Every finding on record at Park Plaza Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 2 of 5 residents (Resident #2 and Resident #43) reviewed for privacy, in that:The facility failed to ensure LVN A locked the computer, which exposed Resident #2's morning medication list after she walked away and left the computer unattended.The facility failed to ensure LVN B locked the computer, which exposed Resident #43's lunch time medication list after she walked away and left the computer unattended.This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.The findings include:Record review of Resident #2's face sheet dated 5.12.26 reflected an 85 - year old female who was admitted to the facility on 11.7.25 with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Respiratory Failure, and Congestive heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing blood to back up and fluid to accumulate in the lungs, legs, and other organs.). Record review of Resident #2's Quarterly MDS assessment, dated 3.4.26, reflected a BIMS score of 12 which indicated moderate cognition impairment.Record review of Resident #43's face sheet dated 5.12.26 reflected an 80- year old male admitted to the facility on 3.22.25 with diagnoses included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Dysphagia (the medical term for difficulty swallowing, indicating a disruption in the process of moving food or liquid from the mouth to the stomach. Symptoms include coughing, choking, or a sensation of food sticking in the throat or chest), and Type 2 Diabetes.Record review of Resident #43's Quarterly MDS assessment, dated 4.15.26.26, reflected a BIMS score of 15 which indicated no cognition impairment.An observation on 5.12.26 at 11:15 am revealed LVN A prepared Resident #2's medication on the medication cart and walked away from the computer revealing Resident #2's medication list, LVN A did not lock the computer screen.An observation on 5.13.26 at 11:40 am revealed LVN B left the nurses station to answer a call light and walked away from the computer revealing Resident #43's medication lists, LVN B did not lock the computer screen.During an interview on 5.12.26 at 2:15 pm, LVN A stated that she did not realize she had left her computer open with resident information on it. She stated she normally was good about closing her computer. She stated she should have shut it because the resident's information could be seen by anyone that walks by which is against the resident's privacy. During an interview on 5.13.26 at 1:15 pm LVN B stated that due to the location of the computer she thought the computer was blocked enough for nothing to be observed. She stated that coming from down the hallway and looked at the screen, she could observe Resident #43's information. She stated she did not realize the computer screen could be seen and would make sure to not leave any resident information up on that computer anymore.During an interview on 5.14.26 at 2:00 pm, the DON stated that she was notified that computer screens had been left open with resident information. She stated that should not have happen. She stated her expectations was that anytime any of her staff leave a computer it should either be shut or the screen minimized to not expose resident information. She stated the negative outcome was that the resident's personal information could be seen, such as SSN, DOB, medications etc.Record review of the facility's policy titled, Resident Rights, not dated, reflected: Privacy and Confidentiality-the resident has a right to personal privacy and confidentiality of his or her personal and medical records.

Based on observations, interviews, and record review it was determined the facility failed to provide pharmaceutical services that ensure the accurate administering of drugs for 1 of 2 nurse medication carts (South Hall) observed for medications stored. properly labeled and accounted for. The South Hall nurse medication cart had two controlled medication blister packs that did not match their corresponding controlled medication count sheet. This failure could place residents at risk of underdose, overdose or drug diversion. Findings included: Review of Resident #4's admission record dated 05/14/2026 revealed the resident was admitted to the facility on [DATE] with diagnosis of pain. He was [AGE] years of age. Review of the current care plan for Resident #4, last reviewed/revised: 03/25/2026, revealed in part: The resident is on Pain medication. The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Administer medication as ordered. Review of Resident #4's physician orders dated 05/14/2026. Hydrocodone-Acetaminophen (narcotic pain medication) oral tablet 10-325 MG. Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident 51's admission record dated 05/14/2026 revealed the resident was admitted to the facility on [DATE] with diagnosis of chronic pain. He was [AGE] years of age. Review of the current care plan for Resident #51, last reviewed/revised: 05/12/2026, revealed in part: The resident is on pain medication therapy related to disease process hip fracture/infection right hip joint, hardware removal and chronic pain. Review of Resident #51's physician orders dated 05/14/2026. Hydrocodone-Acetaminophen oral tablet 10-325 MG. Give 2 tablet by mouth every 4 hours as needed for Pain Right Hip. Observation and record review on 05/12/2026 at 9:10 AM, the north hall medication cart was inspected with LVN A present. The controlled medications were inspected, and the count was compared with the matching count sheet. There were 2 medication blister packs that the count was incorrect when compared to the corresponding count sheets. The medications were as follows: 1 blister pack of hydrocodone/APAP tablet 10/325mg that belonged to Resident #51 that contained 30 tablets. Resident #51's corresponding count sheet indicated the count was 28 and that 2 tablets were administered on 05/12/26 at 8:20am. There was 1 blister pack of hydrocodone/APAP tablet 10/325mg that belonged to Resident #4 that contained 47 tablets. Resident #51's corresponding count sheet indicated the count was 46 and that 1 tablet was administered on 05/12/26 at 7:45am. (APAP - Acetaminophen pain medication). Interview on 05/12/2026 at 9:12 AM, LVN A said she had signed the medications out on the control count sheets but had not administered it yet as she was planning on it but had gotten busy with other things. The LVN said she should not have signed them out and waited till she administered them or else the count would be incorrect and the residents might have not received their medications. Interview on 05/14/2026 at 1:22 PM Resident #4 said he received his pain medication as needed. He said he had a regular pain medication that he received and had a stronger pain medication that he could request as needed. Interview on 05/14/2026 at 1:26 PM Resident #51 said he had no concerns about receiving his pain medication as needed. He said the staff were good about asking him if he had any pain and would administer his medication as needed. Interview on 05/14/2026 at 2:44 PM, the DON said it was expected for the nurse to give the controlled medication and then to sign it out after it was given. The DON said if the controlled medication was signed out but not given then that could lead to the count being incorrect if the nurse forgot to administer the medication. The DON said a possible outcome could be the resident not getting their medication and not knowing when they received their last dose. Interview on 05/14/2026 at 2:52 PM, the Administrator said he agreed with what the DON said regarding the controlled medication count. He said he had the same expectations as the DON stated and also the possible outcomes. Record review of the facility's policy titled Medication Administration Procedures and dated 10/25/17 indicated in part: All medications are administered by licensed medical or nursing personnel. Medications are to be poured, administered and charted by the same licensed person. After the resident had been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration. All nurses administering medications must sign and initial the designated area of each resident's medication/treatment administration record or resident specific master signature log for identification of all initials used in charting.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts (South hall) reviewed for medication storage. The south hall nurse medication cart had one insulin pen that belonged to Resident #5 that had been opened but not dated when it was placed into use. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Review of Resident #5's admission record dated [DATE] revealed he was admitted to the facility on [DATE] with diagnosis of diabetes. He was [AGE] years of age. Review of the current care plan for Resident #5, last reviewed/revised: [DATE], revealed in part: The resident has Diabetes. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #5's physician orders dated [DATE]. Insulin Aspart Subcutaneous Solution Cartridge, inject as per sliding scale: Subcutaneously (Under the skin) before meals and at bedtime related to diabetes. Observation and interview on [DATE] at 9:14 AM, the south hall medication cart was inspected with LVN B present. Inside the top drawer of the cart were several insulin pens. There was one insulin pen that belonged to Resident #5 that had been opened but there was no open date found on the pen. LVN B said she did not know who had opened the pen. The DON was passing by and was made aware of the undated insulin pen. The DON said that once an insulin pen was opened it was good for 28 days. Interview on [DATE] at 2:44 PM, the DON said it was expected for the nurse to give the controlled medication and then to sign it out after it was given. The DON said if the controlled medication was signed out but not given then that could lead to the count being incorrect if the nurse forgot to administer the medication. The DON said a possible outcome could be the resident not getting their medication and not knowing when they received their last dose. The DON said it was expected for the nurses to date the insulin pens after they were initially opened. The DON said the insulin pens were good for 28 days after they were opened. The DON said a possible outcome of a resident receiving an expired insulin could be that the medication might not function as indicated. The DON said that it was each nurses responsibility to monitor the medication cart for insulin pens being dated before administering it. Interview on [DATE] at 2:52 PM, the Administrator said he agreed with what the DON said regarding the controlled medication count and the undated insulin pen. He said he had the same expectations as the DON stated and also the possible outcomes. Record review of the facility's policy titled Insulin pen use and dated [DATE] indicated in part: Once you take the insulin pen out of cool storage you can use it for up to 28 days. Ensure that the pen is dated when placed into use. During this time, it can be safely kept at room temperature up to 86 degrees Fahrenheit. Do no use it after this time.

Based on observation, interview, and record review the facility failed to ensure 1 of 7 residents (Resident #36) with indwelling urinary catheters received appropriate care to prevent urinary tract infections to the extent possible. Resident #36's indwelling catheter tubing was dragging on the floor on 3 of 3 days observed. This failure could place residents with indwelling urinary catheters at risk of infection. The findings included: Resident #36 Record review of Resident #36's admission record dated 03/13/25 indicated he was admitted to the facility on [DATE] with diagnoses of muscle weakness, reduced mobility and retention of urine. He was [AGE] years of age. Record review of Resident #36's care plan dated 10/17/2024 indicated in part: Focus: The resident has an indwelling catheter. Goal: The resident will be/remain free from catheter-related trauma through review date. Interventions: Check tubing for kinks and maintain the drainage bag off the floor. Record review of Resident #36's annual MDS assessment dated [DATE] indicated in part: BIMS = 15 indicating resident was cognitively intact. Appliances had indwelling catheter, Urinary continence = Not rated, resident had a catheter. Observation on 3/11/25 at 12:10 pm Resident #36 self-propelling in wheelchair with foley catheter tubing dragging on the floor. Observation on 3/12/25 at 12:32 pm Resident #36 self-propelling in wheelchair with foley catheter tubing dragging on the floor. Observation on 3/13/25 at 3:20 pm Resident #36 self-propelling in wheelchair with foley catheter tubing dragging on the floor. During an interview on 03/13/25 at 03:10 PM the DON said the bag and/or tubing should not be touching the floor as that could lead to a possible infection and cross contamination. The DON said due to the tubing touching the floor could lead to the risk of infections and possible cross contamination. The DON said the failure occurred probably because the catheter tubing was too low when Resident #36 was placed on his wheelchair. She stated this is a new wheelchair that is smaller than normal, and this may be the reason it is dragging. The DON was not aware that the tubing was dragging. Record review of facility policy titled Catheter Care dated 2/13/2007 revealed a subsection under general guidelines 10. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 4 (Resident #3) reviewed for respiratory care. Resident #3's oxygen nasal cannula and SVN mask were not covered in a plastic bag when they were not used. These failures could place all residents who use respiratory equipment at risk for respiratory infections. The findings included: Record review of Resident #3's admission record dated 03/13/25 indicated she was admitted to the facility on [DATE] with diagnoses of muscle weakness and hypoxemia (Low blood oxygen). She was [AGE] years of age. Record review of Resident #3's care plan dated 10/17/2024 indicated in part: (Focus: Resident has impaired oxygen exchange and shortness of breath r/t COPD and hypoxemia. Uses oxygen @ 3 liters per minute continuously when asleep & PRN during the daytime. Goal: Resident will have adequate air exchange as evidenced by normal breathing patterns and usual mental status through the review period. Interventions: Assure that Resident has oxygen on and there is no kink in tubing. Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated in part: BIMS = 10 indicating resident was moderately impaired. Respiratory Treatments - Oxygen therapy. Record review of Resident #3's Physicians Orders dated 03/13/2025 documented in part: Change O2 tubing and nasal cannula as needed when visibly soiled or malfunctions. During an observation and interview on 03/11/25 at 10:35 AM Resident #3's nasal cannula tubing was seen wrapped around the oxygen tank on her wheelchair. During further observation the resident's SVN mask was seen resting on top of the dresser on and not bagged. The resident was seen in her bed awake and alert and wearing an oxygen cannula that was connected to an oxygen machine. Resident #3 said that when she used her wheelchair she would use the oxygen cannula to get around that was connected to the oxygen tank. The resident said staff had wrapped the nasal cannula tubing around her oxygen tank to store it while she was not using it. Resident #3 said she used the SVN mask to get breathing treatments and was not sure why the SVN mask and nasal cannula were nor placed in a plastic bag. During an interview on 03/13/25 at 11:10 AM RN D said that whenever a resident was not using their oxygen that it was supposed to be stored in a bag so that the nasal cannula was not in danger of becoming contaminated. RN D said it was the same expectation for the SVN masks, that if they were not being used the mask were supposed to be kept in a bag to prevent contamination which could lead to respiratory infections. During an interview on 03/13/25 at 03:08 PM the DON said it was expected for the oxygen cannula tubing and SVN mask to be stored in a bag when not in use. The DON said if the items were not stored in a bag and left out it could lead to potential cross contaminations and infections. The DON said the failure probably occurred because the staff forgot to change the oxygen tubing and SVN masks and store them in a bag. During an interview on 03/13/2025 at 3:46 PM the ADO was made aware of the oxygen items left out and not stored in bags. The ADO said oxygen items left out like that could lead to cross contamination. Record review of the facility's policy titled Respiratory policies and procedures dated June 1, 2006 indicated in part: Oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery and frequency. Gather supplies - Treatment bag-replace entire set-up every seven days, date and store in treatment bag when not in use. Aerosol mask - oxygen therapy via aerosol mask is administered as ordered by a physician and includes flow rate, concentration, mode of delivery and frequency. Gather supplies, replace entire set-up every seven days. Date and store in treatment bag when not in use.

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 nurse medication carts (The north hall medication cart) reviewed for medication storage and security. LVN C failed to ensure the nurse medication cart for the north hall was secured when it was left unattended. These failures could place residents at risk for drug diversion or accidental ingestion. Findings included: During an observation on 03/11/25 at 10:20 AM the nurse medication cart on the north hall was observed unlocked and unattended. During an observation and interview on 03/11/25 10:25 AM LVN C was observed coming out of a resident's room. LVN C said that it was her nurse medication cart and it was her that had accidentally left it open. LVN C said she had stepped away to help one of the staff members and had forgotten to lock the cart. LVN C said leaving the cart unlocked and unattended could lead to unauthorized people having access of the cart. Inside the cart were several bubbled packed prescribed medications, insulin pens and other over the counter medications. During an interview on 03/13/25 at 03:04 PM the DON said it was expected for the medication carts to be locked when left unattended. The DON said if the cart was left unlocked and unattended that could lead to a risk of residents or visitors having access to the cart. The DON said the failure probably occurred because the nurse was called out to assist a staff member and she forgot to lock the cart. During an interview on 03/13/2025 at 3:44 PM the ADO was made aware of the medication cart left unlocked. The ADO said if the cart was left unlocked and unattended that could lead to unauthorized people getting into the cart. Record review of the facility's policy Medication Administration Procedures dated 2003 indicated in part: All medications are administered by licensed medical or nursing personnel. During the medication administration process the unlocked side of the cart must always be in full view of the nurse. After the medication administration process is completed, the medication cart must be completely locked or otherwise secured.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #36) of 7 residents reviewed for infection prevention and control. CNA A and CMA B failed to change her gloves when going from dirty to clean during Resident #36's incontinent care. CNA A and CMA B failed to use PPE during incontinent care and urinary catheter care performed for Resident #36 as the resident was on EBP precautions. These failures could place residents at risk of infections, secondary infections, and communicable diseases. Finding include: Record review of Resident #36's admission record dated 03/13/25 indicated he was admitted to the facility on [DATE] with diagnoses of muscle weakness, reduced mobility, and retention of urine. He was [AGE] years of age. Record review of Resident #36's care plan dated 10/17/2024 indicated in part: (Focus: Resident is on enhanced barrier precautions. Goal: There will not be any transmission of infection from or to the resident. Interventions: Gloves and gown should be donned if any of the following activities are to occur- resident hygiene, transfer, dressing, toileting/incontinent care). Record review of Resident #36's annual MDS assessment dated [DATE] indicated in part: BIMS = 15 indicating resident was cognitively intact. Bladder and Bowel = Urinary Continence Not rated, resident had a catheter. Bowel Continence - Always incontinent. During an observation on 03/11/25 at 11:04 AM CNA A and CMA B performed incontinent care on Resident #36. CNA A brought in a sit to stand lift machine and connected it to the sling the resident already had wrapped around and under his shoulders. Both staff members sanitized their hands and put gloves on. CNA A then pressed the button on the machine and raised the resident to a standing position. CNA A then undid the resident's brief, and it was noted that he had - had a bowel movement. Both CNA A and CMA B took some wet wipes and wiped the bowel movement. It was noted that the resident had a urinary catheter which was attached to his penis and secured to his leg. After CMA B wiped the bowel movement from the resident's rectal area she took some wet wipes and wiped the resident's catheter and penis area while still wearing the same gloves she used to wipe the resident's bowel movement. While still wearing the same gloves she used to wipe Resident #36's bowel movement, CNA A took the old brief and placed it in the trash and then took the new brief and fastened it to the resident. CNA A then pulled Resident #36's pants up and then took the lift machine remote and pressed the down button to lower the resident back unto his wheelchair while still wearing the same gloves that she had used to wipe the resident's bowel movement. Neither of the CNA's were noted to wear any PPE be sides the gloves as outside the resident's door was a posting that indicated Multidrug-resistant organisms (MDROs) are a threat to our residents, Enhanced Barrier Precautions (EBP) steps. During an interview on 03/11/25 at 11:28 AM CNA A said she should have changed her gloves before she applied the new brief, pulled the resident's pants and pressed the remote buttons on the lift to stand machine. CNA A said if she did not change her gloves then it could lead to the spread of infections and cause cross contamination. CNA A said she had forgotten to change her gloves at the proper time. When asked about the posting regarding MDROs posted outside Resident #36's door and if it applied to them during incontinent care CNA A said she was not sure why the posting was there and did not believe it applied to them for incontinent care. During an interview on 03/11/25 at 02:36 PM CMA B said she should have changed her gloves before she performed catheter care to the resident's penis area as she had just wiped the resident's bowel movement with the same gloves. CMA B said not changing her gloves could lead to UTI's and cross contamination. When asked about the posting regarding MDROs posted outside Resident #36's door and if it applied to them during incontinent care CMA B said she was not sure why the posting was there and did not believe it applied to them for incontinent care. During an interview on 03/13/2025 at 3:08 PM the DON said whenever a resident was on EBP staff were expected to use PPE such as gloves and gowns. The DON said staff were expected to wear EBP for Resident #36 during the incontinent care as he had a urinary catheter. The DON said staff not wearing EBP could possibly lead to the spread of infection to others due to possible cross contamination. The DON said the failure probably occurred because the staff was in a hurry, and that the staff would be re-educated on the use of EBP and when to use it. The DON said CMA B should have changed her gloves before she performed incontinent care to Resident #36's urinary catheter. The DON said CNA A should have changed her gloves after she had wiped the resident's bowel movements and then proceeded to do other tasks such as touching the new brief. The DON said the ADON and herself would monitor for infection control by doing rounds and in-services. The DON said she believed the failure occurred because the staff got nervous and forgot the steps. During an interview on 03/13/2025 at 3:48 PM the ADO was made aware of the staff not changing their gloves or using EBP during incontinent care performed on Resident #36. The ADO acknowledged that staff not changing their gloves or using EBP could lead to cross contamination. Record review of the facility's policy titled Infection control plan overview and dated 03/2024 indicated in part: Infection control - the facility will establish and maintain an infection control program designed to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Infection control program the facility will establish an infection control program under which it investigates, controls, and prevents investigations in the facility. Maintains a record of incidents and corrective actions related to infections. Record review of the facility's policy titled Catheter care and dated 02/23/2007 indicated in part: Provide perineal care to the incontinent resident to prevent skin rashes and breakdown. Procedure - gather supplies, gloves, pre-moistened no-rinse disposable wash cloths, wash your hands thoroughly with soap and water or alcohol, apply gloves, gently was rinse and dry around the juncture of the catheter and meatus. If using pre-moistened no-rinse disposable wash cloths, rinsing is not required, then wash the catheter from the meatus down the tube about 3 inches, dispose of wash cloths, remove gloves and wash hands. Record review of the facility's undated policy titled Enhanced barrier precautions indicated in part: Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug- resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more that 1 patient. EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices examples include central lines, urinary catheters. Record review of the facility's policy titled Perineal Care Male and dated 12/08/2009 indicated in part: Purpose to clean the male perineum without contaminating the urethral area with germs from the rectal area. Beginning steps, wash hands, gather needed supplies, expose the resident's perineal area, if heavy soiling is present, wear gloves and use tissues or wipes to remove heavy soiling prior to perineal care. Wash hands and put on clean gloves for perineal care, gently wash perineal area wiping from clean urethral area toward dirty rectal area to avoid contaminating urethral area with germs from the rectum. If at any time your gloves become contaminated with feces change gloves.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1 on 03/29/24. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 04/01/24, revealed an 84- year- old female admitted to the facility on ,d+[DATE]//22 with diagnoses including Covid-19, overactive bladder, gastronomy (feeding tube) and dementia. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required total assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 02/15/22 revealed he had bowel and bladder incontinence related to over-active bladder. Observation of incontinence care for Resident #1 on 03/29/24 at 9:50 a.m. revealed CNA A used antiseptic and donned gloves (after retrieving the gloves her pocket) before commencing care. CNA A removed Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. CNA A did not change gloves but continued to clean Resident #1. CNA A's gloves were visibly soiled with urine. CNA A used the same soiled gloves to apply skin protector to Resident #1. She did not wash her hands, change gloves, or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. CNA A washed hands before leaving Resident #1's room. In an interview on 03/29/24 at 10:03 a.m. with CNA A, she revealed she should have changed her gloves during care. CNA A also stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A was asked why she did not change her gloves. She said she was nervous. CNA A stated she had infection control training (computer-based learning) about 2 weeks ago. She has been employed in the facility for 2 month and did not receive training with return demonstration from the facility. She said the resident could acquire an infection when she did not follow good infection control practices including not changing gloves before retrieving the resident's clean brief. During an interview with the RCN B on 04/01/24 at 4:58p.m., revealed she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand washing or sanitizing hand and change of gloves before retrieving clean brief. RCN B noted the facility conducts yearly competency training and periodic in-services if needed. Review of the facility's Perineal care policy created 04/25/22 reflected: Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident skin condition. Important Points: o If heavily soiled, use an incontinence pad, brief, towel, or wipes to remove soiling, from front to back, prior to performing perineal care. o Do not wipe more than once with the same surface o Doffing and discarding of gloves are required if visibly soiled o Always perform hand hygiene before and after glove use

Based on observation, interview, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 4 residents (Resident #13 & Resident # 45) reviewed for dignity. The facility failed to ensure staff treated Resident #13 & Resident #45 with dignity by covering their catheter bags with privacy bags. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem. The findings included: Record review of Resident # 13's face sheet dated 02/09/2024 revealed, [AGE] year-old female admitted on [DATE] with diagnosis: neuroleptic induced parkinsonism (disorder of the brain that affects the functioning of muscles) and Neuromuscular dysfunction of bladder (disorder of the brain that affects functioning of the bladder). Record review of Resident # 13's comprehensive MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS of 05 meaning severe cognitive impairment; Section GG- Functional Abilities and Goals revealed Resident #13 required substantial/maximal assistance (helper does more than half the effort); Section H- Bladder and Bowel revealed Resident #13 had an indwelling catheter. Record review of Resident #13's care plan dated 01/16/2024 revealed; Focus: The resident an indwelling catheter .Interventions: The resident has an indwelling catheter. Position catheter bag and tubing below the level of the bladder and in a privacy bag. During an observation on 02/06/2024 at 2:31 p.m. Resident #13 was lying in bed with the catheter bag hanging from the bed and no privacy bag covering it. During an observation on 02/09/2024 at 7:37 a.m. Resident #13 was sitting in the dining room with the foley catheter bag touching the footrest of the wheelchair and her sock with no privacy bag covering it. Record review of Resident # 45's face sheet dated 02/09/2024 revealed, [AGE] year-old male admitted on [DATE] with diagnosis: obstructive and reflux uropathy (a condition that obstructs urine from emptying through the urethra). Record review of Resident # 45's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS of 11 meaning moderate cognitive impairment; Section GG - Functional Abilities and Goals revealed Resident #45 required substantial/maximal assistance (helper does more than half the effort); Section H- Bladder and Bowel revealed Resident #45 had an indwelling catheter. Record review of Resident #45's care plan dated 02/09/2024 revealed: Focus: The resident had an indwelling catheter .Interventions: The resident had indwelling catheter. Position catheter bag and tubing below the level of the bladder and in a privacy bag. During an observation on 02/07/2024 at 9:07 a.m. Resident #45 was seen wheeling himself down the 200 halls from the dining room with the foley catheter bag hanging from the bottom of the wheelchair and not covered with a privacy bag. During an interview on 02/08/2024 at 4:31 p.m., Resident #45 stated he would prefer his catheter bag was covered. He stated he was unable to cover the catheter with a privacy bag himself. During an interview on 02/07/2024 at 9:07 a.m., LVN A stated there should be a privacy bag covering the catheter bag. LVN A stated she did not know why the catheter bags did not have a privacy bag. She stated the facility's policy was for catheter bags to be covered with privacy bags. LVN A stated not covering with a privacy bag could cause the resident to have dignity issues. During an interview on 02/08/2024 at 10:24 a.m., the DON stated catheter bags should be covered with a privacy bag. She stated it was the CNAs and charge nurses' responsibility to make sure a privacy bag was covering the catheter bags. The DON stated she monitors CNAs and charge nurses are covering catheters with privacy bags. She stated it was her expectation that privacy bags be covering catheters bags when residents were in their rooms and when they were out of their rooms. She stated not covering the catheter with a privacy bag could affect the resident's dignity. She did not know where the failure to cover had occurred. Review of facility policy titled, Catheter Care dated February 13, 2007, revealed: Review the resident's plan of care daily for changes. Review of facility policy titled, Resident Rights reviewed on 2/08/2024 revealed: The Resident has a right to a dignified existence .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on record reviews and interviews, the facility failed to thoroughly investigate allegations of Abuse and Neglect and Injury of Unknown Origin for 6 of 11 residents (Resident #6, #17, #20, #37, #27 and #42) reviewed. The facility did not have documentation that thorough investigations of allegations of Neglect for Resident #,6, #17, #20, #37, #27 and #42 were completed. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated. Findings included: Resident #6 Record review of Resident #6's electronic face sheet dated 02/07/2024 revealed the resident was a [AGE] year-old female who was admitted on [DATE] and an original admitted [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (airflow blockage and breathing related problems), muscle weakness, Lack of Coordination, violent behavior, spastic hemiplegia (muscle tightness and involuntary contractions in the limbs and extremities on one side of the body) affecting left nondominant side. Review of Resident #6's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #6 had a BIMS score of 08 (moderate impairment); Section GG- Functional Abilities and Goals Resident #6 had upper and lower extremity impairment on both sides and required a wheelchair for mobility. Record review of Facility's Incident report dated 12/07/2023 revealed an allegation of Abuse of Resident #6 and Resident #37, I (was in the Human Resources and hear both resident cursing each other on the hallway. I rushed to hallway. I saw both of resident close to each other and cursing and swinging arms. I saw Resident #6 wheeling her wheelchair backward and run into Resident #37's chair. I separated them and moved Resident #37 back to his room. I ask him what happened, he was unable to verbalize the incident. He Just said Bullshit. I asked med what happened, she said just into him and he was mad. Both residents were separated with there was no physical or emotional destress. Review, on 02/06/2024, of facility's investigation revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #17 Record review of Resident #17's face sheet dated 02/09/2024 revealed: [AGE] year-old male admitted on [DATE] and an original admitted [DATE] with the following diagnosis Intermittent Explosive disorder, Moderate Intellectual disabilities, Major Depressive Disorder, and bipolar disorder. Record review of Resident #17's Annual MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns BIMS score of 5 (severe cognitive impairment). Resident #37 Record review of Resident #37's face sheet dated 02/09/2024 revealed: [AGE] year-old male admitted on [DATE] and an original admitted [DATE] with the following diagnosis Traumatic Brain injury, heart failure, anxiety disorder and Dementia. Record review of Resident #37's Annual MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns BIMS score of 3 (severe cognitive impairment). Record review of Facility's Incident report dated 11/29/2023 revealed an allegation of Abuse of Resident #37 THE REPORTER STATED THE INCIDENT OCCURED ON 11/28/23, AT 5:00 PM, IN THE DINING ROOM. THE REPORTER STATED THERE WERE WITNESSES. Unknown Resident WAS IN THE DINING ROOM WHEN HE SAW Resident #37 STRUCK Resident #17. HE ALSO STATED THAT KITCHEN STAFF HEARD THE INCIDENT. THE REPORTER WAS NOTIFIED AND ASSISTED Resident #37 BACK TO HIS ROOM AND ASKED HIM WHAT HAPPENED. HE STATED THAT HE DIDN'T DO SHIT. THE REPORTER SPOKE WITH Resident #17 AND ASKED HIM WHAT HAPPENED. HE STATED, HE SLAPPED ME. THE REPORTER HAD BOTH RESIDENTS ASSESSED WITH NO INJURIES. THE RESIDENTS WERE NOT EMOTIONALLY DISTRESSED. Record review of Facility's Incident report dated 01/16/2024 revealed an allegation of Abuse of Resident #37 I was in the Human Resources and hear both resident cursing each other on the hallway. I rushed to hallway. I saw both of resident close to each other and cursing and swinging arms. I saw Resident #6 wheeling her wheelchair backward and run into Resident #37's chair. I separated them and moved Resident #37 back to his room. I ask him what happened, he was unable to verbalize the incident. He Just said Bullshit. I asked what happened, she said I just into him and he was mad. Both residents were separated with there was no physical or emotional destress. Review, on 02/06/2024, of facility's investigations revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #46 Record review of Resident #46's face sheet dated 02/09/2024 revealed: [AGE] year-old female admitted on [DATE] and an original admitted [DATE] with the following diagnosis Dementia and Major Depressive Disorder. Record review of Resident #46's Annual MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns BIMS score of 3 (severe cognitive impairment). Record review of Facility's Incident report dated 02/01/2024 revealed an allegation of Abuse of Resident #46 It was brought to my attention this morning that the resident has a bruise of a size of a quarter in her forehead. The resident was assessed by the charge nurse and the DON for any possible discomfort. The resident is unable to verbalize the incident. Both the MD and the responsible party were notified. There was not physical or emotional distress involved and the resident is safe. Review, on 02/06/2024, of facility's investigation revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #20 Record review of Resident #20's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's Disease (disease that destroys memory and other important mental functions), muscle weakness, and lack of coordination. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 0 meaning severe cognitive impairment; Section GG (Functional Abilities) revealed Resident #20 was independent in rolling left to right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Facility's Incident report dated 12/07/2023 revealed an allegation of Abuse of Resident #20 Both residents were sited on the same table in the dining room. #27 started getting agitated and swing her hand toward Resident #20's face. There was no evidence that she intentionally hit her. According to the Certified Nurse that was in the dining room at the time, it seems that she may have hit her in the face unintentionally. There was no bruise on both residents. Both residents cannot verbalize the incident. Both residents were assessed by the charge nurse and the DON. There is no bruises or emotional distress on both residents. Review, on 02/06/2024, of facility's investigation revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #42 Record review of Resident #42's face sheet, dated 02/09/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with the following diagnoses which included type-2 diabetes, hemiplegia (weakness) and hemiparesis (paralyzes) to right dominant side, stroke and lack of coordination. Record review of Resident #42's Quarterly MDS Assessment, dated 01/11/2024, revealed Section C- Cognitive Patterns Resident #42 had a BIMS score of 15 (cognitively intact); Section G: ADL Assistance revealed Resident #42 had functional limitation in range of motion to upper and lower extremity on one side. Record review of Facility's Incident report dated 01/25/2024 revealed an allegation of Neglect of Resident #42 The resident was schedule to see a podiatrist doctor at the beginning of the years 2024 to cut his foot nail. The podiatrist office call to reschedule the appointment later in January because their office is close of the New Year. I called both [family members] to informed them about the changes. The responsible party hanged up the phone on me while I was trying to explain the re-scheduling to her. I went and spoke with the [family member] and give her a copy of the new schedule. Review, on 02/06/2024, of facility's investigation revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. During an interview on 02/06/2024 at 2:30 PM the ADMIN stated he had investigated each intake with in-services and conclusions. He stated he did not print the investigation out for his records. He stated was not aware he had to fill out a 3613-A form. During an interview on 02/07/24 at 11:26 AM the ADO stated the ADMN should have the PIR reports on file. He stated the ADMN should have completed the initial self-report. The ADO stated the facility had protocols in place to aid in completing an investigation correctly. He stated that he expected the ADMN to follow those protocols and should have been completed within 5 days with a conclusion. He stated in completing an investigation and following those protocols, it could have helped and aid the facility staff to take steps and prevent it from happening again. The ADO stated the ADMN monitored investigations using facility program with day 5 the ADMN been reminded of the form 3613-A, submitting all supporting documents from his investigation. He stated a failure to investigate would have a negative impact for residents and visitors which would lead to further intakes. He stated in not coming up with adequate interventions, residents would not have possibly gotten the proper care. The ADO stated he felt the staff not following the policies and procedures and company's expectations led to the failure. He stated his expectations were for staff to follow the protocols with a completed investigation. Record Review of policy titled, Abuse/Neglect dated 03/29/2018, revealed: .The facility will provide and ensure the promotion and protection of Resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . .C. Prevention .6. The facility will designate an Abuse Preventionist to monitor tracking and trending data and completion of investigations as needed . .D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly . .F. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect .and injuries of unknown source will be investigated. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. 2. After receipt of the allegation the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in the policy. 3. A report to the appropriate agency will include the following: . .g. Other pertinent information as available. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form. .6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). A copy of the written report will accompany any personnel action deemed necessary. 7. The facility will report and cooperate with any and all investigations concerning reports of abuse, and neglect . 48883

Based on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 5 (Resident # 32, Resident #33, Resident #44, Resident #48, and Resident #49) of 5 residents reviewed for care plans. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified for Resident #32, Resident #33, Resident #44, Resident #48, and Resident #49. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified with a timeframe to achieve for Resident #32, Resident #33, Resident #44, Resident #48, and Resident #49. These failures could place residents at risk for not receiving timely interventions or interventions not individualized to meet their specific physical, mental, and/or emotional needs. Findings included: Record review of Resident #32's electronic face sheet revealed a [AGE] year-old male, initially admitted on [DATE] with a recent admitted [DATE]. Resident #32's medical diagnoses included chronic respiratory problems, dementia, major depression, heart failure, weakness, heartburn, repeated falls, head injury, high blood pressure, and high cholesterol. Record review of Resident #32's Quarterly MDS assessment dated [DATE], Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #32 was Severely impaired - never/rarely made decisions. Record review of Resident #32's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: Mr. [resident] will not sustain serious injury . , The resident's fall risk will be reduced ., Mr. [resident] will display optimal breathing pattern daily. , Mr. [resident] will pass soft, formed stool. , Mr. [resident] will improve current level of function in ADL's. , Mr. [resident] will have no indications of psychosocial well being problem . , Mr. [resident] will identify coping mechanisms (new and old) . , Mr. [resident] will demonstrate adjustment to nursing home placement. , Mr. [resident] will not have an interruption in normal activities due to pain . , Mr. [resident] will not have discomfort related to side effects of analgesia . , Residents needs will be met . , My/RR's decision for DNR will be honored . , I will have fewer episodes of allergies . , My dignity will be maintained and fewer incidents of incontinence . , Resident will be safe from any injuries . , The resident will cooperate with care . , The resident will demonstrate effective coping skills . , The resident will seek out staff/caregiver when agitation occurs . , The resident will show decreased episodes of s/sx of depression. , The resident will be able to communicate basic needs on a daily basis . , The resident's, dignity and autonomy will be maintained at highest level . , The resident will display optimal breathing pattern daily . , and Resident will maintain ideal weight and receive proper nutrition daily . The objective lacking ability to be evaluated or quantified and did not provide a timeframe for achieving was Maintain stable weight and nutritional parameters. Record review of Resident #33's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of heart failure, Alzheimer's disease, major depression, dementia, history of falling, placement of a cardiac pacemaker (an implanted device to regulate heart rhythm). Record review of Resident #33's Quarterly MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #33 scored 1 out of 15 indicating severe cognitive impairment. Record review of Resident #33's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: Resident/responsible party's decision for DNR will be honored. , The resident will be able to communicate basic needs on a daily basis. , The resident will maintain involvement in cognitive stimulation, social activities as desired. , The resident will verbalize less difficulty breathing and be more comfortable . , The resident will not sustain serious injury . , The resident will not have an interruption in normal activities due to pain . , Dignity will be maintained and the resident will be kept comfortable . , and The resident will maintain or improve current level of function . The objective lacking ability to be evaluated or quantified and did not provide a timeframe for achieving was Maintain stable weight and nutritional parameters. Record review of Resident #44's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of Alzheimer's disease, high cholesterol, difficulty sleeping, major depression, weakness, history of head trauma, disease of the liver, and vitamin deficiency. Record review of Resident #44's Quarterly MDS dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #44 scored 4 out of 15 indicating severe cognitive impairment. Record review of Resident #44's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: My/RR's decision for DNR will be honored ., I will maintain my current level of function . , I will not have discomfort related to side effects of analgesia . , I will verbalize adequate relief of pain or ability to cope with incompletely relieved pain . , I will not sustain serious injury related to a fall . , I will have my needs met with input from my RR . , I will have fewer episodes of allergies . , The resident will demonstrate adjustment to nursing home placement . , Medication will be administers safely., The resident will develop skills to cope with cognitive decline and maintain safety . , The resident's comfort will be maintained . , The resident's dignity and autonomy will be maintained at highest level . , I will have adequate air exchange as evidenced by normal breathing patterns and usual mental status . , The resident will have fewer episodes of yelling out weekly ., and The resident will not have an interruption in normal activities due to pain . The objectives lacking ability to be evaluated or quantified and did not provide a timeframe for achieving were: I will receive medication as ordered by the Physician. while on pass., I will be offered/administered all Immunizations as ordered by his physician., and Maintain stable weight and nutritional parameters. Record review of Resident #48's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of adult-onset diabetes, shortness of breath, Alzheimer's disease, weakness, high blood pressure, difficulty swallowing, depression, and anxiety. Record review of Resident #48's Quarterly MDS dated [DATE], Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #32 was Severely impaired - never/rarely made decisions. Record review of Resident #48's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: The resident will cooperate with care. , I will have adequate air exchange as evidenced by normal breathing patterns and usual mental status . , I will maintain my current level of function . , I will not sustain a serious injury related to a fall . , The resident will be able to communicate basic needs on a daily basis . , The resident will develop skills to cope with cognitive decline and maintain safety . , The resident will improve current level of cognitive function . , The resident's safety will be maintained . , The resident will demonstrate happiness with daily routine . , The resident will be able to communicate basic needs on a daily basis . , and Resident will maintain ideal weight and receive proper nutrition daily . The objectives lacking ability to be evaluated or quantified and did not provide a timeframe for achieving were Request for CPR to be initiated will be followed, Medication will be administers safety and as ordered, The resident will receive medications as ordered by the physician, The resident will be compliant with thyroid replacement therapy., and Maintain stable weight and nutritional parameters. Record review of Resident #49's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses respiratory disease, kidney disease, high blood pressure, heart failure, gout (a type of arthritis that causes pain and swelling in the joints), Sjogren syndrome (a disease that occurs when the immune system attacks the body causing dry skin, dry eyes, fatigue and joint pain), and a skin infection. Record review of Resident #49's Quarterly MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #49 scored 12 out of 15 indicating moderately impaired cognition. Record review of Resident #49's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: My/RR's decision for DNR will be honored . , I will maintain my current level of function . , The resident's comfort will be maintained . , I will have adequate air exchange as evidenced by normal breathing patterns and usual mental status . ,I will not have an interruption in normal activities due to pain . , I will have my needs met with input from my RR . , and The resident will have no s/sx of complications r/t fluid deficit . The objectives lacking ability to be evaluated or quantified and did not provide a timeframe for achieving were: Medication will be administers safety and as ordered, and The resident will receive medications as ordered by the physician, while on pass. During an interview on [DATE] at 10:52 AM, RCN stated goals should be measurable and include a timeframe to complete or be reviewed. She stated previous nursing leadership responsible for creating, reviewing and revising the care plans did not do their jobs. Record review of Facility policy titled Comprehensive Care Planning undated revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . Measurable objectives describe the steps toward achieving the resident's goals, and can be measured, quantified, and/or verified.

45216 48883 Based on interview and record review, the facility failed to review and revise resident-centered comprehensive care plans within 7 days of a comprehensive assessment for 5 (Resident #13, Resident #32, Resident #44, Resident #48, and Resident #49) of 6 residents reviewed for care plans. The facility failed to review and revise Resident #13, Resident #32, Resident #44, Resident #48, and Resident #49's Comprehensive Patient-Centered Care Plan within 7 days following the completion of a comprehensive assessment. This failure could put residents at risk for not receiving the care and services needed to maintain or improve physical, mental, emotional, psychological well-being. Findings included: Record review of Resident #13's electronic face sheet revealed a [AGE] year-old female, initially admitted on [DATE] with her most recent admission on 04/19/2021. Resident #13 was admitted with medical diagnoses that included kidney disease, bipolar disorder, major depression, low thyroid function, drug induced involuntary muscle movement, abnormal weight loss, and history of falls. Record review of Resident #13's Annual MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #13 scored 5 out of 15 indicating severe cognitive impairment. Record review of Resident #13's recent comprehensive assessment revealed a completion date of 01/16/2024. Review of Resident #13's date of last care plan review completed was 11/10/2023. Record review of Resident #32's electronic face sheet revealed a [AGE] year-old male, initially admitted on [DATE] with a recent admitted [DATE]. Resident #32's medical diagnoses included chronic respiratory problems, dementia, major depression, heart failure, weakness, heartburn, repeated falls, head injury, high blood pressure, and high cholesterol. Record review of Resident #32's Quarterly MDS assessment dated [DATE], Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #32 was Severely impaired - never/rarely made decisions. Record review of Resident #32's recent comprehensive assessment revealed a completion date of 11/17/2023. Review of Resident #32's date of last care plan review completed was 10/06/2023. Record review of Resident #44's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of Alzheimer's disease, high cholesterol, difficulty sleeping, major depression, weakness, history of head trauma, disease of the liver, and vitamin deficiency. Record review of Resident #44's Quarterly MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #44 scored 4 out of 15 indicating severe cognitive impairment. Record review of Resident #44's recent comprehensive assessment revealed a completion date of 01/16/2024. Review of Resident #44's date of last care plan review completed was 10/06/2023. Record review of Resident #48's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of adult-onset diabetes, shortness of breath, Alzheimer's disease, weakness, high blood pressure, difficulty swallowing, depression, and anxiety. Record review of Resident #48's Quarterly MDS assessment dated [DATE], Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #48 was Severely impaired - never/rarely made decisions. Record review of Resident #48's recent comprehensive assessment revealed a completion date of 01/11/2024. Review of Resident #48's date of last care plan review completed was 10/06/2023. Record review of Resident #49's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses respiratory disease, kidney disease, high blood pressure, heart failure, gout (a type of arthritis that causes pain and swelling in the joints), Sjogren syndrome (a disease that occurs when the immune system attacks the body causing dry skin, dry eyes, fatigue and joint pain), and a skin infection. Record review of Resident #49's Quarterly MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #49 scored 12 out of 15 indicating moderately impaired cognition. Record review of Resident #49's recent comprehensive assessment revealed a completion date of 12/15/2023. Review of Resident #49's date of last care plan review completed was 09/27/2023. Interview on 02/09/24 at 12:30 PM, the DON stated she was aware that care plans had not been updated due to the previous DON and ADON leaving without notice. The DON stated her expectation was that care plans be comprehensive and be person centered. She also stated her expectation was for care plans to be updated timely. She stated care plans should have been reviewed any time there was a change and at minimum quarterly. DON stated the team (DON, ADON, MDS, and nurses) were responsible to ensure care plans were completed and reviewed timely. Interview on 02/09/24 at 2:34 PM, the MDS Coordinator stated she was behind on updating care plans. The MDS Coordinator stated care plans should be reviewed and revised if needed within 7 days after each comprehensive assessment. She stated the failure occurred due to former nursing leadership walking out in December 2023. Record review of facility policy titled Comprehensive Care Planning undated revealed A comprehensive care plan will be developed within 7 days after completion of the comprehensive assessment, The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals .

Based on observation, interview and record review the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 3 residents (Resident #42) reviewed for foot care. The facility failed to ensure Resident #42 received podiatry care since admission on 06/28/2021. This deficient practice could place residents at risk of overall poor foot hygiene and a decline in resident's physical condition. The findings were: Record review of Resident #42's face sheet, dated 02/09/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with the following diagnoses which included type-2 diabetes, hemiplegia (weakness) and hemiparesis (paralysis) to right dominant side, stroke and lack of coordination. Record review of Resident #42's Quarterly MDS Assessment, dated 01/11/2024, revealed Section C- Cognitive Patterns Resident #42 had a BIMS score of 15 (cognitively intact); Section G: ADL Assistance revealed Resident #42 had functional limitation in range of motion to upper and lower extremity on one side. Record review of Resident #42's Care Plan revised on 01/27/2024, revealed Focus: Goal: Interventions: Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness; Focus: Resident has thick, yellow toenails that require trimming by a nurse Goal : Resident will be free of pain or discomfort Interventions Nursing will perform toenails/fingernails care when needed for resident, Resident will see podiatrist when needed Record review of Resident #42's Order Summary Report revealed a start date of 07/05/2023 and May have Podiatry Consult PRN. During an observation on 02/06/24 at 10:53 AM revealed Resident #42's toenails had been trimmed and were short. Resident #42 stated he had seen the podiatrist on January 30, 2024 he had cut his toenails and he was feeling better and had no pian. During an interview on 02/06/2024 at 3:55 PM the family representative stated Resident #42's toenails had not been clipped in a long time and that he had not been seen by a podiatrist since he had been admitted to the facility. During an interview on 02/08/2024 at 9:15 AM the ADO stated his expectation was residents who were diabetic should have been on the list to be seen by the podiatrist quarterly. The ADO stated his expectation was that when staff observe residents' toenails that needed to be trimmed the nurse should have been notified and the nurse should have trimmed nails immediately. The ADO stated Resident #42 should have been seeing the podiatrist due to his diagnosis of diabetes. The ADO stated when he was made aware of Resident #42's toenails on 01/26/2024 he clipped the resident's toenails himself and attempted to get the resident's appointment moved up from January 30, 2024. The ADO stated Resident #42 had seen podiatrist on January 30, 2024 and was scheduled for routine visits. During an interview on 2/08/2024 at 2:30 PM the ADON stated her first day working at the facility was January 26, 2024 and she learned about Resident #42's issues with his feet. ADON stated Resident #42 was scheduled to see the Podiatrist on January 30, 2024. The ADON stated there were no open areas, redness, or infection. The ADON stated by her observation it had been at least a month since someone had trimmed his toenails. The ADON stated since he was diabetic, he should have been seen by the podiatrist quarterly. The ADON stated the social worker was responsible to schedule podiatrist appointments. The ADON stated nurses were supposed to do a weekly skin assessment and they should have been documenting toenails on the skin assessment. The ADON stated what led to the failure was the nurse was not completing an accurate assessment and lack of communication. The ADON stated the effect on the resident could have been infection or pain to the resident. During an interview on 02/09/24 at 12:30 PM the DON stated her expectation was that residents who were diabetic should have been seen by the podiatrist on a regular basis, and the nurses should have been taking care of clipping residents' nails when an issue arose. The DON stated the nurses were responsible for completing nail care and the ADON and DON were responsible to monitor. The DON stated the effect on residents could have been minor injury and/or infection. The DON stated what led to the failure was the changes in leadership the last several months left no one to monitor the nurses. Record review of facility document for residents with routine foot care for 09/23/23 and 11/30/2023 revealed no evidence of Resident #42 was seen by the podiatrist. Record review of facility policy titled, Foot Care dated 2003 revealed Become familiar with medical conditions that compromise circulation in the feet and assess or need of nail trimming. Request referral to podiatrist if nail trimming is needed.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 5 (Residents #3, #6, and #18) residents reviewed for smoking safety. The facility failed to ensure Residents #6 was supervised when smoking per assessment. The facility failed to ensure Residents #3, #6, and #18's lighters and cigarettes were not stored on their person. These failures could affect residents who smoke at risk of serious bodily harm, physical impairment, or death. The findings included: Resident #3 Record review of Resident #3's electronic face sheet dated 02/09/2024 revealed resident was a [AGE] year-old female who was admitted on [DATE]. Resident #3's diagnoses included: Chronic Obstructive Pulmonary Disease. Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #3 had a BIMS score of 15 (cognitively intact). Section GG-Functional Abilities and Goal: Resident #3 used a manual wheelchair. Record review of Resident #3 Electronic Health Record from 09/07/2023 through 02/09/2024 revealed she did not have any Safe Smoking Assessment. During observation on 02/07/2024 at 1:54 PM, Residents #3 were observed smoking in the designated smoking area of the facility having cigarettes and lighters on their person with no supervision. During an interview on 02/08/2024 at 9:33 AM the ADON stated there was not an assessment on Resident #3. She stated the assessment should have been done upon admission and monthly if needed. She stated herself as ADON, the DON and MDS should have monitored the resident assessments. The ADON stated the negative impact to residents who smoke and not having a smoking assessment would be an unsafe smoking environment for everyone at the facility. She stated the failure was upper management not keeping up with the assessments. Her expectations were to make sure the assessments be done for each resident that smoked. During an interview on 02/09/24 at 1:46 PM the ADO stated the smoking assessments should be done on admission or once they find out they are a smoker. The assessment would then be flagged with a monthly reminder to continue monthly assessments. The ADO also stated if a residents condition changes, an assessment would be done then as well. He stated compliance nurses would also do random auditing, but the DON was the ultimate one to monitor the smoking assessments. He stated the negative impact of not having a smoking assessment would be unsafe for residents possibly start a fire with residents getting burnt. The ADO stated the failure was having changes in upper management. His expectations were for a smoking assessment to be performed on a resident once identified as a smoker and to be done and completed monthly. Record review of facility policy titled Smoking Policy last revised on 11/01/2017 revealed: . .2. A safe smoking assessment will be done regularly for each resident who smokes . Resident #6 Record review of Resident #6's electronic face sheet dated 02/07/2024 revealed resident was a [AGE] year-old female who was admitted on [DATE] and an original admitted [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease, muscle weakness, Lack of Coordination, violent behavior, spastic hemiplegia (muscle tightness and involuntary contractions on one side of the body) affecting left nondominant side. Review of Resident #6's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #6 had a BIMS score of 08 (moderately impairment); Section GG- Functional Abilities and Goals Resident #6 had upper and lower extremity impairment on both sides and required a wheelchair for mobility. Record review of Resident #6's Safe Smoking assessment dated [DATE] revealed: Resident requires direct supervision while smoking; Resident requires a fire-resistant smoking apron while smoking; Residents smoking materials will be kept at the nurses station. Record review of Resident #6's Comprehensive Care Plan last revised on 10/20/2023 revealed: Focus: The resident is a smoker and requires supervision and smoking apron due to shaking, hemiplegia and dexterity issues. Goal: Resident will be able to smoke without causing injury. Interventions: Safe Smoking Assessment every month. Record review of Resident #6's Safe Smoking assessment dated [DATE] (noted assessment date) revealed: A. Evaluation-When observed, the resident cannot independently light smoking materials safely. The resident had only complete use of one hand. The resident has had past accidents/incidents with smoking materials. There were visible burn marks on the residents clothing. B. Summary-The resident requires direct supervision while smoking. The resident requires a fire-resistant smoking apron while smoking. All smoking materials will be kept at the nurses station. Record Review of Resident #6's smoking assessments were initiated on 07/06/2023. She had missing monthly assessments for 09/2023 and 01/2024. During observation on 02/07/2024 at 1:54 PM, Resident #6 was observed smoking in the designated smoking area with no apron for Resident #6 and no supervision. Resident #18 Record review of Resident #18's electronic face sheet dated 02/09/2024 revealed resident was a [AGE] year-old male who was admitted on [DATE] and an original admitted [DATE] with diagnoses that included: heart disease, pain, mild cognitive impairment, muscle weakness, difficultly walking and lack of coordination. Review of Resident #18's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #18 had a BIMS score of 09 (moderately impaired); Section GG- Functional Abilities and Goals Resident #18 used a cane/crutch for mobility. Record review of Resident #18's Comprehensive Care Plan last revised on 07/05/2023 revealed: Focus: The resident is a smoker, and all smoking materials will be returned to charge nurse. Record review of Resident #18's Safe Smoking assessment dated [DATE] revealed: B. Summary-All smoking materials will be kept at the nurses station. During an observation and interview on 02/06/2024 at 11:50 AM, Resident #18 was observed with cigarettes in his shirt pocket. He stated he also carried his own lighter. During observation on 02/07/2024 at 1:54 PM, Residents #18 were observed smoking in the designated smoking area of the facility having cigarettes and lighters on their person with no supervision. During observation and interview on 02/07/2024 at 1:57 PM the Dietary Staff stated those 3 residents (#3, #6, #18) had their own cigarettes and lighters. The Dietary Staff stated she did not usually go out with the residents and realized they had their own cigarettes and lighters but stated she was not supervising the residents at that time. The Dietary Staff stated she did not think the residents were able to have their own. During an interview on 02/07/2024 at 2:55 PM the ADMIN stated there was a lockbox that Residents were supposed to have kept their cigarettes and lighters in after smoking. He stated when the Residents go out with the supervising aide, they would refuse to hand them back in. The ADMIN stated all of the residents who smoked had signed the smoking policy agreement. During an interview on 02/08/24 at 9:07 AM the DON stated all of the smokers were required to be educated on safe smoking in the designated smoking area and follow the policy and procedures they had signed. She stated the code to go out to the designated smoke break area from the dining room should be kept between staff, and residents should not be going out to smoke on their own. The DON stated it was the ADMIN that monitored the code and had not been changed, even though residents were smoking without supervision. She also stated they should not have cigarettes and/or lighters on their person and smoking supplies should have been placed in a lockbox after use. She stated if residents were found to have them, they would have been confiscated. The DON stated the negative impact for unsupervised residents could have been possibly burned, or smoke inhalation. The DON stated there were residents that were supposed to have smoking vests on but some refused most times. She stated the supervising aides were supposed to tell the nurses when they refuse to do so. The DON stated she could not say why the residents were able to smoke unsupervised, and they may have been getting cigarettes from visitors as they came in. She stated the failure occurred when the cigarettes and lighters were not being kept in the lockbox as well as with residents being allowed to keep them. The DON stated the failure also occurred with staff not reporting residents having cigarettes and lighters on their person, to the upper management. Her expectations were that staff would be more knowledgeable about the lockbox with a designated supervised person to be with them. During an interview on 02/09/24 at 1:40 PM the ADMIN stated there were no in services for staff supervising smokers. He stated they should have been in serviced before being allowed to supervise the smoking residents. Record review of facility policy titled, Uniform Smoke Free Policy undated, revealed: No storage is permitted in rooms with gas fired equipment Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel Smoking tobacco, matches, lighter or other smoking paraphernalia are not permitted to be kept or stored in a resident's room. A resident, who is assessed safe to smoke unsupervised, will be instructed to obtain their smoking paraphernalia from a designated, secured area. The resident will be instructed to return the smoking paraphernalia following the smoking session. The resident may smoke at their request, unless the time interferes with resident care A resident who is assessed unsafe to smoke unsupervised must be in direct view of the smoking supervisor, in a reasonably close proximity of the supervisor, and the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor, whether staff or visitor, must be aware of these responsibilities.

Based on observation, interview and record review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #40) of 4 residents reviewed for catheters. The facility failed to provide appropriate treatment and indwelling catheter services consistent with professional standards of practice by not changing Resident #40's urinary catheter as ordered and ensuring Resident #40's urinary catheter collection bag was not on the floor. This failure placed residents with urinary catheters at risk for infection threatening their physical and mental well-being. Findings included: Record review of Resident #40's electronic face sheet revealed a [AGE] year-old female admitted [DATE] with medical diagnoses of a stroke, high blood pressure, paralysis in both arms and legs, neuromuscular dysfunction of the bladder (lacking control of the muscles that control bladder function due to brain, spinal cord, or nerve problems), difficulty eating, adult-onset diabetes, inability to speak, and inability to stand or walk. Record review of Resident #40's Quarterly MDS dated [DATE] revealed in Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #40 was Severely impaired - never/rarely made decisions. Observation on 02/06/24 at 02:31 PM revealed Resident #40's urinary catheter tubing was cloudy. The tubing was not dated. Observation on 02/08/24 at 4:45 PM, revealed Resident #40's urinary catheter collection bag was lying on the floor under the right side of the bed. Observation on 02/09/24 at 07:26 AM, revealed Resident # 40's catheter was in a privacy bag, hanging below the right side of the bed. The tubing was cloudy. The tubing was not dated. Record review of Resident #40's care plan dated 07/05/2023 revealed Focus: The resident has an indwelling catheter. Goal: The resident will show no s/sx of infection through the review date. Review date: 10/22/2023. Interventions: Change the catheter as ordered. Revised 08/23/2023. Review of Physician's order dated 06/17/2023 reflected Change 16f 10 cc foley catheter q28days and PRN one time a day every 28 day(s) related to neuromuscular dysfunction of bladder. Review of Resident #40's Wound Assessment Record dated October 2023 revealed the catheter was due to be changed 10/06/23. The box to note who changed the catheter was blank. Resident #40's progress note on 10/17/23 indicated the urinary catheter was changed. Review of Resident #40's Wound Assessment Record dated November 2023 revealed the catheter was due to be changed 11/03/23. The box to note who changed the catheter was blank indicating the catheter was not changed as scheduled. Review of Resident #40's Wound Assessment Record dated December 2023 revealed the catheter was due to be changed 12/29/23. The box to note who changed the catheter was blank indicating the catheter was not changed on 12/29/23. The record indicated the catheter was changed on 12/01/23. Review of Resident #40's Wound Assessment Record dated January 2024 revealed the catheter was due to be changed 01/26/24. The box to note who changed the catheter was blank indicating the catheter was not changed. During an interview on 02/09/24 at 7:40 AM, MA C and CNA A stated urinary catheter collection bags should never be placed on the floor due to the risk of cross-contamination. MA C stated training on catheter care was provided by the facility about every 3 months either face-to-face or online. CNA D stated placing a catheter collection bag on the floor could put residents at risk for the bladder not draining properly, the collection bag and/or tube could become a trip hazard, the collection bag and/or tubing may get caught up and possibly pull the catheter out, and leaving the collection bag on the floor increased the potential for infection. MA C stated all staff were responsible for ensuring bags were not left on the floor. MA C stated the charge nurse was responsible for monitoring and the administrator checked all residents during morning rounds every day. During an interview on 02/09/24 at 9:28 AM, LVN B stated the physician's order for Resident # 40 was for the urinary catheter to be changed every 28 days and PRN. She stated the resident refused the recent scheduled change because the catheter had been changed a week earlier. LVN B explained a notation would be made in the Wound Administration Record or progress notes if there was an issue and the catheter was not changed when scheduled. She stated nursing personnel were responsible for monitoring proper catheter care. Her expectations were to be informed of issues with catheters such as if there was leaking or no urine output. LVN B stated Resident #40 frequently refused catheter change. She explained Resident #40 prefers only certain staff members to do certain tasks. LVN B stated a notification pops up on the computer when nursing staff access resident records and a catheter change was due. LVN B explained training for catheters was via an online program. She stated staff received notifications when training is due. LVN B could not recall how often catheter training was required. LVN B stated the consequences of placing the collection bag on the floor may be that the bag would get run over, a hole may develop in the bag, or someone may trip and pull the catheter out. She stated the collection bag could have been left on the floor after the resident was transferred to bed and staff forgot to attach the collection bag to the bed. Another reason LVN B provided was because staff often unhooked the collection bag to make it easier to empty at the end of the shift and probably forgot to rehang it. She stated not hanging the collection bag up off of the floor may affect a resident because it could cause bladder spasms from urine backflow. LVN B stated nursing personnel were responsible for monitoring proper catheter care. LVN B stated s/sx of possible infection were complaints of burning or pain from spasms and expected direct care providers to report. LVN B stated Resident #40 was not being treated for UTI. Record review of physician's orders for Resident #40 confirmed LVN B's statement. During an interview on 02/09/24 at 10:52 AM, RCN stated her expectation of catheter care was for catheters to be changed when ordered. She stated several catheter change orders had been changed to PRN only in order to decrease the risk of catheter associated infection. RCN stated the nursing staff were responsible for changing catheters and the DON was ultimately responsible to ensure the changes were done. RCN explained the risk of failing to change a catheter as ordered would be infection. RCN stated when a resident refused a catheter change the provider was notified, a care plan meeting was scheduled, the resident was advised of the consequences including potential transfer to the hospital or to a urologist. She explained a Negotiated Risk Agreement would be reviewed with the resident and/or their representative and the IDT would be involved. RCN stated if the resident's primary physician ordered the catheter change, the facility would be responsible for ensuring it was done. She stated the nursing staff was required to review the WAR daily to see what treatments such as catheter change were due. She stated the nursing administration performed an audit in the electronic records system daily to make sure orders were completed. The RCN accessed Resident #40's records and acknowledged Resident #40 was scheduled for a catheter change on 01/26/24 and it was not done. She explained the electronic system popped up a screen to document a reason when a resident refused a task. She stated unfortunately too many nurses just enter refused as the explanation. RCN stated it was not appropriate for a catheter collection bag to be left on floor. She stated all staff were responsible for ensuring collection bags were off the floor. Her stated expectation was for collections bags to be kept off the floor. She explained staff received training at hire and annually. Face-to-face training was done during orientation and again if a problem was identified, and subsequent training such as annual training was done online. RCN stated staff were notified when online training was due via email and/or text message. She stated staff's notification preference was set-up during orientation. RCN stated compliance with required training was monitored by nursing leadership. Record review of facility policy titled Catheter Care, revised 02/13/07, revealed Change the catheter and drainage system as needed unless ordered otherwise by the physician. and Be sure the catheter tubing and drainage bag are kept off the floor.

48883 Based on observations, interviews and record reviews, the facility failed to ensure that a resident who uses a feeding tube for liquid nourishment, fluids, and medications received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 (Resident #40) reviewed for gastrostomy tube. The facility failed to check the placement of Resident #40's gastrostomy tube prior to administering water flushes and medication administration via gastrostomy tube. This failure could place residents who use gastrostomy tubes at risk of aspiration pneumonia. The findings included: Record review of Resident # 40's face sheet dated 02/09/2024 revealed, [AGE] year-old female admitted on [DATE] with diagnosis: dysphasia following other cerebrovascular disease (difficulty swallowing after stroke) and dysphagia, oropharyngeal phase (difficulty swallowing). Record review of Resident # 40's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior resident was rarely/never understood; Section GG- Functional Abilities and Goals revealed eating not attempted due to medical condition or safety concerns; Section K- Swallowing/Nutritional Status revealed Resident #40 had a feeding tube while a resident. Record review of Resident #40's care plan dated 02/09/2024 revealed; Focus: Resident is NPO and requires an alternate method of nourishment. RP agreed on no residual or placement checks .Goal: I will be free of aspiration through the review date .Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than 100cc. During an observation and interview on 02/07/2024 at 8:23 a.m., LVN A administered a water flush and antinausea medication via Resident #40's gastrostomy tube without checking for tube placement. LVN A stated Resident #40 did not like for staff to check for placement and that was why she did not perform it. LVN A did not know what the care plan stated for Resident #40. She stated not checking for placement put the resident at risk for aspiration. During an interview on 02/09/2024 at 9:08 a.m., ADON stated her expectation would be for RP to sign an associated risk consent when RP did not want the facility to check for gastrostomy tube placement prior to administering nutrition / medication into it. She stated the effect of not checking placement prior to using the gastrostomy tube could cause peritonitis (inflammation in the tissue that lines the inside of the abdominal cavity). ADON stated she and DON were responsible for monitoring staff are properly using gastrostomy tubes. She did not know why the failure occurred. During an interview on 02/09/2024 at 9:08 a.m., DON stated her expectation would be for resident's RP to sign consent and care plan be updated if resident or RP would not allow for gastrostomy tube placement prior to administering medication. She stated she was responsible for monitoring that staff perform care appropriately and did not know if there was a policy for what to do if there was a refusal of placement checks. She stated not checking placement placed resident at risk of infection. She does not know why consent was not gotten because she has only worked at the facility for less than one month. Review of facility policy titled Gastrostomy Tube Care dated February 13, 2007 revealed: Unplug or unclamp the tube and check the placement by aspiration or injecting air and listening to the stomach for sounds .Check its position using the markings on the tube .If the tube has moved or has come out, do not use and call the physician.

Based on observation, interview and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 3 of 3 residents (Resident #20, Resident #25, and Resident #45) reviewed for bed rails. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails. These failures could place residents at risk for injury and restricted movement. The findings include: Resident #20 Record review of Resident #20's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's Disease (disease that destroys memory and other important mental functions), muscle weakness, and lack of coordination. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 0 meaning severe cognitively impairment; Section GG (Functional Abilities) revealed Resident #20 was independent in rolling left to right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #20's care plan reviewed on 02/09/2024 revealed Focus: The resident had an ADL self-care performance deficit related to weakness, cognition deficit, unsteady gait upon mobility, disease process .Interventions: I require limited assistance by 1-2 staff. There was no evidence of interventions for placement and/or use of bed rails. Record review of Resident #20's physician orders dated 02/09/2024 revealed no order for the use of bed rails. Record review of Resident #20's electronic records on 02/09/2024 revealed no evidence of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. During an observation on 02/06/2024 at 10:00 a.m., Resident #20's bed had quarter rails on both sides of bed. Resident #25 Record review of Resident #25's face sheet dated 02/07/2024 revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), abnormalities of gait and mobility, lack of coordination, and right sided hemiplegia and hemiparesis following cerebral infarction (right sided weakness following a stroke). Record review of Resident #25's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 9 indicated moderately impaired and Section GG (Functional Status) revealed Resident #25 needed supervision with rolling left and right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #25's comprehensive care plan reviewed on 02/07/2024 revealed the resident requires 1-2 person assist with bed mobility, she was able to use side rails to help hold self over and to help reposition self in bed. Record review of Resident #25's physician orders dated 02/09/2024 revealed order for 1/4 siderails x 2 when in bed for positioning with start date of 12/21/2021. Record review of Resident #25's electronic records on 02/09/2024 revealed no evidence of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. During an observation and interview on 02/06/2024 at 10:01 a.m., Resident #25 had half rails present to bed. She stated rails help with bed mobility. Resident #45 Record review of Resident #45's face sheet dated 02/09/2024 revealed a [AGE] year-old male was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included pain, abnormalities of gait and mobility, muscle weakness, and reduced mobility. Record review of Resident #45's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 11 meaning moderately impaired and Section GG (Functional Abilities) revealed Resident #13 needed partial to moderate assistance with rolling left to right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #45's care plan reviewed on 02/09/2024 revealed he may use 1/2 rail for turning and positioning as necessary. Record review of Resident #45's physician orders dated 02/09/2024 revealed order for half siderails x 2 when in bed as tolerated with start date of 11/21/2022. Record review of Resident #45's electronic records on 02/09/2024 revealed bed rail consent signed on 02/08/2024 and bed rail assessment completed on 02/08/2024. During an observation and interview on 02/06/2024 at 3:15 p.m., Resident #45 had half rails on his bed. He stated the rail on the right side of his bed was loose. He stated he used rails to help him move around in the bed. During an interview on 02/09/2024 at 10:35 a.m., LVN B stated she did not do risk for entrapment, bed rail assessment, or consents for bed rails. She stated she did not know why they were not completed, and that upper management were who completed those forms. During an interview on 02/09/2024 at 10:38 a.m., the ADON stated her expectation would be that entrapment risk, bed rail assessment be performed, and consent be signed by resident or responsible party prior to bed rails being installed on a resident's bed. She did not know why these steps were not completed prior to bed rails being placed. She stated some information was lost when changing systems. She stated the effect could be that resident could potentially be harmed by entrapment if bed rails were not appropriate for that resident. During an interview on 02/09/2024 at 10:39 a.m., the RCN stated she was unsure what led to bed rail assessment, entrapment risk assessment and consent not signed. She stated the DON was given a list of residents that corporate had identified as needing these assessments and consents, but that staff member had resigned. She was unsure if assessments and consents were performed and could not provide evidence that they were. The RCN stated it was her expectation admitting nurse would perform bed rail assessment, entrapment risk assessment and get consent for bed rails. She stated these forms not being completed could lead to bed rails being used when not appropriate. She stated she was ultimately responsible for making sure the forms were completed but that ADON and DON were to start performing audits to charts to make sure appropriate forms were present after admission paperwork completed. Review of facility policy titled Bed Rails dated November 8, 2016, revealed: This facility will utilize bed rails for those residents that use them for bed mobility. The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements .Assess the resident for risk of entrapment from bed rails prior to installation .Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation .Ensure that the bed's dimensions are appropriate for the resident's size and weight.

Based on observation, interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 2 (Resident #20) residents reviewed for unnecessary medications. The facility failed to ensure Resident #20's PRN lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms and dependence on unnecessary medications. Findings included: Resident #20 Record review of Resident #20's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's Disease (disease that destroys memory and other important mental functions), brief psychotic disorder, muscle weakness, and lack of coordination. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 0 meaning severe cognitively impairment; Section N- Medication's resident received during the last 7 days antianxiety medication checked. Record review of Resident #20's care plan reviewed on 02/09/2024 revealed Focus: The resident uses anti-anxiety medication related to anxiety .Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Record review of Resident #20's physician orders dated 02/09/2024 revealed order for lorazepam 1mg give 1 tablet by mouth every 4 hours as needed for anxiety / restlessness with start date of 11/01/2023 and no end date. Record review of Resident #20's electronic records on 02/09/2024 revealed no evidence of documented rationale for the continued use of anti-anxiety PRN for greater than 14 days. During an interview on 02/09/2024 at 12:07 p.m., the ADON stated she was not able to fine MMR on file for PRN lorazepam. She stated her expectation would be for anti-anxiety medication used PRN would not extend for longer that 14 days unless a physician does not agree with discontinuing at that time. The ADON stated the nurse who receives the order for PRN anti-anxiety would be responsible for filling out forms for physician to review so that medications were not given past 14 days. She stated the DON and her were supposed to monitor that this process was being completed. She did not know what led to the failure since she did not work for facility in November of 2023. She stated the facility's policy stated PRN anti-anxiety medication should be discontinued if physician does not provide rational for it to continue. She stated the effect continuing medication without physician's rational would be that resident could receive medication that was no longer appropriate. During an interview on 02/09/2024 at 1:17 p.m., the DON stated her expectation was for the ordering physician to sign the form with the rational to extend the prn anti-anxiety medication past 14 days. She stated the form with the rational needed to be signed timely but she was not sure exactly what the facility's policy stated. She did not know what led to the failure as she did not work in the facility when the medication was started. She stated both her and the ADON monitor that forms are filled out and physician responded to either extend or discontinue PRN anti-anxiety medications. She stated the effect of this process not being performed depended on the resident and what type of medication was being administered. She did not feel that in this circumstance this resident was harmed. During an interview on 02/09/2024 at 1:19 p.m., the RCN stated she was aware of the regulation on PRN anti-anxiety medications. She stated it was her expectation for rational to be received from physician to extend medication past 14 days. She stated after PRN anti-anxiety rational received twice then another rational would not be needed for 6 months. The RCN stated the DON and ADON were to monitor forms were filled out and physician's response received. She stated in this circumstance this resident was not affected by PRN anti-anxiety medication not being stopped after no physician rational received. Review of facility policy titled Monitoring of antipsychotics dated February 1, 2007, revealed: The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the facility implements gradual dose reductions (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: o anti-psychotic; o anti-depressant; o anti-anxiety; and o hypnotic. The facility must will ensure that: 1. Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; 2. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; 3. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; 4. PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45 (e) (5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. 5. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication storage rooms (North hall medication room) and 1 of 4 medication carts (South nurse medication cart) reviewed. The facility failed to ensure that medications were secured in locked medication cart. The facility failed to ensure that medications were stored in an environment that was dry and without ice buildup. These failures could place residents who receive medications at risk for receiving the wrong medications, outdated medications or contaminated medications which could result in residents not receiving the intended therapeutic effects medications or harm. Findings included: During an observation / interview on 02/06/2024 at 10:37 a.m. revealed the South Hall medication cart sitting in front of the South Hall nurses' station unattended. On the top of medication cart had one bubble pack of trazadone (medication used for insomnia and depression) 50mg with 3 tablets in bubble pack. On the top of medication cart there was clear plastic bag with 6 tablets of cyproheptadine (medication used to relieve allergic symptoms, headaches, and motion sickness) 4mg in it. The medications were not being supervised and residents were moving around the medication cart. CMA F stated she was not supposed to leave medication sitting on top of the cart. She stated she was going to reorder medications and left them there to go into medication room. She stated residents had access to medication and that they could have taken medication that was not ordered for them. During an observation / interview on 02/08/2024 at 10:41 a.m. revealed the North Hall medication room refrigerator had insulins in bags with condensation on outside and label was wet, and ink smeared on medication label. Flu vaccines were stored on the shelf of the refrigerator had ice buildup on the outside of the box that was frozen to the shelf. The DON stated it was her expectation that nurses would report any issues with the fridge verbally to the maintenance man. She stated nurses who use the fridge were responsible for reporting issues of ice buildup or condensation inside of the fridge when performing temperature checks. Observed refrigerator temperature log with no temperatures logged that were out of range and no area for nurses to report unusual refrigerator findings. The DON stated she had not been told of any issues with the refrigerator. She stated medications should not be stored in these conditions and should be discarded. The DON stated she expected for medications to not be left unattended on top of medication cart. She stated she and the ADON were responsible for monitoring nurses and CMAs to ensure they stored medications appropriately. She stated the effect of unsupervised medication being left on top of cart could give residents access to medications that they should not have access to which could harm them. During an interview on 02/08/2024 at 10:42 a.m., the RCN stated she expected medications to be stored so that residents did not have access to them and not on top of medication cart unsupervised. She stated this would give residents access to medications that were not ordered for them and did not know what led to this failure. The RCN stated that medications should not be stored in a wet environment and not have ice buildup outside of medication box. She stated she felt the failure was caused by nurse not reporting issue to maintenance. She stated ADON and DON were to monitor that medications were stored appropriately. Record review of the facility Medication Reconciliation revised on 10/25/2017 revealed: In addition, the pharmacist may collaborate with the facility and medical director on other aspects of pharmaceutical services including, but not limited to .Interacting with the quality assessment and assurance committee to develop procedures and evaluate pharmaceutical services including delivery and storage systems within the various locations of the facility in order to prevent. To the degree possible, loss or tampering with the medication supplies, and to define and monitor corrective actions for problems related to pharmaceutical services and medications .

Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of 1 of 2 (Resident #25) residents reviewed for lab services. The facility failed to provide or obtain lab work as ordered by the physician for Resident #25. This failure could place the residents at risk of missed labs, depriving their physician of monitoring important levels. Findings included: Record review of Resident #25's face sheet dated 02/07/2024 revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included type 2 diabetes (disease that resulted in too much sugar in the blood). Record review of Resident #25's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 9 indicated moderately impaired and Section I (Active Diagnoses) included diabetes. Record review of Resident #25's comprehensive care plan reviewed on 02/07/2024 revealed the resident had diabetes with interventions to monitor/document for side effects and effectiveness of medications. Record review of Resident #25's physician orders dated 02/09/2024 revealed: hemoglobin A1C lab (lab used to monitor the average blood sugar levels over the last 3 months) was to be performed every 3 months, in December, March, June, and September. Insulin Glargine inject 55 units subcutaneously one time a day related to type 2 diabetes. Insulin Aspart inject 12 units subcutaneously with meals related to type 2 diabetes. Insulin Aspart inject as per sliding scale: if 200-250 = 2 units; 251-300 = 4 units; 301 and above give 6 units subcutaneously before meals and at bedtime for diabetes. Record review of Resident #25's electronic records on 02/08/2024 revealed the last hemoglobin A1C lab results performed on 07/25/2023. During an interview on 02/08/2024 at 11:17 a.m., LVN A stated she did set up for labs to be drawn at the hospital when she obtained one-time orders for them. She was unsure who was responsible for making sure that scheduled labs were scheduled to be drawn but felt the DON monitors that they are done. LVN A stated the effect of a resident not having hemoglobin A1C drawn as ordered would be nurse not knowing results and not being able to report range values to physician. During an interview on 02/08/2024 at 4:10 p.m., the ADON stated lab orders should be transcribed into electronic medical record system so that there was a prompt for nurse to order. She felt the failure occurred due to the order not being transcribed correctly and no prompt to the nurse meant the lab was missed. She did not know why the lab was entered incorrectly as she did not work at the facility when the lab was originally ordered, and that nurse no longer worked for the facility. Her expectation would be for the charge nurse to make sure labs were scheduled when they received prompts that lab work due. The ADON stated hemoglobin A1C not being performed as ordered could cause resident to not be on correct dosage of medication to control diabetes. She stated the DON and her were who monitored that charge nurses perform labs as ordered. During an interview on 02/08/2024 at 4:11 p.m., the DON stated it was her expectation that labs be scheduled to be drawn as physician orders specify. She stated she was in the process of putting together a binder to help supplement with monitoring that labs are being done as ordered. She did not know what lead to the failure of this lab not being performed as ordered. She stated the effect could have on the resident would be that her chronic condition would not be managed appropriately. Review of facility policy titled Medication Reconciliation dated 11/14/16 revealed: The Mediation Regimen Review (MRR) is an important component of the overall management and monitoring of a resident's medication regimen .Unnecessary drug is defined as any drug used: In excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 7 residents (Resident #2) reviewed for medication administration. Resident #2 did not receive [MEDICATION NAME] for 44 days as ordered. Resident #2 was admitted to the hospital for decreased cognition and shortness of breath. Resident #2 was diagnosed with [REDACTED]. This failure resulted in harm to Resident #2 and could place 25 residents who take [MEDICAL CONDITION] medication at risk for not receiving the intended therapeutic benefits of their medications. Findings included: Record review of the admission face sheet dated 12/08/16 indicated Resident #2 was admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An admission order dated 12/08/16 indicated Resident # 2 was to receive [MEDICATION NAME] Sodium 125 mcg tablet 1 tablet by mouth in the morning. According to the website, www.drugs.com, accessed 03/08/17, . [MEDICATION NAME] is a [MEDICAL CONDITION] medicine that replaces a hormone normally produced by the [MEDICAL CONDITION] to regulate the body's energy and metabolism. [MEDICATION NAME] treats [MEDICAL CONDITION] (low [MEDICAL CONDITION] hormone). Dangerous side effects including fast or irregular heart rate; fever, hot flashes, sweating; sleep problems ([MEDICAL CONDITION]); or vomiting, diarrhea, appetite changes, weight changes and or death can occur from the misuse of [MEDICATION NAME] . Record review of the MDS dated [DATE] indicated Resident #2 understood others and made her needs known. The MDS indicated Resident #2 did not exhibit behaviors and did not reject care. She required two person extensive assist with bed mobility, dressing, bathing, toilet use, and personal hygiene. Record review of an initial care plan printed 12/26/16 indicated Resident #2 was admitted for [MEDICAL CONDITION]. The plan documented the resident had [DIAGNOSES REDACTED]. The plan included interventions for medication taking and monitoring of the lab level for the [MEDICAL CONDITION] medication. Record review of MAR indicated [REDACTED]. Resident #2 missed 18 doses in December 2016. Record review of MAR indicated [REDACTED]. Resident #2 was admitted to the hospital on [DATE]. Resident #2 missed 26 doses in January while in the facility. Record review of the Physician Telephone orders for Resident #2 for December 2016 and January 2017 revealed no orders for changes to the prescribed [MEDICATION NAME]. Record review of the change of condition nurse note for Resident #2 dated 01/26/17 at 11:50 a.m. noted voice weakened, oxygen saturation 100%, and withdrawn. Physician A notified . Physician A returned call at 12:00 noon, orders received for complete metabolic profile (CMP), complete blood count (CBC), urinalysis (UA) with culture and sensitivity (C&S) stat (right away). Record review of the change of condition nurse note for Resident #2 dated 01/26/17 (untimed) indicated Received orders for UA and C&S, upon collecting UA was dark yellow and cloudy. Notified Physician A. Orders received [MEDICATION NAME] 2 gram intramuscular (IM) now then [MEDICATION NAME] 1 gram IM every day for three days. [DIAGNOSES REDACTED]. Record review of the nurse note for Resident #2 dated 01/26/17 at 2:35 p.m. documented by the DON revealed the following: Results of lab, Creatinine level 4.46, send to local hospital for evaluation and treatment. Results of the creatinine blood test are measured in milligrams per deciliter or micromoles per liter. The normal range for creatinine in the blood may be 0.84 to 1.21 milligrams per deciliter (74.3 to 107 micromoles per liter). Generally, a high serum creatinine level means that your kidneys aren't working well. http://www.mayoclinic.org/tests-procedures/creatinine-test/details/results/rsc- 431 accessed 03/14/2017 Record review of the nurse note for Resident #2 dated 01/26/17 at 4:14 p.m. documented by the DON revealed the following: Received a call from Resident #2 family member states that the family member spoke with Physician A and that Physician A would be sending Resident #2 to the hospital. DON informed the family that labs are pending on Resident #2 and that a final decision would be made based on the results. Record review of the nurse note for Resident #2 dated 01/26/17 at 4:16 p.m. documented by the DON. Revealed the following: Spoke with Power of Attorney (POA) . antibiotic orders obtained by Physician A labs are pending, we will inform Physician A of results so he can make informed decision regarding transfer to hospital. Record review of the change of condition nurse note for Resident #2 dated 01/26/17 (untimed) indicated elevated Creatinine, decreased energy. May send to local hospital emergency room for evaluation and treatment. Record review of the nurse note for Resident #2 dated 01/26/17 at 6:18 p.m. documented by the DON revealed the following: Resident #2 picked up by facility van and transferred to local hospital. Record review of the Provider investigation report dated 01/29/17 revealed that upon receipt of a call from the local hospital on [DATE], where Resident #2 had been transferred to for evaluation of decreased cognition and shortness of breath, the hospital was inquiring about the current [MEDICATION NAME] and last date of administration. The facility performed a chart audit and discovered that the resident last received the [MEDICATION NAME] on 12/13/16. Resident #2 missed 44 doses of the [MEDICATION NAME]. The investigation revealed that the [MEDICATION NAME] had been inadvertently discontinued from the electronic medication record system while two other orders were being correctly discontinued for the same resident. Record review of a Medication Error Report dated 1/29/17, revealed that LVN A inadvertently discontinued the [MEDICATION NAME] order on 12/13/16. Resident #2 was hosptalized on [DATE] for evaluation of decreased cognition and shortness of breath. Record review of the electronic MAR indicated [REDACTED]. In an interview on 2/2/17 at 1:12 p.m. the DON said that he input all new orders in the electronic system and the nursing staff input all discontinued orders. The DON said that the facility interim Pharmacy consultant did not catch the [MEDICATION NAME] medication being discontinued either. In an interview on 2/2/17 at 3:51 p.m., LVN A said that she received new orders for Resident #2 and that she was called away during the time she was inputting the orders into the electronic system. LVN C said she did not notice that she had inadvertently discontinued the [MEDICATION NAME] medication at that time. LVN A said she was made aware by the DON on 1/29/17 that the medication was discontinued at the time she was discontinuing other orders for Resident #2. Record review of local hospital admission record dated 01/27/17 indicated admission for shortness of breath. Resident #2 debilitated [AGE] year old with multiple medical problems, upon admission to the emergency room was found to have [MEDICAL CONDITION] fibriullation with rapid ventricular response and [MEDICAL CONDITION] (a condition resulting from advanced [MEDICAL CONDITION], or deficiency of [MEDICATION NAME]). In an interview on 2/2/17 at 3:25 p.m. with Physician A said that Resident #2 not having her [MEDICAL CONDITION] medication did not help her, but she was already had problems . heart, kidney . she was not eating and drinking, the family played a part as well . discontinuing her medications and seeking advice from a holistic physician who ordered many vitamins and minerals and denial of her condition. Physician A said that the Resident #2 suffered in any case. In an interview on 2/2/17 at 3:40 p.m. with Physician B said that Resident #2 not taking her [MEDICAL CONDITION] medication was a part of her problem but that he could not draw a definite link between not taking the medication and her hospitalization . she had many comorbidities that all play a part in her situation. Comorbidities included Resident #2 was diagnosed with [REDACTED]. The facility provided a policy on discontinuing medications from point click care (PCC) that included . read the order twice, verify you are discontinuing the correct medication, if concerns contact the DON . The DON said on 03/01/17 that 25 residents were taking [MEDICAL CONDITION] medication.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 19 residents reviewed for elopement risk (Resident #1) as evidenced by: 1) failure to adequately train staff to respond to a door alarm. When staff checked the door after the alarm had been sounding, no attempt was made to ensure all residents with a wander guard alarm bracelet were in the building. The staff reset the alarm and returned to work as per facility policy. 2) failure to have a wander guard alarm system that was audible to staff. Resident #1 exited the front door on 12/23/13. The alarm sounded but staff did not immediately hear the alarm. 3) failure to have a plan of care in place for Resident #1 who was an elopement risk and had wandered away from home prior to admission. These failures resulted in Resident #1's elopement from the facility on 12/23/13 sometime between 6:00 p.m. and 6:20 p.m. The facility is on a busy street and Resident #1 crossed 2 busy freeway feeder roads at night when the temperature was forecasted in the 30s, which placed him at risk for harm. An Immediate Jeopardy was identified on 1/16/13. The Immediate Jeopardy was lowered to the potential for more than minimal harm at a pattern on 1/17/14 at 5:00 p.m. The facility remained out of compliance due to the lack monitoring of the facility's plan for effectiveness. These failures could place the 17 residents the facility identified as wanderers at risk for leaving the facility unsupervised and place them in situations that could result in harm or death. Findings included: Review of Resident #1's closed record indicated the [AGE] year-old male resident was admitted to the facility on [DATE] at 3:50 p.m. Review of a Discharge Summary indicated that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was admitted from home due to confusion. The Resident was discharged on [DATE] to a sister facility's locked unit for his safety. Review of the admitting physician's orders [REDACTED]. Review of Resident #1's Resident Admission assessment dated [DATE] at 3:50 p.m. indicated the resident was able to answer questions, but he was confused and forgetful. Resident #1 was able to ambulate well. According to the Resident Admission Assessment, Resident #1 had wandered away once previously, wanting to go to work. According to the assessment, Resident #1 had a small dog at home, which he might miss or look for. Staff were alerted to watch for the resident possibly going to look for the dog. Review of Resident #1's medical record indicated an Elopement Risk Assessment was not completed during the resident's admission process. Review of a Provider Investigation Report dated 12/23/13 at 10:09 p.m., indicated Resident #1 was independently ambulatory and could not make informed decisions. The resident was wearing a wander guard at the time of the incident. According to the Provider Investigation Report Summary, the administrator was contacted on 12/23/13 at 6:49 p.m. of a missing resident who had been admitted earlier that evening. A room-to-room search was started in the building and the family and police department were notified immediately. A search began for the resident within the facility. The DON located the resident at 8:10 p.m. and he was returned to the facility. The resident had a one-to-one caregiver until he could be discharged to a sister facility with a secure unit. According to the National Weather Service Forecast Office for the city in which the facility is located, the actual temperatures for 12/23/13 were a high of 59 and a low of 25 degrees Fahrenheit. Review of an Admission Care Plan dated 12/23/13 indicated that Resident #1 was fully ambulatory and able to transfer independently. The resident was continent of both bowel and bladder and able to perform activities of daily living such as dressing and personal hygiene independently with supervision. The resident was confused and forgetful. There was no mention in the care plan that the resident had eloped in the past, that the resident was assessed by the facility to be an elopement risk, or that the facility had placed a code alert wander guard on the resident. In an interview at 01/16/14 at 9:35 a.m., the administrator said on 12/23/13 a medication aide (MA) heard an alarm go off at the front door and came to the door to check the alarm. The administrator did not know the exact time the MA heard the alarm. The MA did not see anyone at the door. Several minutes later staff realized they could not find Resident #1 in the building. Both the administrator and the DON were gone for the day but immediately returned to the facility. The assistant administrator was at the facility at the time the resident left. The administrator said information that other visitors (who were present at the time of the incident) told him led him to believe a visitor held the door open for Resident #1 thinking the resident was also a visitor. The administrator said Resident #1 was gone from the facility about an hour. The resident was wearing a denim jacket, denim jeans, a denim cap, a long sleeved shirt, and boots. According to the administrator, it was dark when the resident left and which made it more difficult to find the resident wearing dark clothing. The administrator said he thought the temperature that evening was in the mid-50s. In an interview on 01/16/14 at 11:00 a.m., the DON said he was at home when he received a call, at 6:50 p.m., from the facility that a resident was missing. The DON immediately returned to the facility and began searching for the resident. The DON said all department heads came and joined in the search. The DON said he and 2 other staff were driving the streets in grids and other staff were searching on foot. The DON said he located the resident and tried to get the resident to get in the DON's car. The resident was wary at first and resisted and then began swinging at the DON. The DON talked to the resident, using his name and convinced the resident that the DON knew the resident and his daughter. The DON said he tried to call the administrator to inform him he had found the resident, but the resident grabbed the DON's phone and turned it off. He said they were in the middle of the street in front of the vehicle headlights. The DON said once the resident got in his car the DON brought him back to the facility. When they returned to the facility after getting a physician order [REDACTED]. According to the DON, the resident lived alone in another city and his wife lived in the nursing home there. There was no bed available for Resident #1 at the facility where his wife lived. The resident wandered away from home and was found 2 blocks away. The DON said this prompted the resident's family to place him in the facility until a bed became available in the facility where his wife lived. Continuing the interview, the DON said the temperature was in the low 50s when he began looking for the resident, and according to his car thermometer, when the resident got in the car with the DON the car thermometer read 47 or 48 degrees Fahrenheit. The DON said it was forecasted to get into the 30s that night. According to the DON, when the resident left the building, the door alarm sounded. MA A responded to the alarm. The MA worked the 2:00 p.m. to 10:00 p.m. shift. MA A told the DON when he responded to the door alarm he did not see a resident near the door and he reset the alarm. The DON said he thought approximately 10 minutes later it was discovered that the resident was missing and the search began. In an interview on 01/16/14 at 11:50 a.m. the assistant administrator said he was at the facility on 12/23/13. He said he was in his office completing some paperwork on Resident #1, who had been admitted earlier that afternoon. The assistant administrator said he completed his paperwork and decided to go check on Resident #1 before he left the facility. He looked in the resident's room but the resident was not there. The assistant administrator said he did not know what time this was. The assistant administrator then stepped outside the building and saw CNA B sitting outside and asked the CNA if he had seen Resident #1. CNA B told the assistant administrator Resident #1 had been in his room a few minutes earlier. The assistant administrator went and checked the resident's room and bath room but failed to find him. He said he then went back out and told CNA B to search the facility. CNA B came back a few minutes later and told the assistant administrator that he had not been able to find the resident. The assistant administrator then instructed all the staff to look for the resident. Staff searched the facility and immediate grounds, but could not locate the resident. The assistant administrator said he then called the administrator and DON. The police, the resident's family, and the resident's physician were also notified. The assistant administrator then called all administrative staff in to search for the resident. After some time, the assistant administrator said he did not know how much time, the DON called the assistant administrator and said he had found the resident. The resident was then brought back to the facility by the DON. According to the assistant administrator, Resident #1 had a wander guard bracelet on his wrist and it was working when he left the facility. The assistant administrator said Resident #1 had been at the facility approximately 1 hour before he eloped. In an interview on 01/16/14 at 12:30 p.m., MA A said he worked the 2:00 p.m. to 10:00 p.m. shift on 12/23/13. The MA said he was in the back of the facility in the bathroom. When he exited the bathroom, he heard an alarm going off at the front door. The MA did not know the exact time, but estimated it to be between 6:00 and 6:10 p.m. The MA said he went to the door, but he did not see a resident inside the facility near the door. The MA then stuck his head out the door and looked both ways and he still did not see anyone. According to MA A, a visitor in the lobby said the alarm had been going off, "for a while" but the MA did not know how long. MA A said he reset the alarm and since he did not see anyone inside or outside the facility, he went back to work. The MA said he did not think there was a problem. He said he figured a resident got close to the door, setting off the alarm, and then turned around and went back down one of the halls. According to the MA, approximately 20 minutes later staff told him a resident was missing and all staff on both sides of the building began a room-to-room search of the entire building. The police were called and department heads started arriving at the facility. The MA said Resident #1 was newly admitted to the North side of the building and the MA worked on the South side of the facility, so he never actually saw the resident. He said he did not know what the resident looked like. According to the MA, staff responsibility at the time of the incident was to respond immediately to the alarm and to check and make sure no one was outside the building. After the incident, staff were still required to do that plus they were to locate all residents within the facility who had wander guards and make sure they were in the building. The MA said he had worked at the facility for 4 years and he did not remember ever having an in-service or training specifically about wander guards. In an observation on 01/16/14 at 2:40 p.m., a measurement was conducted with a private automobile odometer. According to the odometer readings, Resident #1 was found 1.5 miles from the facility. It was noted in the observation that the resident's path crossed a freeway. There was a bridge with a walkway over the freeway, but the resident crossed 2 busy feeder roads on either side of the bridge. In an interview on 01/16/14 at 3:05 p.m., LVN C said she worked the 2:00 p.m. to 10:00 p.m. shift on the South side of the building on 12/23/13. The LVN said she did not hear an alarm that evening. The LVN said supper was served at the facility at 5:00 p.m. and there were a lot of things going on that evening. She said she did not know where she was at the time the alarm at the front door went off. Once she became aware that a resident was missing, she began searching her half of the nursing facility (South side) on the inside and other staff were searching the grounds. LVN C said she had worked at the facility for [AGE] years. According to LVN C, if a door alarm goes off staff were to go immediately to the door and check inside and then step outside to see if any residents were outside. In an interview on 01/16/14 at 3:10 p.m., the administrator said the facility had no written policy for the use of wander guards prior to 12/23/13, but actions in place were: 1) CNA's were checking and documenting placement of wander guards 7 days a week on the CNA flow sheet, 2) the assistant administrator was checking the system every Monday, Wednesday, and Friday and documenting results, and 3) staff were following the alarm manufacturer's guidelines. The administrator said the policy was updated on 12/23/13. According to the new policy put into effect on 12/23/13, in the event that the system goes into alarm, an immediate survey of all exterior grounds would be made. In addition, a 100% audit of all residents who wear a wander guard would be made to ensure that all residents are accounted for. The facility must assume when the alarms are sounding that a resident has set the alarm off and that the resident is outside the facility. A list was kept at each nurses' station of all residents with wander guards. According to the administrator, the facility also scheduled a quality assessment meeting to be done on 01/25/14 to review the current policy with the facility's 2 medical directors. In an interview on 01/16/14 at 3:20 p.m., LVN D said she was working as the charge nurse on the 2:00 p.m. to 10:00 p.m. shift on 12/23/13 on the North side of the facility. The LVN said she admitted Resident #1 to the facility. LVN D said the resident had a wander guard bracelet on at 5:00 p.m. when she checked the resident's blood sugar and oxygen saturations. When she finished checking the resident, the certified occupational therapy assistant (COTA) told LVN D she would take the resident to the dining room to eat. LVN D said that was the last time she saw the resident until approximately 2 hours later when the resident had been found and returned to the building. Prior to 5:00 p.m., LVN D said she had seen the resident sitting on a couch in the lobby watching television. LVN D said she did not hear an alarm that evening. The assistant administrator approached her about 6:30 p.m. and asked her where Resident #1 was, stating that the resident was not in his room. The LVN said all facility staff began to search the facility. According to LVN D, it was everyone's responsibility to respond to a wander guard alarm going off. Whoever was first to the door had the responsibility to make sure there was no one outside the facility. LVN D said a resident elopement had never happened at the facility before. The LVN said when a wander guard alarm sounds the door will lock immediately. She said usually when staff respond to a door alarm they arrive at the door to find a resident close to the door, but not outside and not gone. In an interview on 01/16/14 at 3:35 p.m., CNA E said she was working on 12/23/13 when Resident #1 was admitted . CNA E said the last time she saw Resident #1 he was sitting on the couch in the television room at about 6:15 or 6:20 p.m. CNA E said the resident was wearing a cap, jeans, and a jacket. The CNA said she did not hear the alarm. The CNA said she was working on the North side of the building. CNA E said prior to the incident on 12/23/13, staff were to respond immediately to a door alarm and open the door and make sure there were no residents outside before the alarm could be turned off. In an interview on 01/16/14 at 3:45 p.m., CNA B said he was working on the North side of the building on 12/23/13. The CNA said he saw Resident #1 just before supper in the resident's room talking to the DON. The CNA got busy with supper and did not hear a door alarm. CNA B said he was in the very back of the hall on the North side of the building and was busy with a Resident at the approximate time the alarm went off. According to CNA B, all staff were to respond immediately to a door alarm and look outside and make sure no one was outside the facility. In an interview on 01/16/14 at 4:15 p.m., the facility was advised an immediate jeopardy had been identified. In an interview on 01/17/14 at 11:20 a.m., the COTA said when Resident #1 was admitted to the facility on [DATE], she had been asked to evaluate the resident's bed for his comfort. According to the COTA, when the resident's family left, she came into the room to talk with the resident. She said Resident #1 did not seem to mind his family leaving. Approximately 25 minutes later, Resident #1 told the COTA he needed to take care of some business downtown. The COTA said she tried to reorient the resident, but the resident was too confused. The COTA said the last time she saw Resident #1 was at approximately 6:00 p.m. when the resident was in the foyer talking with the DON. In an interview on 01/17/14 at 8:20 a.m., the DON said a new alarm system had been installed and the volume at each nurse's station had been increased. There was also a new panel at each nurses station fully labeled indicating which door was alarming. In an observation on 1/17/14, at 8:30 a.m., the alarm on the front door could be faintly heard at the end of the hallway on the North wing of the facility. Inside 3 rooms near the end of the hall, the alarm could not be heard at all. The facility submitted the following action plan for removal on 1/17/14 1. On 1/16/14 Seventeen current residents were identified as being at risk for elopement. All residents at risk were checked to ensure their Code Alert (wander guard) was in place and properly functioning. 2. An In-service for all staff was initiated on 1/16/14 to educate staff on proper response to ensure resident safety when facility door alarm sounds. 3. In-service for all staff was initiated on 1/16/14 to educate staff that the Northwest exit will be utilized for van transport only. 4. Facility implemented Policy and Procedure for Code Alert monitoring on 1/16/14. Maintenance staff will check functionality on all residents with code alert wander guards daily and document results. CNAs will check all residents' code alert wander guards for proper placement and document every shift in the CNA flow books at each nursing station.. 5. Facility implemented the following Policy and Procedure for Code Alert Alarm Response, dated January 2014: a) Staff will respond immediately to any code alert system alarms. b) An enunciator panel is located at each nurses' station. This alarm panel has both auditory and visual alarm indicators, with labels on each indicator light indicating which exit door is alarming. c) A master list of residents with code alert bracelets will be kept in each 24-hour report book. d) if a code alert exit alarm sounds, staff will proceed to the appropriate exit as indicated by the enunciator panel to initiate investigation. If staff cannot visually verify which resident initiated the alarm, an immediate survey of all exterior grounds must be performed. In addition, each charge nurse will be responsible for ensuring that a 100% audit of each resident with a code alert bracelet is performed, verifying that each resident is accounted for. e) If a resident is found to be missing, the administrator and director of nursing will be notified and the facility's elopement policy will be initiated. 6. The facility had new enunciator panels installed at each nurse's station to increase alarm volume and with a different alarm pitch. This was completed on 1/14/14. 7. All exit doors were checked to ensure proper functioning of door alarm, magnetic lock, code alert, or keypad. This was completed by the assistant administrator on 12/23/13 at 9:30 p.m. 8. The 2 facility medical directors were notified by telephone on 1/16/14 of the immediate jeopardy and the facility action plan and were requisitioned for counsel. 9. Beginning 1/16/14 pictures with the names of new admissions will be placed on the Welcome Board next to the employee time clock. The picture will remain posted for a minimum of 4 days. 10. A list of residents with special needs will be kept at both nurses' stations. Medical staff will review this list every shift change and sign off. DON/Designee will determine daily if updates of special needs is warranted and will distribute this list as warranted. 11.The plan was implemented on 1/16/14 and will be monitored through personal observation by the administrator and verbal reports to the corporate regional director of operations. In interviews on 01/17/14 from 1:50 to 3:55 p.m. 14 staff, including MA A, were able to relate all aspects of the new wander guard policy entitled Policy and Procedure for Code Alert alarm and inservice conducted 1/16/14 to educate staff on proper response to ensure resident safety when facility door alarm sounds. In an observation on 01/17/14 at 3:05 p.m., the wander guard door alarms were fully audible from all areas in the facility, including the rooms at the ends of both the North hall and the South hall. During the exit conference on 1/17/14 at 5:00 p.m. the facility was notified that the Immediate Jeopardy was lowered to deficient practice with the potential for more than minimal harm at a pattern when the action plan was fully implemented. During an interview on 1/17/14 at 3:25 p.m. the administrator said there were currently 17 residents in the facility who wore Code Alert wander guard bracelets and were at risk for elopement from the facility.