73 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. Record review of an annual MDS dated [DATE] indicated Resident #73 was moderately impaired of cognition, was negative for PASRR condition, had a diagnosis of bipolar disorder and received an antipsychotic medication 7 of 7 days. Record review of a care plan initiated 05/30/23 indicated Resident #73 was moderately impaired of cognition and currently taking psychotropic medication. Record Review of physician orders dated July 2023 indicated Resident #73 was prescribed divalproex 125 mg every 12 hours for dipolar disorder with a start date of 07/18/23 and quetiapine 25 mg every day at bedtime for bipolar disorder with a start date of 07/18/23. 3. Record review of a face sheet dated 07/25/23 indicated Resident #89 was a [AGE] year-old male admitted on [DATE]. He had diagnoses including post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depression disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During an interview on 07/26/23 at 10:35 a.m., the DON indicated Resident #89 should have had a positive PL1 due to diagnosis of PTSD. She said he was supposed to be exempted hospital admission and stay less than 30 days but the PL1 was not marked for this. Record review of a PL1 completed by a transferring facility dated 06/26/23 indicated there was no evidence or indicator Resident #89 had a mental illness diagnosis. The section for Exempted Hospital Discharge which would indicate a resident to stay at a facility for less than 30 days was left blank. Record review of the admission MDS dated [DATE] indicated Resident #89 had moderately impaired cognition with a BIMs score of 08 out of 15; he had no behaviors; he had diagnoses of anxiety disorder, depression, and PTSD; and he received antianxiety and antidepressant medications for 7days of the 7 days look back period. During an interview on 07/25/23 at 11:13 a.m., the DON said the MDS nurse was responsible for the PASRR process and ensuring all PL1s were completed correctly. She said the MDS nurse quit 2 weeks ago without notice. The DON said herself and the SW were the back up to double check PL1s were completed correctly. She said Resident #55 and 73's PL1s were just missed. She said the PL1 for both Resident #55 and Resident #73 should have been should have been positive. The DON said the risk of a PL1 completed incorrectly was the resident may miss out on deserved services. During an interview on 07/26/23 at 10:21 a.m., the SW said he and the DON were responsible for completing the PL1s and putting the PL1 from the admitting facility into the computer system since they no longer had an MDS nurse. He said when entering the PL1 he referred to the resident's diagnoses to ensure the PL1 was correct. The SW said Resident #55's and #73's PL1 were put in the system by the last MDS nurse and she just missed it. He said the PL1s were negative and should have been positive. The SW said he was unaware PTSD was a PASRR potential diagnosis. The SW said the risk of a PL1 completed incorrectly was the resident could miss out on services. During an interview on 07/26/23 11:30 a.m., the administrator said her expectation was PASRR forms to be completed correctly and timely. She said Resident #55 and #73's PL1s were just missed. The administrator said the MDS nurse was responsible for PASRR and PL1s to be completed correctly but the MDS nurse recently quit, and the DON and SW were the back up. She said the risk of a PL1 not being completed correctly was a resident could miss deserved services. Record review of an undated facility policy, titled Nursing Facility Responsibilities Related to PASRR, indicated, .PASRR is required of each state's Medicaid program to ensure that those with Mental illness (I) / Intellectual or Developmental Disability (IDD) are care for properly. CRC gathers information for PL1 for ALL patients and gives to PCC (patient care coordinator) prior to patient admission. PCC - submits PL1 and becomes the gate keeper of all things {PASSR}.

Based on observation, interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 3 of 23 residents reviewed for accuracy of assessments. (Resident #s 40, 42 and 71) The facility did not accurately complete the MDS assessment to indicate Residents #40 and #42 had dental concerns. The facility did not accurately complete the MDS assessment to indicate Resident #71 received continuous oxygen. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of physician orders dated 07/26/23 indicated Resident #40, admitted [DATE] was [AGE] years old with diagnoses of diabetes (a disease in which the body ability to produce insulin is impaired resulting in high levels of glucose in the blood), heart failure (a chronic condition in which the heart does not pump blood efficiently) and end stage renal disease (condition in which a person's kidneys cease to function on a permanent basis). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #40 was alert, oriented and had a BIMS of 12 indicating moderate cognitive impairment. The assessment indicated the resident did not have oral or dental concerns. Record review of the care plans dated 03/3/22 to present indicated Resident #40 did not have dental concerns. The facility had a PIP (a project the facility puts in place to correct a concern they have found) in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During observation and interview on 07/24/23 at 9:40 a.m., Resident #40 had no teeth to the top oral cavity and had multiple missing, broken and decayed teeth with black areas to the bottom oral cavity. The resident said she had not seen a dentist since being admitted to the facility. She said she would like to see a dentist. The resident denied dental pain. During an interview and record review on 07/26/23 at 11:54 a.m., the DON said the MDS dated [DATE] did not indicate Resident #40 had dental concerns and was completed incorrectly. She said the MDS nurse quit without notice on 07/14/23 and she had not hired a nurse to take her place. She said her expectations were for the residents' assessments to be completed correctly and accurately. She said the residents could possibly not receive the care they required if the MDS was not completed correctly. 2. Record review of the physician orders dated 07/26/23 indicated Resident #42, admitted [DATE], was [AGE] years old with diagnoses of congestive heart failure (a chronic condition in which the heart does not pump blood efficiently), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and protein calorie malnutrition (inadequate intake of food to meet nutritional needs). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS dated [DATE] indicated Resident #42 was alert, oriented and had a BIMs of 15 indicating the resident was cognitively intact. The assessment indicated the resident did not have oral or dental concerns. Record review of the care plans dated 07/21/22 to present did not indicate Resident #42 had dental concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During observation and interview on 07/24/23 at 10:07 a.m., Resident #42 was edentulous (had no teeth). She said she had lost weight over the last year and her dentures would not fit. She said the facility had referred her to the dentist. During an interview on and record review on 07/26/23 at 11:54 a.m., the DON said the MDS dated [DATE] did not indicate Resident #42 had dental concerns and was completed incorrectly. She said the resident wore dentures and the MDS should indicate so. She said the MDS nurse quit without notice on 07/14/23 and she had not hired a nurse to take her place. She said her expectations were for the residents' assessments to be completed correctly and accurately. She said the residents could possibly not receive the care they required if the MDS was not completed correctly. 3. Record review of physician orders dated July 2023 indicated Resident #71, admitted [DATE], was [AGE] years old with diagnosis of acute respiratory failure. The orders indicated Resident #71 received continuous oxygen at 2 L/min per nasal cannula. Record review of the quarterly MDS dated [DATE] indicated Resident #71 was alert and had a BIMS of 3 indicating the resident had severe cognitive impairment.) The assessment indicated the resident had no respiratory treatments such as oxygen. Record review of the care plans dated 11/11/22 to present indicated Resident #71 did not have oxygen concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 7/18/23 that was to be completed by 8/17/23. During observation on 07/24/23 at 09:00 a.m., Resident #71 was lying in bed with oxygen infusing at 2 L/min per nasal cannula via concentrator at bedside. Resident #71 was non-interviewable. During an interview on 7/26/23 at 4:05 p.m., the corporate nurse said the facility followed the RAI as policy for MDS assessment accuracy. Record review of the RAI section L0200: Dental indicated: . Poor oral health has a negative impact on quality of life, overall health, nutritional status. Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions such as aspiration, malnutrition, pneumonia, endocarditis and poor control of diabetes. 32217 Based on observation, interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 3 of 23 residents reviewed for accuracy of assessments. (Resident #s 40, 42 and 71) The facility did not accurately complete the MDS assessment to indicate Residents #40 and #42 had dental concerns. The facility did not accurately complete the MDS assessment to indicate Resident #71 received continuous oxygen. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of physician orders dated 07/26/23 indicated Resident #40, admitted [DATE] was [AGE] years old with diagnoses of diabetes (a disease in which the body ability to produce insulin is impaired resulting in high levels of glucose in the blood), heart failure (a chronic condition in which the heart does not pump blood efficiently) and end stage renal disease (condition in which a person's kidneys cease to function on a permanent basis). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #40 was alert, oriented and had a BIMS of 12 indicating moderate cognitive impairment. The assessment indicated the resident did not have oral or dental concerns. Record review of the care plans dated 03/3/22 to present date indicated Resident #40 did not have dental concerns. The facility had a PIP (a project the facility puts in place to correct a concern they have found) in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During observation and interview on 07/24/23 at 9:40 a.m., Resident #40 had no teeth to the top oral cavity and had multiple missing, broken and decayed teeth with black areas to the bottom oral cavity. The resident said she had not seen a dentist since being admitted to the facility. She said she would like to see a dentist. The resident denied dental pain. During an interview and record review on 07/26/23 at 11:54 a.m., the DON said the MDS dated [DATE] did not indicate Resident #40 had dental concerns and was completed incorrectly. She said the MDS nurse quit without notice on 07/14/23 and she had not hired a nurse to take her place. She said her expectations were for the residents' assessments to be completed correctly and accurately. She said the residents could possibly not receive the care they required if the MDS was not completed correctly. 2. Record review of the physician orders dated 07/26/23 indicated Resident #42, admitted [DATE], was [AGE] years old with diagnoses of congestive heart failure (a chronic condition in which the heart does not pump blood efficiently), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and protein calorie malnutrition (inadequate intake of food to meet nutritional needs). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS dated [DATE] indicated Resident #42 was alert, oriented and had a BIMs of 15 indicating the resident was cognitively intact. The assessment indicated the resident did not have oral or dental concerns. Record review of the care plans dated 07/21/22 to present did not indicate Resident #42 had dental concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During an interview on and record review on 07/26/23 at 11:54 a.m., the DON said the MDS dated [DATE] did not indicate Resident #42 had dental concerns and was completed incorrectly. She said the resident wore dentures and the MDS should indicate so. She said the MDS nurse quit without notice on 07/14/23 and she had not hired a nurse to take her place. She said her expectations were for the residents' assessments to be completed correctly and accurately. She said the residents could possibly not receive the care they required if the MDS was not completed correctly. 3. Record review of physician orders dated July 2023 indicated Resident #71, admitted [DATE], was [AGE] years old with diagnosis of acute respiratory failure. The orders indicated Resident #71 received continuous oxygen at 2 L/min per nasal cannula. Record review of the quarterly MDS dated [DATE] indicated Resident #71 was alert and had a BIMS of 3 indicating the resident had severe cognitive impairment. The assessment indicated the resident had no respiratory treatments such as oxygen. Record review of the care plans dated 11/11/22 to present indicated Resident #71 did not have oxygen concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 7/18/23 that was to be completed by 8/17/23. During observation on 07/24/23 at 09:00 a.m., Resident #71 was lying in bed with oxygen infusing at 2 L/min per nasal cannula via concentrator at bedside. Resident #71 was non-interviewable. During an interview on 7/26/23 at 4:05 p.m., the corporate nurse said the facility followed the RAI as policy for MDS assessment accuracy. Record review of the RAI section L0200: Dental indicated: . Poor oral health has a negative impact on quality of life, overall health, nutritional status. Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions such as aspiration, malnutrition, pneumonia, endocarditis and poor control of diabetes.

Based on interview and record reviewed, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 23 residents records reviewed for MDS assessments. (Residents #80) The facility did not ensure the discharge MDS assessment was completed and transmitted as required for Resident #80. This failure could place residents at risk of not having their assessments transmitted timely. Findings included: Record review Resident #80's Admission record dated 07/26/23 indicated she was admitted on [DATE] with a discharge date of [DATE]. Resident #80's diagnoses included shortness of breath, chronic obstructive pulmonary disease and lung cancer. Record review of the MDS for Resident #80 indicated the most recent MDS completed was on 02\02\23. There was not a discharge MDS completed or transmitted after 02/24/23. Record review of the nurse's notes 01/18/23 to 02/24/23 indicated Resident #80 was discharged home on 02/24/23. During an interview on 07/26/23 at 03:14 p.m., the DON said Resident #80 was discharged home and there should had been a discharge MDS completed and submitted. She said they used the RAI manual for the policy. During an interview on 7/26/23 at 3:30 p.m., the administrator said she expected the MDS to be completed and transmitted for discharge. Reference obtained on 07/31/23 from the CMS website, https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf indicated the following: CMS's RAI Version 3.0 Manual indicated . Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below). This assessment includes clinical items for quality monitoring as well as discharge tracking information. RAI OBRA-required Assessment Summary .Discharge Assessment - return not anticipated (NoncComprehensive) A0310F = 10 discharge date + 14 calendar days .

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, to the Administrator and the State Survey Agency, for 1 of 2 residents reviewed for reporting allegations of abuse. (Residents # 9 and #66) The facility did not report physical abuse within 2 hours when Resident #9 reported to facility staff that CNA B slapped her in the face. This failure could place the residents at risk of abuse and neglect. Findings include: Record review of clinical notes indicated on 6/28/2023 at 2:43 am resident ask to see nurse and she reported to LVN H that she did not want CNA B in her room anymore or to care from her anymore, said CNA had been rough with her when cleaning her, and she came in and slapped her in the face. Record review of an email to HHSC Complaint and Incident Intake dated 06/28/23 at 6:48 a.m. indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 06/28/23 approximately 01:30 p.m .a detailed narrative of the incident; [Resident #9] made a statement to staff member that on 6/28/2023 at approximately 1:30 a.m. the CNA B slapped her in the face. Record review of the Provider Investigation Form indicated the following: * Date Reported to HHSC-06/28/23 * Time: 08:20 a.m. * Incident Category: Abuse * Incident Date: 06/28/23; and * Time of Incident: 01:30 a.m. During an interview on 07/26/23 at 01:00 p.m. the ADM said she was the acting Abuse Coordinator (AC). She said on 6/28/2023 she woke up around 5:30 a.m. - 6 a.m., she realized she had 13 missed calls from the facility. She stated, I have never slept through that many calls before, I am still beating myself up for that one. She said the facility staff was calling to inform her that Resident #9 said that CNA B slapped her, incident occurred around 1:30 am and resident was assessed around 2pm. She said the facility staff did call the DON, the alternate AC, however, the DON did not know staff could not reach the administrator/AC. She said she emailed incident to HHS around 6:30am and faxed it in around 8:30 am. The administrator said the abuse allegation was not reported to HHS in the 2-hour time frame as required. She said she knew all allegations of abuse were to be reported to HHSC within 2 hours regardless of if there was serious bodily harm or not. Record review of Facility Abuse Protocol Revision dated April 2019 in part revealed: Fundamental Information: (Protection) 10. The Abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to the Department of Aging and Disability Services (DADS) and other appropriate authorities' incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to THE Department of Aging and Disability Services (DADS) and other appropriate authorities as required under applicable regulations and regulatory guidance.

Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 2 of 4 residents reviewed for advanced directives. (Residents #19 and #65) The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #19 and #65 This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Record review of the Out-of-Hospital Do-Not-Resuscitate Order accessed on [DATE] at https://www.hhs.texas.gov/regulations/forms/advance-directives/out-hospital-do-not-resuscitate-ooh-dnr-order indicated on page 2: Instructions for Issuing An OOH-DNR Implementation: The OOH-DNR Order may be executed as follows: In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician 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 professionals . Definitions: Qualified Witnesses One of the witnesses must meet the qualifications in HSC S166.003(2), which requires that at least one of the witnesses not be (7) an employee of a health care facility in which the person is a patient if the employee is providing direct patient care to the patient or is an officer, director, partner, or business office employee of the health care facility or any parent organization of the health care facility. 1. Record review of a face sheet dated [DATE] indicated Resident #19 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included atrial fibrillation (a type of irregular heartbeat), hypertension (a condition in which the force of the blood against the artery walls is too high), and myopathy (any disease that affects the muscles that control voluntary movement in the body). She was her own responsible party. She was designated as DNR. Record review of the current MDS dated [DATE] indicated Resident #19 was alert to person, place, and time with a BIMS of 15 indicating she was cognitively intact. Record review of physician orders for [DATE] indicated Resident #19 had an order dated [DATE] for DNR. Record review of the EMR for Resident #19 had a scanned OOH-DNR dated [DATE] with witness signatures of the HR and Receptionist. During an observation and interview on [DATE] at 12:45 PM Resident #19 was sitting up in her bed. She said she did not want someone pounding on her chest if she died . 2. Record review of face sheet for Resident #65 indicated admitted [DATE] was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (respiratory disease). Record review of the current MDS dated [DATE] indicated Resident #65 was alert to person, place, and time with a BIMS of 13 indicating he was cognitively intact. Record review of physician orders for [DATE] indicated Resident #65 had an order with start date of [DATE] for DNR. Record review of the EMR for Resident #65 had a scanned OOH-DNR dated [DATE] with witness signatures of the HR staff and another employee. During an interview on [DATE] at 9:31 AM, Resident #65 said he received hospice services and did not want CPR if he passed away. During an interview on [DATE] at 1030 AM, the HR staff said the signatures on Resident #65 OOH-DNR were herself and a former housekeeper, who had a termination date in 2023. The HR staff said she thought if they both did not perform direct care, it was ok. During an interview on [DATE] at 03:55 PM, the DON said she was unaware of the inaccurate DNRs. She said the DNRs could not have 2 staff signatures as witnesses. She said these issues would make the DNR invalid and the residents would be a full code. She said as a result of an inaccurate DNR the residents would have lifesaving procedures performed when they did not want them. During an interview on [DATE] at 4:00 PM, the administrator said for OOH-DNR forms they should have one facility staff as a witness signing the form and one witness, who was not a facility staff, as the secondary witness. She said the forms needed to be filled out correctly. An Advance Directives policy dated [DATE] mentioned OOH-DNR but there was no information about the facility ensuring the accuracy of the OOH-DNR. The policy did not address the issue with the witnesses. 33460

Based on interview and record review the facility failed to ensure an effective discharge planning process to effectively transition to post discharge care and reduce factors leading to preventable readmissions was provided for 1 of 3 residents reviewed for discharge. (Resident #1) The facility did not develop and implement a discharge plan to meet the needs of Resident #1 prior to sending her home. Resident #1 was found by the fire department lying in feces and unable to get out of bed 2 days after she was discharged from the facility. The resident was hospitalized with COVID-19, UTI, dehydration and altered mental status. An Immediate Jeopardy (IJ) situation was identified on 07/24/20. While the IJ was removed on 07/25/20, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for a decline in heath, hospitalization and death. Findings included: A face sheet dated 07/24/2020 indicated Resident #1 was admitted [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #1 was cognitively intact, required extensive assistance with 2-person physical assist with bed-mobility, transfers, and dressing, extensive assistance with 1-person physical assist with personal hygiene and total dependence with 2 person physical assist with bathing. The MDS indicated the resident was continent of bowel and had a Foley catheter. A baseline plan of care dated 06/24/20 for Resident #1 indicated: *assistive device/mobility-wheelchair assist ¼ rail x 2 (2 sides) *indwelling catheter *touchdown weight bearing right leg *physical therapy screen/evaluation *incontinent of urine *continent of bowel *voiding method-toilet/bathroom *transfer status- gait belt-assist x 2 (2 person assist) *dressing/grooming-assist x 1 (1 person assist) The clinical record from 06/24/20 through 07/15/20 for Resident #1 indicated there was no comprehensive care plan. During an interview on 07/23/20 at 4:09 p.m., MDS LVN D said she completed Resident #1's MDS on 07/01/20 and knew the comprehensive care plan was supposed to be completed within 7 days of the MDS. She said the comprehensive care plan was not completed and available to staff. She said the social worker was responsible for completing Resident #1's discharge plan. During an interview on 07/27/20 at 10:00 a.m., ADON M said when a resident admitted to the facility there was a basic care plan in the computer. She said she would pull the baseline and transcribe it to the comprehensive care plan within 7 days of the compressive assessment. She said Resident #1's comprehensive care plan should have been completed by 07/08/20. She said she did not complete Resident #1's comprehensive care plans on time and as required because she was on vacation. She said the previous DON was her back up and it was not completed. She said she completed the comprehensive care plan on the evening of 07/23/20. A laboratory report dated 7/9/20 indicated Resident #1 had a urinalysis with 5-15 white blood cells (normal is negative) indicative of a urinary tract infection. A nursing note dated 07/10/20 at 3:23 p.m., completed by LVN G indicated Resident #1 had a fever of 101.2 and was administered Tylenol. The resident was checked 1 hour after Tylenol administration and her temperature was 98.4. The resident was clammy and flushed in the face and afebrile. The resident was checked during the next rounds and her temperature was 99.7. Resident #1 complained of a headache and had a productive wet cough, eyes red around the edges and center, dilated pupils, and did not want to eat or drink. The note indicated Resident #1's laboratory results indicated a UTI and dehydration. The physician was notified and the following new orders were received: *obtain 2 sets of blood cultures; *2 view chest X-ray; *1 liter of IV fluids of D5W at 50ml/hr; *health shakes three times a day; *start [MEDICATION NAME] (used to treat and prevent fungal infections) 150 mg now, then 150 mg by mouth in 72 hours then discontinue; *[MEDICATION NAME](antibiotic) 500 mg 1 tablet twice a day for 3 days pending culture and sensitivity results. *recheck for COVID-19; The note indicated the specimen for COVID-19 was collected and Resident #1 was fatigued and refused food and liquids. A physical therapy discharge summary completed 07/10/20 and signed 07/14/20 for Resident #1 indicated the resident received physical and occupational therapy from 06/25/20 through 07/10/20. The summary indicated Resident #1 was to be discharged to live with family/friends and assistance and support was to be provided by a care assistant in the morning and evening. The summary indicated the prognosis for Resident #1 to maintain her current level of function was good with strong family support. During an interview on 07/24/20 at 11:02 a.m., PT E said Resident #1 was assessed 07/10/20 and was able to get out of bed and walk to the shower with her walker. He said OT assessed Resident #1 as able to walk to the counter and brush her teeth. He said he thought she had family support available at home was not aware she was not able to care for herself and did not have assistance. An occupational therapy discharge summary completed 7/10 20 and signed 7/14/20 indicated the prognosis for Resident #1 to maintain her current level of function was excellent with strong family support, good with strong family support. The discharge recommendations for Resident #1 was 24-hour care, a low bed, and a shower bench. A microbiology culture and sensitivity report dated 7/11/20 indicated Resident #1 had a urinary tract infection caused by proteus mirabilis (bacteria) that was resistant to [MEDICATION NAME] (Cipro). A laboratory report dated 07/11/20 indicated Resident #1 tested positive for COVID-19 on 07/10/20. A nursing note dated 07/13/20 at 10:31 a.m., completed by LVN J indicated she called Physician I's office to report Resident #1 had a positive COVID-19 result and had a dry, scratchy cough. Physician I's office staff said she would talk to NP C, and call back for new orders. A nursing note dated for 07/14/20 at 9:49 a.m. and completed as a late entry on 07/17/20 at 9:51 a.m. by RN F (the previous DON) indicated he spoke with Resident #1's family by phone and the family was concerned the facility was discharging Resident #1 with a positive Covid-19 diagnosis. The note indicated RN F told the resident's family 07/14/20 was Resident #1's planned discharge date , she was her own responsible party, was able to make her own decisions, and the facility could not hold Resident #1 against her will. During an interview on 07/24/20 at 11:15 a.m., RN F (previous DON) said Resident #1 was diagnosed as positive for COVID-19 on 07/13/20. He said the ambulance transport refused to transport Resident #1 to her home on 07/14/20. He said Resident #1 was transported by ambulance to her home on 07/15/20. A social work note dated 07/14/20 at 11:19 a.m. and completed by SW B indicated Resident #1's 20th day was 07/13/20 and Resident #1 did not want to stay in the facility for additional days. The note indicated the resident said she already owed money to the facility and did not want to incur costs for additional days. A physician order [REDACTED].#1 indicated a telephone order dated 7/14/20 at 8:40 a.m. to discharge the resident home with home health services, PT, OT, skilled nursing (nursing services to include catheter care and education, medication management, disease education and management) and a social work consult. The order sheet indicated the order source was a telephone order read back by SW B. During an interview on 07/23/20 at 3:07 p.m., SW B said she usually obtained a physician order [REDACTED]. She said the home health agency would get the signed order for services from the physician. She said she faxed the home health agency Resident #1's face sheet, history and physical, and all current orders on 07/14/20. She said she had proof on her phone she called the home health agency to confirm they received the fax, but she did not have a fax confirmation. She said Resident #1 was originally scheduled for discharge on 07/14/20. She said the transport ambulance refused to transport Resident #1 to her home on 7/14/20 because she was lethargic. The SW said she did not remember who she spoke with at the home health agency or when she contacted them about Resident #1. During an interview on 07/23/20 at 1:58 p.m., home health staff A said SW B contacted her on 07/15/20 and said Resident #1 would be ready for discharge that day. She said the home health agency was not allowed to be at the home waiting for the resident when they were dropped off. She said she found out on 7/16/20, Resident #1 was discharged home. She said the agency required a signed physician order [REDACTED].#1's regular physician would not order home health without a face to face visit because he had not seen her since January 2020. She said she tried to get in touch with the NP C but did not receive a return call. She said it usually was not a problem for the agency to get a signed order because the medical director of the facility was also the medical director of the home health agency. She said Resident #1's physician during her stay at the facility was not the medical director. She said Resident #1 was transported from home to the hospital before they could begin services. An unsigned patient discharge plan of care dated 07/14/20 for Resident #1 indicated the following: *You are being discharged : home alone *Services Provided: Home health agency and phone number *Required Equipment: blank *General Comments/Other instructions: blank *Scheduled Follow-up Appointments: blank *Dietary recommendations: blank *Wound Care Treatments: blank *Patient Instructions/Teaching: blank *Pharmacy Name/Phone: blank *Primary Physician Contact Information: blank **discharge date : 7/14/20 *Patient/Patient Representative Signature: blank A nursing note dated 07/14/20 at 12:17 p.m. completed by LVN G indicated she educated Resident #1 to continue to monitor for signs and symptoms of COVID-19 and Resident #1 was positive and stated, It's not that big of a deal I will be fine. The note indicated LVN G educated Resident #1 to report to home health daily any signs and symptoms. The note indicated Resident #1 understood and was able to verbalize her own needs and requested discharge around 2:00 p.m. that day. A nursing addendum note dated 07/15/20 at 7:47 p.m. (late entry) completed by LVN G indicated Resident #1 was set up to be discharged on [DATE] at 2:00 p.m. The note indicated the EMS service arrived at the facility at 4:30 p.m. on 7/14/20 and refused to transport the resident to her home because the resident had increased lethargy (impairment of consciousness resulting in reduced alertness and awareness) and would be going home alone with no one at the home waiting for her. The note indicated LVN G notified her supervisor and called Resident #1's physician and left a voice message asking for a return call. During an interview on 07/27/20 at 12:31 p.m., LVN G said she called NP C on 07/14/20 and left a voicemail message regarding Resident #1's lethargy and the EMS refusal of transport. She said she did not receive a response back from the NP before she left her shift that evening. During an interview on 07/24/20 at 11:46 a.m., LVN G said Resident #1 did not want to stay at the facility any longer because she did not want to pay for the stay. She said Resident #1 was supposed to go home on 07/14/20, but when the transport ambulance got to the facility to pick her up, the resident was very lethargic. She said the ambulance personnel said they were acting as an advocate and would not transport Resident #1 to her home because there was no one there to take care of her. She said Resident #1 had gotten a little weaker and more tired after she was diagnosed with [REDACTED].#1 was being discharged with a Foley catheter and she was concerned about Resident #1 going home with the catheter. She said Resident #1 had been performing self-catherization (emptying the bladder by inserting a urinary catheter into the bladder) for [AGE] years, but no one assessed Resident #1 to see if she was still able to do so before she discharged from the facility. She said she did not know if anyone assessed Resident #1 for Foley catheter care. She said she did not feel Resident #1 would be able to care of herself at home. LVN G said Resident #1's daughter was aware Resident #1 was scheduled for discharge to home. She said she asked Resident #1 if her daughter was going to help her and Resident #1 laughed and said her daughter did not help her. LVN G said when Resident #1 was discharged on [DATE] and the home health service would not be able to see her until at least the next day. She said she did not express her concerns to anyone. During an interview on 07/29/20 at 8:10 a.m., EMS Q said she was dispatched to the facility's COVID-19 unit to transport Resident #1 to her home on 07/14/20. She said the nurse did not know if Resident #1 had anyone to meet her at home. She said the nurse indicated Resident #1 lived alone. She said she went into Resident #1's room and called her name loudly and the resident moaned. She said she called Resident #1's name a second time and asked her name. She said Resident #1 could not say her name, pointed at the wall, and moaned. She said she asked Resident #1 if she was ready to go home and if there was anyone to meet her at home. She said Resident #1 did not respond to any questions. She said she asked the nurse if Resident #1 was continent and she was told the resident had a Foley catheter. She said the nurse did not say anything about bowel continence. She said she told the nurse she was not comfortable transporting Resident #1 home and did not feel it was safe. EMS Q said she called her supervisor and contacted the home health agency that was supposed to provide services for Resident #1 and the home health agency said Resident #1 was not a current patient. She said she would not transport Resident #1 to her home. A nursing noted dated 7/15/20 at 2:10 p.m., ADON M indicated Resident #1's culture and sensitivity (test used to determine what antibiotics are effective) of urine collected 7/9/20 was resistant [MEDICATION NAME](antibiotic). The note indicated Resident #1 was [MEDICATION NAME] mg twice a day for 3 days beginning 7/11/20. The note indicated the physician was made aware and would review and get back with the nurses with a new order. A nursing noted dated 7/15/20 at 4:11 p.m., completed by LVN J indicated Resident #1 sat the resident up to eat breakfast and the resident was not eating. The note indicated LVN J fed the resident a few bites, then checked on the resident about 30 minutes later and the resident had eaten approximately 50% of her meal. The note indicated Resident #1 said she was wanted to go home but .I just don't know about making meals . A nursing note dated 7/15/20 at 4:14 p.m., completed by LVN J indicated Resident #1 had a tele-med appointment with Physician I and a new order was received for [MEDICATION NAME] 875 mg 2 times a day for 7 days. The note indicated LVN K (physician I's nurse) would fax the order to a local pharmacy for Resident #1 to pick up. A nursing note dated 07/15/20 at 4:28 p.m., completed by LVN J indicated she received a fax from LVN K (Physician I's nurse) on 07/15/20 with instructions to schedule the resident a follow-up appointment with her primary care physician within 1-2 weeks after discharge, repeat the COVID-19 test after 14 days (notify PCP), and to setup home health service before the resident left the facility. During an interview on 07/24/20 at 12:37 p.m., LVN J said Resident #1 was forgetful. She said she was worried about Resident #1 being able to take her medications when she was discharged . She said the resident was more tired and confused after she was diagnosed as positive for COVID-19. During an interview on 07/27/20 at 2:24 p.m., LVN J said the only time the resident would get up and transfer or ambulate was with therapy. She said Resident #1 used a brief and the CNAs were changing her briefs because she was not able to get up and transfer or ambulate to the toilet. She said she did not notify the physician the resident was not able to transfer without assistance or go to the toilet. She said she did not inform the physician of Resident #1 not being able to care for herself. A nursing noted dated 7/15/20 at 5:11 p.m. by LVN H indicated EMS was at the facility to transport Resident #1 to her home. The note indicated home medications were sent with the resident and the office staff was notified of her discharge. The note indicated the resident was in stable condition. During an interview on 07/24/20 at 12:08 p.m., LVN H said the day Resident #1 was discharged on [DATE] and she was awake and alert and ready to go home. She said Resident #1 needed some assistance with care. She said she did not call Resident #1's daughter to let her know the resident was discharged because she thought it had already been taken care of by the administrative staff. She said she did not know Resident #1 was going home alone. She said she sent Resident #1's medication list home with her and instructions on how to take them. She said she was not aware Resident #1 had any medication changes or had any follow-up appointments. During an interview on 07/29/20 at 8:02 a.m., EMS P said the dispatch records dated 07/14/20 indicated the transport was delayed and cancelled. He said the dispatch records for 07/15/20 indicated the EMS staff did not feel comfortable leaving Resident #1 in her home due to poor living conditions and she was not able to stand unassisted. The record indicated the resident was taken into her home via stretcher, and left on the couch in the living room. A hospital ER record dated 07/17/20 at 3:52 p.m. indicated a wellness check was performed at Resident #1's residence (by local fire department) and she was found covered in feces. A Foley was noted, to gravity drainage (draining by force of gravity) and the urine was overflowing. The record indicated Resident #1 was responsive to voice, lucid, able to follow commands, confused, and unable to answer questions appropriately. A hospital ER nursing note dated 07/17/20 at 4:30 p.m. indicated Resident #1 covered in dried feces .reports per EMS report . was found lying in feces for unknown amount of time. A hospital ER record dated 07/17/20 Indicated: Resident #1 is resting comfortable .symptoms do not appear to be due to acute stroke, intercerebral hemorrhage or meningitis . unsure the acute [MEDICAL CONDITION] but may be secondary to COVID 19 . Resident #1 is unable to meet her ADLS . Although Resident #1 is maintaining an O2 SAT she is not able to take care of herself at home .will be admitted . An emergency room record dated 7/17/20 6:24 p.m. for Resident #1's [DIAGNOSES REDACTED]. A hospital progress note dated 07/17/20 for Resident #1 indicated: . assessment/plan - 1.UTI complicated ESBL (Extended Spectrum Beta-Lactamase - resistant to some antibiotics) 2. COVID [MEDICAL CONDITION] illness, 3. Dehydration . A hospital progress note dated 07/18/20 indicated Resident #1 was to receive IV fluids, IV antibiotics, and physical and occupational therapy. A hospital progress note dated 07/19 20 indicated Resident #1 was clear from a COVID/pulmonary/medical standpoint to discharge; however, she did not have a place to go and apparently could not return home with her family. The note indicated the hospital was unable to reach the nursing home Resident #1 was recently discharged from to see if they would consider readmitting her for skilled services versus custodial care. A hospital progress note dated 07/20/20 for Resident #1 indicated she remained on oxygen at 3L per nasal canula. A hospital progress note dated 07/22/20 for Resident #1 indicated she remained on room air. The note indicated a consult was placed for SNF due to the resident's deconditioning and the resident would be discharged on ce a placement was obtained. During an Interview on 7/23/20 at 8:47 a.m., a hospital case worker said Resident #1 remained a patient in the hospital. During an interview on 07/24/20 at 9:24 p.m., Resident #1's daughter said she received a call notifying her of Resident #1's planned discharge. She said she could not remember the date or who called, but told them Resident #1 was not able to care for herself and there was no family at her home to care for the resident. She said she called the facility because she did not know Resident #1 was discharged . She said the facility staff told her Resident #1 signed herself out on 07/15/20. She said she was not able to reach Resident #1 at home by phone on 07/15/20 or 07/16/20. She said she found Resident #1 late in the day on 07/16/20, lying in feces and unable to move off her bed. She said Resident #1 was supposed to receive home health services and she expected the home health staff would be at Resident #1's home on 07/15/20, 07/16/20, and 07/17/20. She said she was not able to contact Resident #1 at her home 07/17/20 and had a family friend go over to Resident #1's house. She said the family friend was not able to open the door and could not enter the home due to Resident #1's COVID-19 diagnosis. She said the family friend called the fire department to gain access and the fire department found Resident #1 laying in feces and unable to move. She said the fire department transported Resident #1 to the hospital on [DATE]. During an interview on 07/27/20 at 1:00 p.m., CNA N said Resident #1 was sleeping a lot more than usual the week of her discharge. She said Resident #1 would not eat or wake up and was very lethargic. She said the only time Resident #1 would transfer or walk was during therapy and with therapy staff. She said Resident #1 did not transfer to go to the toilet or walk with a walker to the toilet. She said Resident #1 wore a brief and would be incontinent of bowel. During an interview on 07/27/20 at 1:06 p.m., CNA O said Resident #1 was not able to transfer and could not walk to the toilet with her walker. She said Resident #1 wore a brief and was incontinent of bowel. She said Resident #1 was not eating and slept a lot, more than she had the previous week and prior to her discharge. During an interview on 07/27/20 at 12:19 p.m., LVN K (nurse for Physician I and NP C) said the facility never contacted her about told Resident #1's lethargy, not being able to care for herself, or not being able to self-transfer and ambulate without assistance. She said she was told the ambulance refused to take Resident #1 home on 07/14/20 because of her positive COVID-19 status. She said she learned of the change of condition when she called the facility on 07/15/20 to set up the telehealth visit. During an interview on 07/24/20 at 12:12 p.m., Physician I said during the telehealth visit 07/15/20 she was told Resident #1 and her family were ready to go home. She said she was under the impression Resident #1 would have family with her at home. She said the facility never contacted her about Resident #1 being lethargic or told her the ambulance refused to take the resident home the day before (07/14/20) the telehealth visit. She said she would not have discharged Resident #1 had she known of her decline and that she was going home with no support. During an interview on 7/23/20 the administrator said Resident #1 was her own responsible party and was discharged accordingly. A facility policy titled Discharge of the Patient dated 03/2019 indicated: Purpose .To provide safe departure from the Facility. Equipment: *patient's medical record *discharge order *medications *discharge instruction forms Procedure: *Explain discharge procedure to patient. Complete discharge home instructions. * The attending physician is required to write a discharge order. Telephone orders are acceptable. Documentation: *Patient status, physical and emotional. * Type of transportation; whether or not medication was given to patient . A facility Social Services policy dated 11/2016 indicated: 2. A patient Discharge Plan of care must be completed for each patient discharging to home or to another facility by the interdisciplinary team members. A copy of the patient Discharge Plan of care must be given to the Patient and/or Patient Representative at discharge .i. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the patient's follow-up care and any post-discharge medical and non-medical services to prevent readmissions .5. The facility must ensure that a transfer or discharge of the patient is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider. The facility's Patient care Management System dated 11/2017 indicated: A Comprehensive, Person-centered Plan of Care, . must be completed by the 21st day after admission (or within 7 days of the CAA completion date) and must include discharge planning as appropriate. The administrator was notified on 07/24/2020 at 2:46 p.m., an IJ situation was identified due to the above failures and the IJ template was provided. On 07/25/20 at 10:38 a.m., the facility plan of removal was accepted and included: Please accept this as a Plan of Removal to lift the alleged Unsafe Discharge and Administration Immediate Jeopardy initiated at 2:46 pm on 7/24/2020 based on interviews and record reviews made by the survey team on 7/24/2020 related to discharge planning for Resident. The following corrective actions have been taken for Resident admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident was discharged home on[DATE] thus the facility clinical team is not able to assess the current condition of the patient. Attending physician while patient was in facility was notified on 7/24/20. Social services personnel is suspended immediately on 7/24/20 pending outcome of internal investigation. RN Regional Director Clinical Services will in-service with return competency of understanding proper discharge planning procedures to licensed nursing team and leadership team in facility. Executive Director, ADON, Director of Rehab, Patient Care Coordinator, Medical Records. Unit Manager is currently working nights and DON is currently out sick with COVID-19 and were in-serviced via facetime. All education will be completed by 7/25/20 at 10:00 AM. Corporate Director of Social Services, will complete audit of discharge planning and provide outcome of audit with needed corrective action to facility Executive Director and Director of Nursing. 1. In-Services a. RN Regional Director Clinical Services will in-service with return competency of understanding proper discharge planning procedures to licensed nursing team and leadership team in facility. Completed by 7/25/20 at 10:00 AM. b. Validity of in-services will be demonstrated through competency regarding discharge planning to include: physician discharge orders; face to face physician evaluation for home health scheduled; notification to patient representative of discharge; discharge instructions and plan of care sent with patient and representative; follow-up contact with patient post discharge; provision or orders for home health service and durable medical equipment as needed/warranted. Completed by 7/25/20 at 10:00 AM. 2. QA Meeting conducted with Medical Director 7/24/2020 to review QA action plan and abatement plan. On 07/25/20 the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by: A quality assurance attendance record dated 7/24/20 indicated a meeting regarding discharge of residents was held and attended by the corporate RN, medical director and administrator. In-service training reports dated 07/24/20 and 07/25/20 presented to all licensed staff indicated staff must coordinate services and document discharge planning for all residents who are discharging from the facility. During interviews on 07/25/20, ADON/LVN, MDS Coordinator/LVN, medical records LVN, the Director of Rehabilitation Services, 2 LVNs and the administrator were knowledgeable of the requirements for discharge planning and stated they had received training regarding discharge planning and documentation. They were aware of the facility's systemic approach to discharge, the equipment and forms required, the procedure and the documentation required, the physician order [REDACTED]. During interviews on 07/25/20, the administrator and corporate RN, confirmed all licensed staff currently working at the facility had been trained on discharge planning and documentation of resident's discharge plans. The administrator said other staff would receive training before starting their next shift. On 07/25/20 at 11:45 a.m., the administrator was notified the IJ was removed. However, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.