Every finding on record at Pure Health Transitional Care at Texas Health Pres

Based on interview, observation, and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, the medical record was maintained on each resident which was complete and accurately documented for two (Residents #44 and Resident #59) of five residents' records reviewed for medical records. The facility failed to ensure Resident #44's and Resident #59's medication orders entered by LVN A on the residents' admission dates of 08/13/26 (Resident #44), and 08/17/26 (Resident #59) included the accurate medical diagnoses for medications. Medication diagnoses were documented as for medical diagnosis. This failure could place residents at risk of inaccurate information and resulting inappropriate care. Findings included: An interview and observation on 08/18/26 at 12:28 p.m. of Resident #59 revealed she said she was admitted the night before (08/17/26), and the nurses were providing her medications with no problems. Resident #59 appeared to be having difficulty breathing, and her nasal cannula was incorrectly placed. The resident was able to correct it when it was pointed out to her. An interview and observation on 08/18/26 at 2:43 p.m. with Resident #44 revealed he said he was happy with the care, was getting his medications timely, and requested the nurse to bring the medication for his itchy scalp. Resident #44 was observed to have a significant tremor of both hands, and had a small bandage on his scalp. An interview and observation on 08/18/26 at 2:47 p.m. revealed LVN A stated the resident had a cream for his scalp, and he finished what he was entering in the computer and went to the resident's room. Review of Resident #44's admission Record, dated 08/20/26, reflected he was an [AGE] year-old male, admitted on [DATE], with diagnoses of metabolic encephalopathy (a loss of brain function caused by the effects of other illnesses), skin and prostate cancers, dementia, and parkinsonism (Parkinson-like effects, e.g. muscle stiffness, tremors, and balance problems, resulting from a number of possible sources, like other illnesses, medications, or environmental exposure to chemicals). Resident #44 was his own responsible party. Review of Resident #44's admission MDS assessment (a set of standardized assessments done on admission, quarterly, and with a significant change of condition, on each resident), dated 08/16/26, reflected he was able to be understood, and to understand others. He had a BIMS (a standardized assessment to measure long and short-term memory) score of 15, indicating he was cognitively intact. Further review indicated Resident #44 had no signs of delirium or psychosis, and no behavioral issues during the assessment period. He required moderate staff assistance for eating, oral hygiene, and dressing his upper body, maximal assistance for dressing his upper body, and required staff to bathe him. The MDS indicated he was able to roll himself over in bed but required moderate staff assistance for transferring himself between surfaces. The document reflected his primary admitting condition was other neurological conditions (condition affecting the nervous system, including the brain, spinal cord, and nerves), and he received an antipsychotic medication (a medication for mental health conditions which have psychotic symptoms such as hallucinations, delusions or severe agitation) routinely while in the facility. The MDS reflected Resident #44 was receiving physical and occupational therapies. Review of Resident #44's care plans reflected the following:- The resident used psychotropic medications, dated 08/14/26, having interventions including administering medications as ordered by the physician, and monitoring for, and documenting side effects, adverse reactions, and efficacy. Review of Resident #44's Order Summary, dated 08/20/26, reflected the following:- Ascorbic Acid Oral Tablet (Ascorbic Acid) Give 250 mg by mouth one time a day for medical diagnosis, start date 08/14/26.- Cholecalciferol Oral Tablet (Cholecalciferol) Give 2000 unit by mouth one time a day for medical diagnosis, start date 08/14/26.- Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for medical diagnosis, start date 08/13/26.- Vitamin B12 Oral Tablet 500 MCG (Cyanocobalamin) Give 1000 mcg by mouth one time a day for medical diagnosis, start date 08/14/26. Review of Resident #44's medications orders in the EMR, on 08/20/26, reflected LVN A entered the admitting medication orders. 2. Review of Resident #59's admission Record, dated 08/18/26, reflected she was a [AGE] year-old female, admitted on [DATE], with diagnoses of STEMI (a severe type of heart attack caused by a total artery blockage), heart disease, asthma, emphysema (damage to the tiny air sacs in the lungs, causing them to break down, and make breathing difficult), and anxiety disorder. Resident #59 was her own responsible party. Review of Resident #59s electronic medical record on 08/18/26 reflected her admission MDS assessment was in progress. Review of Resident #59's care plans, reflected the following:- The resident was on anticoagulant therapy, dated 08/18/26, having interventions of administering medications as ordered by the physician and monitoring for and documenting side effects, adverse reactions and efficacy.- The resident was on anti-anxiety medication, dated 08/18/26, having interventions of administering medications as ordered by the physician and monitoring for and documenting side effects and efficacy.- The resident was on antidepressant medication, dated 08/18/26, having interventions of administering medications as ordered by the physician and monitoring for and documenting side effects, adverse reactions and efficacy. Review of Resident #59's order summary, dated 08/20/26, reflected the following:- Aspirin 81 Oral Tablet Chewable 81 MG (Aspirin) Give 1 tablet by mouth one time a day for medical diagnosis, started on 08/18/26.- Azelastine HCI (a form of salt used in medications to stabilize them, and make them easier to dissolve, and absorb) Nasal Solution 137 MCG/SPRAY (Azelastine HCl) 2 spray in both nostrils two times a day for medical diagnosis, started on 08/17/26.- Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day for medical diagnosis, started on 08/18/26.- Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) Inject 0.4 ml subcutaneously one time a day for medical diagnosis, started on 08/18/26.- Loratadine Oral Tablet 10 MG (Loratadine) Give 1 tablet by mouth one time a day for medical diagnosis, started on 08/18/26.- Mirtazapine Oral Tablet 15 MG (Mirtazapine) Give 1 tablet by mouth at bedtime for medical diagnosis, started on 08/17/26.- Nicotine Step 3 Transdermal (absorbed through the skin) Patch 24 Hour 7 MG/24HR (Nicotine) Apply 1 patch transdermally one time a day for medical diagnosis and remove per schedule, started on 08/18/26.- Nitroglycerin Sublingual Tablet Sublingual (under the tongue) 0.4 MG (Nitroglycerin) Give 1 tablet sublingually (under the tongue) every 5 minutes as needed for medical diagnosis, started on 08/17/26.- Urea Oral Packet 15 GM (Urea (Dietary Management)) Give 1 packet by mouth one time a day for medical diagnosis, started on 08/18/26. Review of Resident #59's medications orders in the EMR on 08/20/26 reflected LVN A entered the admitting medication orders. An interview on 08/20/26 at 12:42 p.m. with RN B revealed she admitted residents and had to put their orders in the EMR. She said the hospital sent the orders, and she sometimes had to get clarification on them from the physician, for example if they were on insulin and the hospital did not send the sliding scale numbers. She said an order which said the medication was for medical diagnosis was not normal, and the diagnosis should be included in order for it to be clear to the nurses and the resident why they were taking it. She said she was normally able to look through the additional documentation and find the diagnosis for the medication, and if not she would clarify it with the physician. An interview on 08/20/26 at 3:28 PM with the DON revealed when they hired new nurses they went through an orientation, which included how to put orders in the EMR. She said there was a dummy account in the EMR, so they could actually practice on it. She said they did not specifically go over the medication matching the diagnosis in the orientation, and she thought that was common sense. She said she was very frustrated, because LVN A, who worked as a PRN nurse for the facility, was a phenomenal nurse, and she did not know why he put the orders in without a diagnosis. She said that she and the ADONs did admission audits on each admission and fixed any orders that did not include a diagnosis, but it could take a day or two for that to happen. She said the Nurse Practitioner or Physician reviewed the medications, but she did not know if they reviewed them for diagnosis. She said it was important to know the diagnosis, because there were some medications which could be given for various reasons, and the nurses needed to know what the medication was given for, in order to watch for anything they might need to monitor for, including duplicate medications, when giving the medication. She provided a copy of the admission Checklist she had created, which the nurses admitting residents followed. An interview and observation on 08/20/26 at 4:00 PM with LVN A and the DON revealed LVN A confirmed he entered the admitting orders for Residents #44 and #59. He said he did not know the diagnosis, and to avoid putting the wrong one in, he entered medical diagnosis and his supervisor would later enter the correct diagnoses. He said he was not a physician and did not want to duplicate medications or give someone the wrong diagnosis. He said he was not trained to do it that way. He said he entered for medical diagnosis so the resident would be able to get their medications timely, and he would not cause a medication error by the resident missing a dose. The DON stated when the medication orders were entered into the EMR, the orders went to the pharmacy so they could be delivered with the next delivery. LVN A said he thought the pharmacy had a cut-off time, so he always tried to get the orders in as quickly as possible. Observation of the DON on her laptop and demonstrated how they put the orders in, and said that if the resident was a re-admission, the diagnoses were already in the EMR, so it was easier to connect the medications to a diagnosis, but if the resident was being admitted for the first time, they had to enter the diagnoses. She then showed another screen, which was the medication information a resident was admitted with, and it listed the medications and dosages, but no diagnosis information. Review of a blank copy of the facility's admission Checklist, revised 08/14/26, reflected blanks for the patient name, admission date, and the name of the admitting nurse. The list of Nurse Items to Do included Enter medication orders into (name of EMR) with appropriate indication for use. Review of the facility's policy titled, Medication and Treatment Orders, revised 08/2024, reflected the following: Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing.; Policy Interpretation and Implementation: (.) 7. Orders for medications must include: (.) e. clinical condition or symptoms for which the medication is prescribed; (.)

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care.The facility failed to ensure Resident #1 received dressing changes and assessments of her nephrostomy sites.This failure could place residents at risk of pain, the nephrostomy tubes becoming dislodged, and infection. Findings include:Record review of Resident #1's admission MDS assessment, dated 7/10/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included respiratory failure, diabetes, and hydronephrosis (swelling of both kidneys caused by a buildup of urine). Resident #1 had a BIMS score of 15, which indicated intact cognitive status. Record review of Resident #1's provider progress note, dated 7/10/2026, reflected the resident had a pelvic mass which caused her kidneys to buildup fluid. The resident underwent nephrostomy tube placement (a procedure that inserted a thin tube directly into the kidneys through the skin in the lower back to drain urine) on 6/24/2026. The provider noted in the progress note to keep nephrostomy tubes in place and provide nephrostomy care. Record review of Resident #1's provider orders, dated 7/8/2026, reflected there was an order for dressing change daily of Resident #1's nephrostomy sites. Record review of Resident #1's skin assessment, completed on 7/8/2026 and 7/17/2026, by the wound nurse reflected the nurse documented no abnormal findings at nephrostomy sites. There was no documentation of wound care provided by the wound nurse. Record review of Resident #1's treatment administration record, from 7/8/2026 to 7/16/2026, there was documentation of nephrostomy output recorded by the wound nurse, RN A and LVN B. Record review of Resident #1's hospital record, dated 7/17/2026 at 12:42 PM, reflected the resident was transferred to the ED for pain at her nephrostomy sites. Imaging in the ED, dated 7/17/2026, reflected there was no indwelling right-sided nephrostomy tube, left-sided nephrostomy tube was still intact. Record review of Resident #1's treatment record, from date 7/8/2026 to 7/16/2026, there was documentation that dressing was changed daily by the wound nurse, RN A and LVN B.In an observation on 7/22/2026 at 8:00 AM, revealed Resident #1 was inpatient at the hospital. Resident #1 had two intact and dressed nephrostomy sites on her lower back, labeled 7/21/2026.In an interview with Resident #1 and family member, who was Resident #1's MPOA, on 7/22/2026 at 8:05 AM revealed the dressings on the resident's nephrostomy sites were still labeled as 7/7/26 when the resident was taken to the ED on 7/17/2026. The family member stated she called emergency services because Resident #1 was in pain and she noticed reduced output on one of her nephrostomy draining bags. Resident #1 stated she did not receive dressing changes while she was at the facility. The family member stated the hospital replaced one of the tubes and dressed the sites. In an interview with the facility's wound nurse on 7/22/2026 at 11:45 AM, the wound nurse stated she only provided a dressing change for Resident #1 one time. The wound nurse stated Resident #1 did not have an open wound, therefore, it was the floor nurse's responsibility to check the nephrostomy sites, perform dressing changes, and record output. She stated she was not sure why the dressings on Resident #1 were still labeled with the date 7/7/26. She stated she did not remember Resident #1's nephrostomy tube getting dislodged while she was at the facility. In an interview with RN D on 7/22/2026 at 12:00 PM, she stated she was the assigned nurse working with Resident #1 on the day she was transferred to the hospital. She stated she did not work with the resident prior to that day. RN D stated there was nothing unusual from the resident on that day, she stated Resident #1 did not report any pain. She stated family came in and called 911 without asking the facility and the resident was transferred to the hospital. In an interview with RN A on 7/22/2026 at 12:05 PM, she stated she delegated all dressing changes for Resident #1 to the wound nurse. She stated she did not perform dressing changes for Resident #1 while the resident was residing at the facility. She only recorded output of the nephrostomy bags and made sure the dressing was still intact. She stated she did not realize the dressing was from 7/7/2026. She stated she was not aware if the tube was dislodged because she did not perform dressing changes. She stated the dressing looked normal and there was no abnormal leakage or pain reported by the resident. She stated she marked the dressing was done because she thought it was done by the wound nurse. In an interview with LVN B on 7/22/2026 at 1:43 PM, she stated she remembered Resident #1 having 2 nephrostomy tubes but she did not provide any dressing change. She stated she thought it was the wound nurse's responsibility. She stated she checked and recorded output and if the dressing was intact, but she did not look at the date labeled on dressings. She stated there was no leakage or skin issue at the nephrostomy sites. In an interview with the ADON on 7/22/2026 at 12:10 PM, she stated she expected nursing staff to follow provider orders. She stated all nurses should ensure any wound dressings were performed and labeled, ensure no signs of infection, redness or swelling, ensure tubes were in place. She stated she was not sure when there was an in-service on quality of care, resident assessment, and dressing change provided. She stated she would discuss with the DON, who was out of town, and she would provide in-services to all nursing staff to ensure to follow provider's orders. In an interview with the facility's administrator on 7/22/2026 at 1:08 PM, he stated he expected his staff to provide care based on physician's order and to verify the orders if they had questions. He stated he was not sure what went wrong. He stated he would work with the team to make sure there was clear communication between staff to ensure quality care was provided. An attempt to interview Provider C on 7/22/2026 at 1:30 PM, was unsuccessful. The administrator stated provider C was in a meeting. A return call was not received from Provider C. Record review of facility's Routine Resident Checks policy, revised 08/2024, reflected staff shall make routine resident checks to help maintain resident safety and well-being. Routine resident checks involve [.] identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.Record review of facility's Medication and Treatment Order, revised 8/2024, reflected Facility licensed staff will provide care to patients according to provider orders.Record review of facility's Wound Care policy, 9/2024, reflected Verify that there is a physician's order for this procedure. The following information should be recorded in the resident's medical record:1.The type of wound care given.2.The date and time the wound care was given.3.The name and title of the individual performing the wound care.4.Any change in the resident's condition.5.All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.6.Any problems or complaints made by the resident related to the procedure.7.If the resident refused the treatment and the reason(s) why.8.The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to secure confidential and personal medical records for eleven of eighteen residents reviewed for privacy and confidentiality of records. The facility failed to ensure the private healthcare and confidential information for 11 residents was removed from Resident #1's room that was observed on 07/01/25. This failure could place all residents at risk of exposure of their personal and medical information being disclosed to unauthorized individuals including visitors and other residents causing embarrassment, frustration, loss of dignity, decreased privacy and psycho-social well-being. Findings included: In an observation on 07/01/25 at 8:45 AM, the door to Resident #1's room was open. Resident #1 was asleep in his bed. An observation on 07/01/25 at 8:47 AM revealed the white sheet of paper on the dresser below the television titled, Vital Signs Sheet in Resident #1's room. The white sheet of paper was dated, 6-30-25, 2p-10p Shift and displayed the vital signs for 11 residents including the resident's room number/location, blood pressure, temperature, pulse/h/r, respirations, and O2 Oxygen. An observation on 07/01/25 at 9:41 AM revealed LVN D was sitting at the Nurses Desk located in front of Resident #1's room. An observation and interview with Resident #1 on 07/01/25 at 9:42 AM revealed, the door was open to Resident #1's room. Resident #1 was observed alert and standing in his room and picked up a piece of paper on the dresser below the television. Resident #1 was reading the information on the white sheet of paper. Upon entering Resident #1's room, he placed the white paper back on the dresser. An observation of the white sheet of paper on Resident #1's dresser reflected, 6-30-25, 2p-10p Shift and displayed the vital signs for 11 residents including the resident's room number/location, blood pressure, temperature, pulse/h/r, respirations, and O2 Oxygen. Resident #1 is verbal but was non-interviewable. In an interview with LVN D on 07/01/25 at 9:50 AM, LVN D entered Resident #1's room to perform incontinent care on Resident #1. LVN D was shown the Surveyor's observation of the white sheet of paper titled, Vital Signs Sheet for 06/30/25 for the 6a-6p shift on the dresser in Resident #1's room. LVN D stated that the document, Vital Signs Sheets was recorded by CNA D on 06/30/25 for the 6a-6p shift and should have been removed from the dresser in Resident #1's room. LVN D removed the Vital Signs Sheet document from the dresser in Resident #1's room, folded and placed it under here arm. LVN D then began incontinent care on Resident #1, and the Surveyor exited Resident #1's room. In an interview with RN E on 07/01/25 at 2:33 PM, she stated that she was unaware, on 07/01/25 at 9:48 AM, the Surveyor observed the Vital Signs Sheet for 06/30/25 for the 6a-6p shift on the dresser in Resident #1's room. RN E stated that the facility's Vital Signs Sheet was used in-house and recorded residents' vital signs such as temperatures, blood pressure, oxygen levels and respirations. RN E stated that the Vital Sign Sheet does not contain the names of residents, but contains the room numbers for residents, which was identifiable. RN E stated that the CNAs record the residents vital signs on the Vital Signs Sheet each shift. RN E stated that at the end of each shift, the CNA on duty was to provide the completed Vital Sign Sheet to their Nurse on duty. RN E stated that the Vital Signs Sheet was shredded and disposed of at the end of each shift. RN E stated that she did not know why the Vital Sign Sheet for 06/30/25 for the 6a-6p shift was not properly disposed in a secured area. RN E stated that the risk of the facility's Vital Signs Sheet being left in an occupied resident's room was that it violated HIPAA because the sheet contained residents confidential information regarding their health. RN E stated that every 3 months, she had taken In-Service Trainings on HIPAA via the computer. In an interview with LVN D on 07/01/25 at 3:12 PM, LVN D stated that she had been employed at the facility for 1 1/2 year. She stated that she worked the 6a-6p shift with CNA C on 06/30/25 and both were assigned to Resident #1's room. LVN D stated that she was unaware that the Vital Signs Sheet for 06/30/25 for the 6a-6p shift was on the dresser in Resident #1's room. LVN D stated that the CNAs would record the vital signs for the residents they were assigned to during their shift. LVN D stated that CNA C had left the Vital Signs Sheet in Resident #1's room accidently. She stated that normally, the CNA would record the vital signs for the residents on the Vital Signs Sheet and at the end of the shift, the CNA would provide the document to the Nurse on duty, who would shred the document at the end of the shift. LVN D stated that she could not remember if CNA C handed her the Vital Signs Sheet on 06/30/25 at the end of her shift. LVN D stated the information on the Vital Sign Sheet was confidential and because it was not shredded and disposed of, there was the risk that the information on it could cause can be used against the potentially affected residents she privacy for all residents under her care. In an interview with the DON on 07/02/25 at 1:17 PM, the DON stated she had been employed at the facility for 9 years. The DON stated that she was unaware that the Vital Signs Sheet for 06/30/25 for the 6a-6p shift was located on the dresser in Resident #1's room by the Surveyor. The DON stated that the Vital Signs Sheet was used in-house by staff to record the vital signs of the residents. The DON stated that the CNAs were assigned with the task of completing the Vital Signs Sheet for the residents they were assigned to every shift. The DON stated that at the end of each shift, the CNAs were to give the Vital Signs Sheet to their Nurse for review. The DON stated after the Nurse reviewed the Vital Signs Sheet, which included residents vital signs such as temperatures, blood pressure and respiratory/oxygen levels, the form is then to be shredded at the end of the shift in the designated shredding container confidential storage container located in the hallway at the facility. The DON stated it was her expectation that residents' health information was to be kept private to prevent HIPAA violations. The DON stated that CNA C and LVN D, should have ensured that the facility's Vital Signs Sheet was not visible to Resident #1 or any other persons. She said the health information of a resident should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said all employees were expected to provide full privacy and confidentiality of information for all residents. The DON stated that she would collaborate with the ADON's about the issue of resident rights, confidentiality, and HIPAA. The DON stated she would immediately start an In-service Training with all staff about privacy, confidentiality of the residents' information such as personal and medical information and HIPAA. The DON stated that there were not any potential risks or harm to any residents associated with the Vital Sign Sheets document for 06-30-25 being observed on 07-01-25 in Resident #1's room. The DON stated the facility did not have a policy related to HIPAA policies, procedures, and guidelines. She stated that the facility follows the HIPAA Guidelines in relation to the Health Insurance Portability and Accountability Act of 1966. In a telephone interview with the CNA C on 07/02/25 at 1:33 PM, stated that she had been employed at the facility since February 2025. She stated that she worked the 6a-6p shift with LVN D on 06/30/25, and both were assigned to Resident #1's room. CNA C stated that the Vital Signs Sheet was used by CNAs at the facility to record residents vital signs such as blood pressures, temperatures, respirations, oxygen levels, heart rates and weights. She reported that the Vital Signs Sheet was also used to record residents' weights, but the weights were recorded on Sundays, and according to the residents' doctors' orders. CNA C stated that she was unaware on 07/01/25 at 9:48 AM, the Surveyor observed the Vital Signs Sheet for 06/30/25 for the 6a-6p shift on the dresser in Resident #1's room. CNA C stated at the end of each shift, she would give the Vital Signs Sheet to the Nurse on duty. CNA C stated that the Vital Signs Sheet was shredded by the Nurse each day. CNA C stated that she did not leave the Vital Signs Sheets in Resident #1's room and gave it to LVN D on her 6a-6p shift on 06/25/25. She said the information on the facility's Vital Sheets Sheet was confidential and should not be seen by unauthorized individuals because it contained several residents personal and confidential information. She said the risks of residents' confidential information on the Vital Signs Sheet being available to unauthorized persons in Resident #1's room might cause a resident to feel embarrassed that others would know they had hypertension or other health issues, which violated the HIPAA guidelines. CNA C stated that she attended trainings on HIPAA during her New Hire Orientation in February 2025. An observation on 07/02/25 at 1:45 PM, revealed a shredding container and confidential storage container on the hallway located near the Administrator's Office. Record review of the Staff Schedule for 06/30/25 revealed CNA C and LVN D were assigned the 6a-6p shift on Resident #1's hallway. Record review of the facility's In-service Training records from 03/01/25 to 06/30/25, revealed there were no In-Service Trainings conducted with staff relating to residents' privacy and /or residents' rights, or HIPAA during this period. Record review of the facility's section of the General New Hire Classroom Training, reflected section, Compliance & State Regulated Trainings, with a subsection Training for Essentials of HIPAA, which included a 7-hour Training for staff. Record review of the facility's policy, Electronic Messaging and Internet Usage, dated October 2021, reflected no information regarding securing confidential and clinical records for residents that were available on paper. Record review of the CMS website revealed, The Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes national standards to protect individuals' medical records and other personal health information. The HIPAA Privacy Rule also gives individuals rights over their health information, like getting a copy of their records and seeking correction. The Rule applies to 3 types of HIPAA covered entities, like health plans, health care clearinghouses, and health care providers that conduct certain health care transactions electronically to safeguard protected health information (PHI) entrusted to them. On 07/03/25 at 1:21 PM and 3:21 PM, emails were sent to the Administrator and DON requesting the facility's Resident Rights Policy and there were no replies.

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 2 of 6 residents (Resident #4 ) reviewed for infection control. 1, LVN A failed to wear the appropriate PPE while providing wound care to Resident #18. 2. CNA B failed to wear the appropriate PPE while providing transfer to Resident #4. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Findings included: Review of Resident #18's face sheet dated 07/02/25 revealed she was a [AGE] year-old female, she was originally admitted on [DATE] and re-admitted on [DATE]. Admitting diagnoses included, pneumonia, Type 2 diabetes, asthma, muscle weakness, chronic kidney disease, heart failure and need for assistance for personal care. Review of Resident #18's care plan initiated on 07/18/24 reflected, the resident the resident had stage 4 pressure ulcer of sacrum or potential for pressure ulcer development. Review of Resident #18's orders summary dated 06/19/25 for the month of July reflected, an order to clean stage IV pressure injury to (sacrum)with normal saline, cover the wound bed with moist hydrofera blue and border foam dressing every day shift for pressure injury. Another order dated 6/18/25 reflected an order of a urinary catheter - [16] F [10 ml] bulb. Review of Resident #4's face sheet dated 07/02/25 revealed she was a [AGE] year-old female, she was admitted on [DATE]. Admitting diagnoses included, anxiety, seizures, anemia, arthritis, muscle weakness and need for assistance for personal care. Review of Resident #4's care plan initiated 06/11/25 reflected, the resident was on intravenous medications. Review of Resident #4's order summary dated 06/23/25 for the month of July reflected, right lateral thigh to clean with normal saline apply a dry dressing. Monitor for signs or symptoms of infection. Resident #4 was on intravenous medications. Observation on 07/01/25 at 09:53 AM revealed LVN A completing wound care to Resident #18. LVN A was providing care without the appropriate PPE for the residents who had wound and foley catheter. In an interview on 07/01/25 at 10:15 AM with LVN A she stated she was not aware the resident was on enhanced barrier precaution until she was asked about the resident being on enhanced barrier precaution. LVN A stated there was supposed to be a sign on the door indicating the resident was on enhanced barrier precaution because she had a foley catheter and a wound. LVN A stated she was supposed to use the gown and gloves when providing care to the resident. LVN A stated she was supposed to use gown and gloves to prevent cross contamination, and she stated she had completed in-service on infection control training a few weeks on enhanced barrier precaution. Observation on 07/02/25 at 10:40 AM revealed CNA B transferring Resident #4 from the wheelchair to bed. The posting on the door indicated the resident was enhanced barrier precaution. During the transfer CNA B had only gloves on. Resident #4 was observed with an intravenous line to the left upper arm. In an interview on 07/02/25 at 10:48 AM with CNA B, she stated she was supposed to use a gown as it indicated on the door, while she was transferring the resident from the chair to bed. She stated she was supposed to use the gown and gloves because the resident had an intravenous line. CNA B stated she was supposed to use the appropriate PPE to prevent cross contamination. CNA B stated she had been in-serviced on infection control and use of PPE last week, could not remember the specific day. In an interview on 07/02/25 at 12:44 PM with the DON she stated there were resident who were on EBPs in the facility. The DON stated the staff were expected to put on the appropriate PPEs while providing care to the residents who were on EBPs. The list the DON expected to put on while proving care to the residents on EBPs were the gowns and gloves. The DON stated if there was a posting on the door and if the residents had wounds, foley catheter, and intravenous line, the staff were expected to have a gown and gloves on while providing care to the resident. PPE use on residents on EBPs was required to prevent cross contamination. The staff had been in-serviced on infection control and the use of PPE. Record review of the facility policy dated August 2022 and titled Enhanced Barrier Precaution reflected, Enhanced Barrier Precaution (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include. c. Transferring. h. Wound care (any skin openings requiring a dressing).

37193 Based on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #17) reviewed for infection control, in that: CNA A did not change her gloves or wash her hands after providing incontinent care for Resident #17 CNA A used a pillow that was on the floor to position Resident #17 CNA A used a brief on Resident #17 that she had picked up from the floor. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #17's face sheet, dated 06/14/2024, revealed a [AGE] year-old female with an admitted [DATE] with diagnoses which included: Anxiety, depression, repeated falls, muscle weakness, limited mobility, and limitations to activities due to disability. Record review of Resident #17's Admission MDS assessment, dated 05/20/2024, revealed Resident #17 has a BIMS score of 15, which indicated no cognitive impairment. Resident #17 was indicated to always being incontinent of bowel and bladder. Review of Resident #17's care plan, initiated 05/17/2024, revealed a focus of, The resident has bladder incontinence r/t Neurogenic bladder. Goal, the resident will remain free from skin breakdown due to incontinence and brief use through the review date. Intervention, Clean peri-area with each incontinence episode. Observation on 06/12/2024 at 12:20 PM revealed CNA A assisting Resident #17 to bed and providing the resident with incontinent care. After transferring Resident #17 in bed, CNA A completed hand hygiene and put on gloves and then gathered supplies for incontinence care. CNA A placed the supplies on the foot of the bed, the clean brief fell on the floor and CNA A picked up the brief from the floor and placed it back on the bed. Then CNA A informed the resident she was ready to complete incontinent care and positioned the resident on her side. While CNA A was positioning the resident a pillow fell from the bed to the floor and CNA A picked the pillow up from the floor and placed it on top of the sink. CNA A proceeded to clean the resident who was moderately soiled with urine. After cleaning the resident without any form of hand hygiene CNA A applied the barrier cream on the resident's bottom area. Then the aide proceeded to applying the resident's clean brief, the one that was picked from the floor. CNA A then changed her gloves without any form of hand hygiene and repositioned the resident and used the pillow that she picked from the floor to elevate the resident's arm. Interview on 06/13/24 at 12:52 PM with CNA A, she stated she was in a hurry to finish from the room and that was the reason why she did not complete hand hygiene and change gloves while providing incontinent care to Resident #17. CNA A stated she was not supposed to use the brief and pillow that were on the floor because they were considered contaminated. CNA A stated she forgot and used the brief and pillow. CNA A stated she had completed a hand hygiene and infection control in-service about 1 month ago. CNA A stated she was supposed to complete hand hygiene and change gloves during incontinent care to prevent cross contamination. Interview on 06/13/24 at 01:04 PM with the DON, she stated while providing incontinent care the staff was to maintain infection control. The DON stated the brief, and the pillow were considered dirty because they were on the floor which was considered contaminated, and the staff was not supped to use them on the resident. The DON stated after cleaning the resident the staff was supposed to complete hand hygiene, after cleaning the resident and before touching the clean brief. The DON stated she expected the staff to maintain infection control. She stated infection control and hand hygiene in-service completed in the last three week. Review of the facility policy revised August 2019 titled Handwashing/Hand Hygiene reflected, This policy considers hand hygiene the primary means to prevent the spread of infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for three (RN A, CNA E, and Hoursekeeper F) of eight staff reviewed for infection control. 1. The facility failed to ensure CNA E and Housekeeper F handled linens in a safe and sanitary manner. 2. The facility failed to ensure RN A doffed PPE prior to exiting Resident #4's room. These failures could place residents at risk of contracting infectious disease. The findings included: 1. An observation on 05/15/2023 at 9:25AM revealed Housekeeper F coming down the hall (Therapy Zone) carrying unbagged linens draped over his left arm and secured against his body. DON D was observed calling Housekeeper F into her office. Housekeeper F went into DON D's office and emerged minutes later still carrying linens draped over his arm and held against his body. DON D was observed taking the linens from Housekeeper F and placed them in a bag. An interview on 05/15/2023 at 9:33AM with Housekeeper F reveled he was called into DON D's office because he was carrying linen through the hall that were not contained in a bag and held against his body. He stated he was cleaning a resident room and removed the bed sheets - then went to the end of the hall to get clean sheets for the room. He said the sheets he had in his arm, held against his body were to be placed in the resident's room when DON D called him to her office. He said housekeeping services were provided by a hospital and his boss was the Support Services Manager. He stated he had not been trained on how to handle linens properly and did not know he may contaminate linens by transporting them through the halls held against his body until DON D informed him. An observation on 05/15/2023 at 9:40AM revealed CNA E in the (Therapy Zone) carrying uncontained linens in her arms and secured against her body. CNA E placed the linens on the PPE bin outside Resident #2's room. Signage noted Resident #2's room was isolated and contact precautions were needed. In and interview on 05/15/2023 at 9:42AM, CNA E stated she was bringing clean sheets to Resident #2. She said she know she should not be carrying linens against her body, and she should not have placed them on the PPE bin outside Resident #2's room. She stated she should have the linens in a bag to ensure they were transported in a sanitary manor. She stated it was important to ensure she followed safe infection control practices because Resident #2 was on contact precautions for c-diff (a germ (bacterium) that caused diarrhea and colitis) and Resident #3 - across the hall was on contact precautions for ESBL (A difficult to treat bacteria that can't be killed by many of the antibiotics that doctors use to treat infections). She said she was trained in infection control practices but could not recall when the last trained was. An interview on 05/15/2023 at 9:53AM with the Hospital's Support Services Manager revealed - he provided housekeeping staff for the facility. He said he was responsible for ensuring housekeeping staff were trained in proper linen handling and infection control. He said training was provided via a check off orientation at hire. He said he was not sure why Housekeeper F was carrying linens because housekeeping staff only provide cleaning service to the facility. He said he was not clear about infection control practices in the facility and was used to managing housekeeping in the hospital. In an interview on 05/15/2023 at 10:15AM the Administrator stated housekeeping staff should not be handling linens but should be following the facility's policy and expectations on safe linen handling practices. He said he spoke to the Support Services Manager, and he will provide in-servicing to the housekeeping staff. 2. An observation on 05/15/2023 at 10:55AM revealed RN A leaving Resident #4's isolated room (Admission Zone) with her face shield. The room had signage on the door indicating contact precautions and a PPE bin was located outside the door. RN A went down the hall to the nurses' station where she placed it on the desk. An interview on 05/15/2023 at 10:59AM with RN A revealed Resident #4 was on contact precautions for c-diff (a germ (bacterium) that caused diarrhea and colitis). She stated she donned a gown, face mask, gloves, and face shield prior to entering the room. She said she went into the room to check on Resident #4 and should have doffed all PPE prior to exiting the room. She stated she left the room with her face because she intended to reuse it. She said she knew to leave all PPE in the isolated rooms when exiting to ensure to minimize any risk of spreading infection. In and interview on 05/15/2023 at 3:05PM DON C/IP and DON D stated staff were to don PPE prior to entering contact isolated rooms for any reason. DON D stated all staff should doff in the isolated room prior to exit and leave used PPE in the bins within the isolated rooms. DON C/IP stated any used PPE brought to the hall from an isolated room placed residents at risk of the spread of infection. She said the facility did not have any COVID-19 positive residents but did have three residents on isolation for ESBL and c-diff. She said linen should be transported in bags and should not be held against staff bodies during transport. She said this also posed a risk of the spread of infection. DON D said she agreed and stated she called Housekeeper B into her office to instruct him on proper handling of linens when she observed him carrying clean linens in the hall against his body. The facility's policy on donning and doffing was requested but not provided. Past in-services records were requested for contact precautions, safe handling of linens, and donning and doffing - non were provided. Review of in-service records dated 05/15/2023 revealed Nursing presented an in-service titled Handling soiled linens and Contact isolation. Review of the facility's policy titled Laundry and Bedding, Soiled and dated 10/2018 revealed .Bedding shall be handled, transported and processed according to best practices for infection prevention and control .Clean linens are protected from dust and soiling during transport and storage to ensure cleanliness .

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity, care, and in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one resident (Resident #1) of six reviewed for dignity. RN A and PT B failed to ensure Resident #1's foley catheter bag was covered while in common areas of the facility. This failure could place residents at risk of feeling uncomfortable, disrespected, decreased self-esteem and a diminished quality of life. Findings Included: Review of Resident #1's face sheet dated 05/15/2023 revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, Other spinal cerebrospinal leak (Occurs anywhere in the spinal column), Unspecified asthma (A chronic disease in which the bronchial airways in the lungs become narrowed and swollen), Dysphasia (A language disorder), Paraplegia (Paralysis of the legs and lower body), and Neuromuscular dysfunction of bladder (Lack bladder control due to a brain, spinal cord, or nerve problem). Review of Resident #1's initial MDS assessment dated [DATE] revealed a BIMS of 14 indicating independent with cognitive skills and daily decision making skills. She required extensive assist with toileting and transfers. She had an indwelling catheter. An observation on 05/15/2023 at 10:10AM revealed PT B was providing Resident #1 physical therapy services in the therapy gym. PT B was observed sitting on a chair to the front and side of Resident #1. Resident #1's foley catheter bag was hanging, uncovered, on the front right side of her electric wheelchair. The bag was approximately half full of urine and in full view of other residents and staff in the gym. Seven other residents were observed in the gym receiving services during this time. An interview on 05/15/2023 at 10:49AM with Resident #1 revealed RN A helped her to get ready for therapy today. She stated RN A hung her foley bag on the front of her electric wheelchair and she went to therapy on her own. Resident #1 said neither RN A nor PT B asked her about the catheter bag being exposed. She said she knew the bag should be covered so no one else can see it but did not think about covering it at the time. She said she did have some covers but did not think to ask the nurse to put one on. An interview on 05/15/2023 at 10:59AM with RN A revealed she did move Resident #1 to her wheelchair today and hung her foley catheter bag on the front of the wheelchair. She said she did not place a cover on the bag to ensure Resident #1's privacy and dignity. She said Resident #1 did go to the therapy gym with the uncovered bag and returned to her room with the bag still uncovered. She stated the bag should be covered to ensure infection control and Resident #1's dignity. An interview on 05/15/2023 at 12:09PM with PT B revealed he had worked with Resident #1 in the therapy gym earlier in the day. He said Resident #1's foley catheter bag was hanging on the front of her electric wheelchair, uncovered, while in the therapy gym. He stated he did not know why the bag was not covered but knew he should have covered it up when he discovered it. He said he worked at the facility for two years and understood an uncovered catheter bag may impact resident's dignity or self-worth because everyone in the gym could see the bag containing urine. In an interview on 05/15/2023 at 1:04PM the Administrator said he expected foley catheter bags to be covered at all times. He said this was an infection control concerns as well as an issue of privacy and dignity for Resident #1. In an interview on 05/15/2023 at 3:05PM, the DON C/IP and DON D stated the foley catheter bags should be covered to ensure resident's dignity. DON/IP C stated the facility has purchased catheter bags with built in covers to ensure the bag was always covered. She stated she did not know why RN A had not placed a cover on the bag or why PT B did not cover the bag when it was discovered exposed in the therapy gym. She stated staff had been trained on resident dignity but could not recall when the last in-service was delivered. Review of the facility's policy titled Dignity and dated 02/2021 stated, .each resident should be treated in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example, helping the resident to keep urinary catheter bags covered .

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for two (Resident #86 and Resident #87) of five residents reviewed for baseline care plans. The facility failed to complete Resident #86's and Resident #87's baseline care plan within 48 hours of admission that included the minimum required healthcare information including physician orders, dietary orders, therapy services, and social services. This failure placed residents at risk of not receiving effective and person-centered care. Findings included: 1. Review of Resident #86's Face Sheet, dated 04/19/23, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included a right femur neck fracture (hip fracture), type 2 diabetes mellitus (insulin resistance), hypertensive heart disease without heart failure (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), and atrial fibrillation (an irregular and often very rapid heart rhythm). Review of Resident #86's Baseline Care Plan, dated 04/14/23, reflected it did not address therapy services. In addition, the dietary/nutritional status and social services sections were not fully completed (dietary/nutritional status was missing information including dietary preferences and dietary risks, as applicable and social services was missing informaiton including PASRR recommendations). The Baseline Care Plan was not completed until 04/18/23. 2. Review of Resident #87's Face Sheet, dated 04/19/23, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), anemia (a lack of red blood cells), hypothyroidism (low activity of the thyroid gland), and hyperlipidemia (a condition in which there are high levels of fat particles or lipids in the blood). Review of #87's Baseline Care Plan, dated 04/17/23, reflected it did not address therapy services or social services. In addition, the dietary/nutritional status section was not fully completed (dietary preferences and dietary risks, as applicable). The Baseline Care Plan was not completed until 04/18/23. During a telephone interview with the MDS Coordinator on 04/18/23 at 1:45PM, she stated she was responsible for ensuring baseline care plans were completed upon resident admissions. She stated upon a resident's admission, she generated a blank baseline care plan in the resident's electronic health record. Each department (dietary, therapy, social services, etc.) was then responsible for completing their portion of the baseline care plan. Upon completion, she and the DON reviewed the baseline care plan and saved it as completed. The baseline care plan was then provided to the resident. During an interview with the DON on 04/18/23 at 1:30PM, she stated baseline care plans were to be completed within 48 hours of a resident's admission. She stated the MDS Coordinator generated a blank baseline care plan in the resident's electronic health record, and then each appropriate department completed their portion of the baseline care plan. Upon completion, the baseline care plans were reviewed by herself and/or the MDS Coordinator and provided to the resident. The DON stated because this was a short-term facility, there was not a risk to residents if the baseline care plan was not completed within the regulatory guidelines. She stated the resident's care was implemented based off items such as the resident's hospital orders and assessments. Review of the facility's Care Plans - Baseline policy, dated 03/22, reflected, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . and .1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable .

Based on observation, interviews and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 of 4 medication carts (Station #1) and ensure drugs and biologicals for 1 (South wing) of 2 treatment carts were secured properly. The faclity failed to ensure: 1. An opened insulin was labeled with opened date on the station #1 medication cart 2. The South Wing treatment cart was locked or supervised. These failures could place residents at risk of receiving expired medications, ingestion of drugs and biologicals, and the facility at risk of drug diversion. Findings included: An observation on 02/07/23 at 7:30 AM revealed licensed staff were not in view of the South wing treatment cart which was unlocked and unsecured with drawers facing outward toward a breezeway between two halls. Further observation of the treatment cart revealed: *Antifungal Cream 2% Miconazole (medication is used to treat vaginal yeast infections) *Betamethasone Dipropionate ointment 0.5% (used to help relieve redness, itching, swelling, or other discomforts caused by certain skin conditions) *Triamcinolone Acetonide Cream USP, 0.5% (used to treat the symptoms of topical inflammatory dermatoses, oral inflammatory or ulcerative lesions) * Triamcinolone Acetonide Cream USP, 0.1% (used to treat the symptoms of topical inflammatory dermatoses, oral inflammatory or ulcerative lesions) *Mupirocin Ointment (used to treat certain skin infections such as impetigo) *Diclofenac Sodium Topical Gel, 1% (used to relieve joint pain from arthritis) *Colloidal Silver 30 PPM (used in wound dressings, creams, and as an antibiotic coating on medical devices) *Povidone -iodine 10% (sterilize routine cuts and scrapes, or clean skin before stitches or surgical procedures) *Chlorhexidine Gluconate Solution 4.0% (treats gingivitis, a gum disease that causes red, swollen, and easily bleeding gums.) During an interview and observation on 02/07/23 at 7:48 AM the Director of Medical Records stated the treatment cart (South Wing) did not have to be locked. The Director of Medical Records stated there was nothing in the treatment cart that would harm the residents. During the observation, the Director of Medical Records locked the treatment cart (South Wing) and walked off. An observation on 02/07/23 at 7:55 AM of Station #1 medicaiton cart revealed: *(2) Lantus SoloStar subcutaneous solution pen- injector 100 Unit/ML *Insulin Lispro-aabc injection solution 100 Unit/ML *(2) Humalog 100 unit/ML *(2) Insulin Lispro 100 Unit/ML *Insulin Lispro 100 Unit/ML vial *Admelog 100 Unit/ML vial During an interview and observation on 02/07/23 at 8:00 AM with ARN A who worked station #1 and stated today was her second day to work in the facility. 7 insulin pens and 2 insulin vials were observed opened and used, but dod not include an open date and had a sticker which reflected to dispose after 28 days. ARN A stated the open date should be on the insulin pens and the insulin vials. ARN A stated there was no way to know if the medication was expired. During an interview on 02/07/23 at 1:30 PM, the DON stated insulin should be dated when opened, and could stay on the medication cart for 28 days once it was opened.The DON stated insulins that are on the medication cart had been opened and used. The DON stated unopened insulins are kepted in the medication storage room refrigerator.The DON stated possible harm to residents of undated and expired insulin was that the insulin could lose its potency. The DON stated residents were not in the facility long enough for the insulin to not be safe to inject since they were there for a short time frame. The DON stated the treatment cart(South Wing) had not been used that morning for treatment and she was not sure who left it unlocked. The DON stated the treatment cart should be locked when not in use. The DON stated that residents could get into the cart and harm themselves by ingesting drugs and biologicals. Record review of the storage medication policy Interpretation and Implementations (Revised November 2020) revealed compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Record review of Administering medications-Policy Interpretation and Implementation (Revised 2019) revealed, 12 .When opening a multi-dose container, the date opened is recorded on the container.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for one of 4 residents (Resident #1) reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #1. This failure could place residents at risk of not receiving effective and person-centered care and services which could result in a diminished quality of care and quality of life. Findings include: Record review of Resident #1's admission MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Cognitive Patterns section of his MDS revealed he had moderately impaired cognition. The resident's Functional Status section of his MDS revealed he required two-person physical assist with transfers, toilet use, and personal hygiene. He required one-person assist with dressing and eating. The resident's Skin Conditions section of his MDS revealed he admitted to the facility with a stage 1 pressure injury and stage 4 pressure ulcer. He had a total of 4 venous and arterial ulcers. He received the following skin and ulcer/injury treatments: pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings, and application of ointments/medications. His Special Treatments, Procedures, and Programs section of his MDS revealed he received oxygen therapy, IV medications, physical therapy and occupational therapy. Record review of Resident #1's electronic medical record revealed no evidence a baseline care plan had been completed. In an interview with the DON on 11/17/22 at 3:11 PM revealed RNs were responsible for completing the baseline care plans but the DON, ADON, PRN RN, and MDS Coordinator could complete them if needed. She stated baseline care plans were to be completed 48 hours after admission. She stated she opened Resident #1's baseline care plan for the RNs to complete. She stated there was no reason for the baseline care plan to not be completed. She stated the purpose of the baseline care plan was to inform staff of the residents care needs. She stated she thought Resident #1 had a care conference meeting. She stated the IDT had an initial care plan meeting to establish goals and discharge planning because the resident was a short stay. She stated medical records audits to see if the baseline care plans were completed. She stated she was the DON and completion of baseline care plans was her responsibility at the end of the day. She stated the resident was dependent with ADLs, had wounds, wound infection, midline issues, pacemaker, and a PICC line was scheduled 11/20/22. She stated he was receiving IV antibiotics for a wound infection. She stated there were no risks for Resident #1 not having a completed baseline care plan because the residents chart was reviewed, there was follow up, needs were being met, treatments were effective, and he was being monitored. She stated the baseline care plan was a regulatory requirement. In an interview with LVN A on 11/17/22 at 4:00 PM revealed the purpose of a baseline care plan was to inform staff of the needed care of the resident. She stated the DON and management were responsible for completing the resident's baseline care plan. She stated baseline care plans were to be completed 48 hours after the resident admitted to the facility. She stated she did not know why Resident #1's baseline care plan was not completed. She stated Resident #1 not having a completed baseline care plan could cause staff to not provide the resident the care he needed such as isolation precautions and fall risks. Record review of the facility's policy Baseline Care Plan, dated March 2022, reflected, A baseline of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 1 (Hall 500) of two medications carts reviewed for medication storage. The facility failed to lock 1 medication cart located on Hall 500. This failure could affect residents by placing them at risk of not having their medications available as prescribed or possible drug diversion. Findings Included: Observation on 06/14/22 from 1:13 PM to 1:16 PM revealed there was an unlocked medication cart on Hall 500. All drawers of the medication cart could be opened, and the medications were easily accessible. The cart was unattended for approximately 3 minutes once it was discovered, before surveyor intervention pointing it out to the RN A. One resident was observed on the hall with therapy staff getting assistance with walking. Interview with RN A on 06/14/22 at 1:17 PM revealed she did not realize she had left the medication cart unlocked. She stated she had left her cart because there was a call light ringing. She stated she should not have left the cart unlocked or unattended. She stated the risk of her not locking her medication cart could result in medications being taken and missing. She stated she was trained and in-serviced sometime last month about medication cart security. Interview with the ADON on 06/14/22 at 2:05 PM revealed her expectation regarding medication carts was they were always locked if they walked away from it. She stated they did an in-service regarding medication cart security but did not remember when. She stated it was unacceptable to leave the cart unlocked. Review of the facility policy, Security of Medication Cart, dated April 2007, revealed, The medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry .3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the residents room. 4. Medication carts must be securely locked at all times when out of the nurse's view .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for eight (Residents #1, #2, #3, #4, #5, #6, #7, #8) of nineteen residents reviewed for infection control. The facility failed to cohort residents based on the residents' COVID-19 status. These failures could place residents at risk for developing COVID-19. Findings included: During entrance conference on 11/06/20 at 9:55 AM, the DON stated the facility's warm unit, were newly admitted residents and residents in their 14-day quarantine, were units one and two. Observation of Units One and Two on 11/06/20 at 11:39 AM revealed Residents #1, #2, #3, and #4 were four of eight residents were in their 14- day quarantine on unit one, and Residents #5, #6, #7, and #8 were four of ten residents were in their 14- day quarantine on unit two. Review of Resident #1's face sheet, dated 11/06/20, revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's primary [DIAGNOSES REDACTED]. Review of Resident #2's face sheet , dated 11/06/20, revealed Resident #2 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #2's primary [DIAGNOSES REDACTED]. Review of Resident #3's face sheet , dated 11/06/20, revealed Resident #3 was a [AGE] year-old male who admitted to the facility on [DATE]. Residents#3's primary [DIAGNOSES REDACTED]. Review of Resident #4's face sheet, dated 11/06/20, revealed Resident #4 was a [AGE] year-old female, who re-admitted to the facility on [DATE]. Resident #4's primary [DIAGNOSES REDACTED]. Review for Resident #5's face sheet, dated 11/06/20, revealed Resident #5 was an [AGE] year-old female, who admitted to the facility on [DATE]. Resident #5's primary [DIAGNOSES REDACTED]. Review of Resident #6's face sheet, dated 11/06/20, revealed Resident #6 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #6's primary [DIAGNOSES REDACTED]. Review of Resident #7's face sheet, dated 11/06/20, revealed Resident #7 was a [AGE] year-old male who admitted to the facility on [DATE]. His primary [DIAGNOSES REDACTED]. Review of Resident#7's physician orders [REDACTED]. Review of Resident #8's face sheet, dated 11/06/20, revealed Resident #8 was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #8's primary [DIAGNOSES REDACTED]. Interview with the DON on 11/06/20 at 11:55 AM revealed, the facility did not use units three and four because of staffing. The interview further revealed, the facility staffs three nurses and two to three certified nurse's aides through the day shifts and two nurses and certified nurse's aides at night. She stated that additional certified nurse's aides were scheduled, but they were not needed due to a low census. Observation of lunch pass on 11/06/20 at 12:45 PM revealed CNA B was observed entering the rooms of three residents , including Resident #2. The observation further revealed CNA C only donned additional PPE when delivering lunch to Resident #1. In an interview on 11/06/20 at 3:45 PM, CNA D stated when caring for a resident on transmission-based precautions, they must don the appropriate PPE, which was posted on the door, and then enter. She stated they must perform hand hygiene in between residents' rooms. In an interview on 11/06/20 at 4:37 PM, the Administrator stated he was unsure of the guidance that was followed to comingle quarantined residents and non-quarantined residents and that he thought it was an issue when he started. The interview further revealed that wings three and four just became equipped to house residents, as the hospital recently provided the facility with beds for the wings. Review of the facility's Infection Control: COVID-19 Population Management policy, dated 03/30/20 revealed: General Guidelines it is recommended that residents newly admitted and or leave the Healthcare center for any purpose(s) are sequestered to a designated step-down unit up to 14 days due to the potential risk of infectious transmission of COVID-19. Isolating these high-risk residents are essential to prevent unnecessary exposures among community residents . Policy Interpretation and Implementation 1. Obtain Physician order [REDACTED]. 3. Cohort newly admitted resident to a specific area designated with in the Healthcare Center . 4. Limit number of staff providing care while coordinating interactions of treatment to minimize interactions The COVID-19 Response for Nursing Facilities dated 08/18/20 indicated: To avoid transmission within facilities, NFs should use separate staffing teams for COVID-19-positive residents to the best of their ability, and designate separate facilities or units within a facility to separate residents into three categories: those who are COVID-19-negative, those who are COVID-19-positive, and those with unknown COVID-19 status. New admissions, readmissions, and residents who have spent one or more nights away from the facility are all considered residents with unknown COVID-19 status.

Based on observation, interview and record review, the facility failed to establish and maintain an infection policy and procedure designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 (Resident #1) of 1 residents reviewed for infection control. The facility failed to prohibit non-essential visitors from entering the facility and having direct contact with residents in an effort to prevent the spread of COVID-19 during the pandemic. These failures placed residents at risk for exposure to COVID-19 which could result in illness, hospitalization , and death. Findings included : Review of Resident #1's Face Sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #1's Hospital to Post-Acute Care Facility Transfer - COVID-19 Assessment revealed the resident tested negative for COVID-19 on 05/04/20. Observation of Resident #1 on 06/20/20 at 3:10 PM revealed he was sitting across a table from a visitor in the facility lobby. Resident #1 and the visitor were wearing surgical masks, gloves, and a protective gown. Resident #1 and the visitor were approximately three feet away from each other at a table. There were no other residents in the area. Interview with Resident #1's visitor on 06/20/20 at 3:10 PM revealed he was at the facility visiting Resident #1 for the first time. He stated Resident #1 was his family. Observation of the receptionist's desk on 06/20/20 at 3:53 PM revealed a taped sign titled Family Visits regarding visitation guidelines. right next to the hand sanitizer and COVID 19 screening tool. Review of the facility visitation policy Family Visits revealed visitation hours are Monday to Sunday from 9am -2pm for 30 minutes. The visitation guidelines are no physical contact, patients must wear a mask, family members must don PPE; face mask, gloves, and a gown upon arrival, family members must remove PPE and don a new mask upon departure, and sanitize chairs and table after the visitor's departure. Interview with the Receptionist on 06/23/20 at 4:50 PM revealed non-essential visitors were being allowed into the facility. She stated the facility was allowing visitors for the last month. She stated she was informed by HR and the Administrator visitors were allowed. She stated visitors could visit in the lobby or, if the Administrator approved, visits would take place in residents' rooms. Interview with the CNA A on 06/20/20 at 3:15 PM revealed non-essential visitors were allowed visitation with residents in the facility lobby for the past two weeks. She stated the DON informed her residents could have visitors. Interview with the ADON on 06/20/20 at 2:17 PM revealed the facility was allowing non-essential visitors into the facility for the past two weeks. Interview with the DON on 06/20/20 at 2:45 PM revealed the facility was allowing non-essential visitors into the facility for the past 2 weeks. He stated residents could only have one visitor at a time for 30 minutes in the facility lobby. He stated all visitors were screened for signs and symptoms of COVID-19 prior to visiting the resident. He stated the facility was following the Governor's orders regarding visitation . Interview with the DON on 06/22/20 at 5:50 PM revealed the facility was allowing non-essential visitors. He stated the Administrator thought the Governor's Executive Order allowed visitation in all nursing homes. He stated the administrator also read the HHSC visitation guidelines wrong. The DON stated he read the HHSC COVID-19 Response for Nursing Facilities. He stated allowing non-essential visitors did not have an effect on residents or staff. He stated allowing non-essential could have a potential effect on resident and staff health by potentially exposing them to COVID-19. Interview with the Administrator on 6/23/20 at 5:13 PM revealed the facility allowed a family member to visit a resident in the front entry of the facility. He stated visitors were being screened and donning PPE. He stated there have been special exceptions for visitors.receiving therapy services . He stated residents had positive outcomes and were more productive with therapy services. He stated he did not know about the visitation sign on the receptionist's desk. He stated sometimes staff took initiative and made their own rules regarding visitation. Review of an Executive Order by the Governor of the State of Texas Executive Order GA 26, dated 06/03/20, revealed: People shall not visit nursing homes, state supported living centers, assisted living facilities, or long-term care facilities unless as determined through guidance from the Texas Health and Human Services Commission (HHSC). Nursing homes, state supported living centers, assisted living facilities, and long-term care facilities should follow infection control policies and practices set forth by HHSC, including minimizing the movement of staff between facilities whenever possible. Notwithstanding anything herein to the contrary, the governor may by proclamation add to the list of establishments or venues that people shall avoid visiting. Review of The Texas Health and Human Services COVID-19 Response for Nursing Facilities, version 3.1 dated 06/02/20, revealed: On March 13, 2020, the Centers for Medicare and Medicaid Services (CMS) released a memorandum directing all NFs to restrict visitors except those deemed medically necessary. This is an important measure to prevent the introduction of [MEDICAL CONDITION] that causes COVID-19 into NFs. DSHS recommends all NFs restrict all non-essential visitation except in end-of-life care.

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 #22) of two residents reviewed for infection control practices. The facility failed to ensure CNA A and CNA B performed hand hygiene and changed gloves as appropriate while providing incontinence care to Resident #22. These failures could place resident risk for cross contamination and the spread of infection. Finding included: Review of Resident #22's Face Sheet dated 11/14/19 revealed she was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22s Minimum Data Set (MDS) Assessment signed on 10/28/19 revealed Resident #22 required extensive assistance with most activities of daily living (ADLs) and was occasionally incontinent of bowel and bladder. An observation on 11/13/19 at 10:25 a.m. of incontinence care for Resident #22 in his room revealed CNA A and CNA B performed hand hygiene and donned gloves before starting care. Resident #22's brief was soiled with urine and fecal matter. CNA A and CNA B removed Resident #22's soiled brief. CNA A wiped Resident #22 from back to front. She performed hand hygiene and put on new gloves. CNA A repositioned the Resident #22 and continued to clean the resident's perineal area. CNA A retrieved a clean brief while wearing soiled gloves, and without performing hand hygiene or changing gloves fastening it on Resident #22. CNA B was assisting CNA A during the repositioning of Resident #22 and did not changed gloves before helping to fasten the clean brief. CNA A and CNA B completed incontinence care and performed hand hygiene before exiting Resident #22's room. During an interview on 11/13/19 at 11:15 a.m. CNA A said she had been employed in the facility for one month and received infection control training during orientation. CNA A stated cross contamination was mixing clean with dirty. CNA A acknowledged she should have changed gloves before picking up the clean brief and fastening it on Resident #22. She added Resident #22 could get infection for not following good infection control practice. During interview on 11/13/19 at 11:18 a.m. CNA B said cross contamination was going from clean to dirty. She acknowledged not changing gloves before retrieving Resident #22's clean brief. CNA B stated she has been employed one month in the facility and received infection control training during orientation. In an interview on 11/15/19 at 12:07 p.m. the DON acknowledged being aware of some of the concerns raised about infection control practice. She explained the aides were expected to follow standard precautions including performing hand hygiene and changing gloves while providing care. The facility policy and procedure revised (MONTH) 2012 revealed the purpose was to provide guidelines for general infection control while caring for residents. The general guidelines include the following: 1) Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluid, secretions, and excretions regardless of whether they contain visible blood, non-intact skin, and/or mucous membranes. 2) Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a) Before and after direct contact with residents b) When hands are visibly dirty or soiled with blood or other body fluids .

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for four of six residents reviewed for quality of care (Residents #1, #2, #3 and #4). The facility failed to administer pain medications timely when; [NAME] Resident #1 was out of her [MEDICATION NAME] 5-325 for two days (6-26-19 and 6-27-19) until surveyor intervention on (06-27-19). It was the second time the facility did not have her [MEDICATION NAME]. B. Resident #2 did not receive her [MEDICATION NAME] 50 mg tablet until 4:00 PM when she first requested it at 9:00 AM on 06-27-2019. C. Resident #4 did not receive her requested hour of sleep medications until 10:00 PM at night when she requested them at 6:30 PM on 06-25-2019. D. Resident #3 did not receive her PRN (as needed) [MEDICATION NAME] 10-325 mg every six hours as she requested and was ordered. This failure to obtain and administer pain medications timely led to frustration, lack of sleep and feelings of insignificance. Findings Included: [NAME] In an interview on 06/26/2019 at 1:00 PM Resident #1 stated she had been given the last [MEDICATION NAME] out of the facility dispenser this morning and she was supposed to have received two. She further stated her order was for two every four to six hours. She stated this was the second time the facility ran out of [MEDICATION NAME]. Review of Resident #1's Care Plan with a start date of 05/24/2019 reflected she was admitted for Recurrent Right Hip Dislocation. Resident has surgical incision to right thigh. Resident #1's pain care plan reflected the goal was for the resident to verbalize relief of pain and the interventions included; Administer medications: [REDACTED]. Her ADL care plan reflected; Patient is admitted to skilled nursing for IV antibiotic therapy for infection and [MEDICAL CONDITION] reaction due to infected hardware right hip joint. Goal: Patient to discharge back home with family. A second pain care plan reflected Administer pain medication as ordered by physician and assess effectiveness. Review of Resident #1's History and Physical dated 05/27/2019 by her MD reflected; Resident is a [AGE] year old female with multiple hip revisions in the last year, which is very frustrating for her. She is depressed and anxious. Musculoskeletal: Chronic right hip pain. Review of Resident #1's Physician order [REDACTED].#1 was admitted on Friday, 05/24/19 at 10:30 PM with orders dated Saturday, 05/25/2019 for; [MEDICATION NAME] 5-325 mg tablets one every four hours as needed. [MEDICATION NAME] 5-325 mg two tablets every four hours as needed. [MEDICATION NAME] 300 mg one capsule three times a day 9:00 AM, 1:00 PM and 5:00 PM. Review of a copy of Resident #1's controlled narcotic prescription original reflected the MD had prescribed [MEDICATION NAME] 5-325 mg one or two tablets every four to six hour as needed for pain. Dispense 30 tablets. The script was dated 05/21/2019 (three days prior to admission to the facility). Review of Resident #1's Progress Notes reflected: Sunday, 05/26/2019 at 6:06 PM On Friday 05/24/2019 around 10:00 PM guest admitted . 06/07/2019 at 2:53 PM Received a new triplicate for [MEDICATION NAME] 5-325. Tylenol #3 is to be discontinued once [MEDICATION NAME] is available to be administered. (There was no note documenting when Resident #1 ran out of [MEDICATION NAME] or any other attempts to notify the MD.) 06/26/2019 at 1:22 PM Called MD about needing a triplicate for her [MEDICATION NAME]. MD stated to ask the Pain Management doctor, informed MD Pain Management doctor is not following, and he stated he would send a triplicate. (There was no note documenting when Resident #1 ran out of [MEDICATION NAME] or any attempts to notify the MD.) Review of Resident #1's Nurse Treatment Administration Record reflected Resident #1 received pain medicine daily starting with [MEDICATION NAME] and Tylenol #3 with [MEDICATION NAME] on 05/25/2019 and starting her [MEDICATION NAME] for the first time on 05/27/2019. She received [MEDICATION NAME] daily except for 05/30/2019 when she did not receive any pain medication. Resident #1 took her [MEDICATION NAME] 5-325 mg on 06/01/19 and 06/02/19 and then she did not receive [MEDICATION NAME] again until 06/07/2019 at 3:03 PM. (See Progress note above - 06/07/19 received new triplicate.) Resident #1 received her [MEDICATION NAME] daily (except 06/14/2019) from 06/07/2019 until she received her last one on 06/26/2019 at 11:01 AM. The TAR reflected Resident #1 no longer had the option of taking [MEDICATION NAME] or Tylenol #3 as they were struck out on the (MONTH) 2019 TAR from (MONTH) 7, 2019 forward. In an interview on 06/27/2019 at 9:54 AM Resident #1 stated I haven't received any [MEDICATION NAME] since the last one I got yesterday. My pain right now is about a seven. I hurt all the time. I can't lay on my right side where I have had my hip replacement. I have had nine surgeries. My back is hurting also. I hurt everywhere. I need my pain medicine. I did not sleep last night. I hurt all night. They gave me Tylenol but that was all they could give me. I take [MEDICAL CONDITION] medicine and it doesn't mix with a lot of medication. Nothing helps like two [MEDICATION NAME]. I have been on [MEDICATION NAME] since 2013. In an interview on 06/27/2019 at 4:04 PM. LVN D stated Resident #1 was out of [MEDICATION NAME] and the doctor needed to write a script to refill the [MEDICATION NAME] for Resident #1. She stated the Pyxis dispenser does not show a count of narcotics for the residents and she has no way of knowing when the resident is running out of medications. B. In an interview on 06/26/2019 at 2:10 PM Resident #2 stated she used her call light at 9:00 AM and asked for pain medication. She stated the voice on the intercom told her they would bring her some. Resident #2 stated she had not received any pain medicine yet. Review of Resident #2's Physician order [REDACTED].#2 was a [AGE] year old female admitted on [DATE] at 10:21 PM with [DIAGNOSES REDACTED]. An order dated 06/23/2019 was for [MEDICATION NAME] 50 mg one tablet every six hours. There was no other order for pain medications. Review of Resident #2's Care Plan dated 06/20/2019 reflected Resident #2's care plan for ADLs reflected she was to participate with therapy to reduce chronic pain and to restore her physical function. Resident #2's discharge plan was to return home. Staff were to monitor her for pain every shift. Staff were to Administer pain medication as ordered by physician and assess effectiveness. Review of Resident #2's Progress Note dated Sunday, 06/23/2019 at 2:30 PM (third day after being admitted with Chronic Pai[DIAGNOSES REDACTED]) reflected; Spoke with MD about guest's complaint of pain to her back at 9 of 10. New order received for [MEDICATION NAME] 50 mg tablet one every six hours as needed. New order faxed to pharmacy. Review of Resident #2's Medication Administration Record [REDACTED]. There were no other pain medications available to Resident #2. Review of Resident #2's MAR indicated [REDACTED]. It reflected she last received a pill at 10:08 PM on 06/25/2019 (the previous night). Observation on 06/26/2019 at 2:17 PM revealed Resident #2 activated her call light and asked for pain medicine. The voice on the intercom told her they would bring her some pain medicine (in the surveyor's presence). Observation on 06/26/2019 at 2:35 to 2:45 PM revealed Resident #2 was walking in the hall with her walker waiting for pain medicine. In an interview on 06/26/2019 at 3:13 pm Resident #2 was back in her room and stated she had not received a pain pill. She stated she had sciatic nerve pain and in her lower back her pain was 9.5 on a scale of one to ten. She stated walking was better for the pain than sitting. In an interview on 06/26/2019 at 3:49 PM revealed Resident #2 stated she had not received a pain pill. (One hour and 30 minutes after being told the staff would bring her a pain pill.) In an interview on 06/26/2019 at 3:55 PM LVN [NAME] stated she was Resident #2's nurse and she had been out of the facility to get a new patient from the hospital but had not taken a wheelchair, so she would be going back to the hospital to get the patient in a wheelchair. She further stated she had received a report for a second new patient to go get but didn't recall anyone telling her Resident #2 needed a pain pill. LVN [NAME] stated she would get Resident #2 a pain pill before she took a staff member with her to the hospital to get the two new residents. In an interview on 06/26/2019 at 4:14 PM Resident #2 stated she received her pain medicine just a few minutes prior (two hours after asking the second time and with surveyor intervention). In an interview on 06/27/2019 at 9:41 AM Resident #2 stated; They brought my night time medication around 11:00 PM last night. At home I go to bed at 8:00 PM. I stayed up waiting on my medicine. My medicine is very important because it knocks the pain out in my back and lets me go to sleep. Last night it was a 9.5 when they gave me my pain meds. It was about 12:00 or 1:00 AM before I went to sleep because of the pain. I last saw a doctor here in the last several days. I didn't tell the nurse or anyone this is not acceptable. I try not to make waves. I got my morning medicine about 8:00 this morning. When I came up on this floor (from the hospital) the medicine times changed. I didn't know they had to call the medicine in and then wait for it to get here and all of that. It was like 6:00 PM or 7:00 PM at night when I came to this unit. I don't think I got my medicine that night. They said they didn't have a prescription for my medicine and different excuses like that. My pain that first night was more. It was hurting in my heart and it seemed like everything was going wrong. I was hurting everywhere. I can't recall the next morning's events. Review of Resident #2's MAR indicated [REDACTED]. Review of Resident #2's History and Physical dated 06/23/2019 at 11:51 PM reflected the MD wrote; On and off chest pain-pressure like, no troponin leak, but electrocardiogram with some st - t (wave) changes. Resolved. Stress test unremarkable. Chronic pai[DIAGNOSES REDACTED], Neuralgia . C. In an interview on 06/26/2019 at 2:00 PM Resident #4 stated she requested her medicine at 8:30 PM on 06/25/2019 so that she could go to sleep at 9:00 PM. She stated she received her medicine at 10:00 PM. Review of Resident #4's care plan dated 06/23/2019 reflected; Resident is admitted to facility for Fracture to Right Pubis. Discharge to community after therapy completed. Medications; Administer medication as ordered by physician. Monitor presence, location and character of pain. Encourage resident to request pain medication before pain becomes unbearable. Review of Resident #4's Physician order [REDACTED]. She had an orders for; [MEDICATION NAME] 500 mg one four times daily as needed for muscle spasms. Tylenol with [MEDICATION NAME] 300 - 30 mg one or two every six hours as needed. [MEDICATION NAME] 300 mg one twice a day at 9:00 AM and 8:00 PM. [MEDICATION NAME] 50 mg one every six hours as needed. [MEDICATION NAME] adhesive patch 5% two topically to skin once a day. Tylenol extra strength 500 mg one three times a day; 9 AM, 1 PM and 5 PM. Tylenol extra strength 500 mg one every six hours; 12 AM, 6 AM, 12 PM and 6 PM. Review of Resident #4's MAR indicated [REDACTED] Tylenol with [MEDICATION NAME] 300 - 30 mg two tablets were administered on 06/25/2019at 9:58 PM for lower back pain rated 8 of 10. Her routine [MEDICATION NAME] was charted as administered within the 8:00 PM parameters; an hour before to an hour after the scheduled time. In an interview on 06/27/2019 at 10:08 AM Resident #4 stated, The girl said she would give me a bath this morning, but then she had an emergency. I had a hard day and wanted my medicine after dinner on Tuesday, so I could get some sleep. I get up around 6:00 am and wanted to go to bed by 9:00 pm. I take a pain pill at night. They didn't give it to me until late. I was hurting, and I needed and wanted it, but I didn't get it. My pain was between an eight and ten. I just had to lay still, and it helped. The pill that I have taken for years for [MEDICAL CONDITION], [MEDICATION NAME], helps me sleep easy. I am getting it here. They work for me. I have a friend wanting a knee replacement and I shook my head when she asked about whether I recommend this place or not. They say they will be back in a minute and it's two hours later. They always put me off for medication and bathing. D. In an interview on 6/26/2019 at 1:40 PM, Resident #3 stated the only issue she has at the facility is that her pain medication is not strong. She stated she told the nursing staff and the facility physician, but she has not received more or stronger pain medication. She stated she is in the facility doing physical therapy after breaking her hip, and she has pain in her hip and back. Review of physician orders [REDACTED]. Review of internal medicine physician daily progress notes for Resident #3 dated 6/26/19 reflected the following: I have reviewed labs, prior records and discussed with nursing. (Resident #3) says operative site pain is 9/10. Complains of chronic pain in the right knee that she attributes to arthritis and [MEDICAL CONDITION]. History of [MEDICAL CONDITION] and chronic pain. The patient reports she takes [MEDICATION NAME]/benzos chronically. Review of MAR for Resident #3 reflected administration of [MEDICATION NAME] 10-325 mg 2 tabs recorded on 6/23/2019 at 5:01 AM and 11:57 AM, on 6/24/2019 3:48 PM and 9:21 PM, on 6/25/2019 at 4:38 AM and 7:20 PM 6/26/2019 at 1:34 AM, 7:42 AM, 12:27 PM, and 6:53 PM, and on 6/27/2019 at 4:37 AM and 8:26 AM. In an interview on 6/27/2019 at 10:18 AM, Resident #3 stated she was nauseated and in so much pain. She stated she was taking notes on when she receives care and medications. She stated that she received her PRN [MEDICATION NAME] the previous day at 12:30 PM and should have had another dose at 6:30 PM, but she did not get more until 12:00 AM. She stated that she then did not get more until 8:30 AM this morning. She stated that if she gets the pain pills every six hours when she is supposed to get them, it stays on top of her pain, but that has not happened since she entered the facility. She presented a spiral notebook with detailed notes spanning several pages of every time she has received medication, a meal, or other visits from staff to offer services. Her data for receipt of PRN [MEDICATION NAME] was not consistent with the MAR for that order. She was able to relay her orders for [MEDICATION NAME], the name of the physician who prescribed it, the date she entered the facility, and what she was served for dinner the prior night and exhibited no sign of impaired memory or cognition. In an interview on 06/27/2019 at 11:04 AM the Interim Director of Nursing (IDON) stated residents with orders for [MEDICATION NAME] as needed and routine was dispensed out of the facility pharmacy machine as long as the prescription was current. She stated she did not know Resident #1 had run out of [MEDICATION NAME] and she did not know why the facility had not received a refill. The IDON stated the staff had not notified her Resident #1 did not have [MEDICATION NAME] and Surveyor was the first person to bring it it her attention. In an interview on 06/27/2019 at 1:36 PM IDON stated she had researched the reason why Resident #1 did not have any [MEDICATION NAME] and reassured the [MEDICATION NAME] for Resident #1 would be delivered. She stated the MD wrote the triplicate on a script pad the pharmacy no longer recognized as adequate. The MD wrote a triplicate and the pharmacy received it on 6/21/19 but would not honor it. Resident #1's MD thinks he sent in his script, but the script pad changed on 6/01/19. The pharmacy says they notified the MD. The pharmacy system acknowledges that it received a triplicate, but the pharmacist won't allow the triplicate to be utilized. The MD says he did not receive notification. The Nurse did call the doctor and the pharmacy. The pharmacy and the doctor stood without calling the other. We need the nurses to be able to give the medicines timely. In an interview on 06/27/2019 at 2:10 PM the IDON stated she expected the Nurses to administer medications timely and Residents #2 and #4 did not receive their medications timely. She further stated the staff should have notified her about the situation with Resident #1's [MEDICATION NAME]. Review of the policy Pain Assessment and Management dated (MONTH) (YEAR) reflected: The pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Implement the medication regimen as ordered, carefully documenting the results of the interventions. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as necessary. Report to the practitioner if there is prolonged, unrelieved pain despite care plan interventions. Review of the policy Administering Medications dated (MONTH) 2012 reflected: If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of the medication is clinically advised. Review of the policy Accepting Delivery of Medications dated (MONTH) 2007 reflected; The dispensing pharmacy, consultant pharmacist and the Director of Nursing Services shall be notified of medication order errors.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of six residents reviewed for quality of care (Resident #1). The facility failed to maintain stock and administer pain medications timely when Resident #1 was out of her [MEDICATION NAME] 5-325 for two days (06/26/19 and 06/27/19) until surveyor intervention on 06/27/19. It was the second time the facility did not have her [MEDICATION NAME] (06/03/2019 to 06/06/2019). This failure to obtain and administer pain medications timely led to frustration, lack of sleep and feelings of insignificance. Findings included: In an interview on 06/26/2019 at 1:00 PM Resident #1 stated she had been given the last [MEDICATION NAME] out of the facility dispenser this morning and she was supposed to have received two. She further stated her order was for two every four to six hours. She stated this was the second time the facility ran out of [MEDICATION NAME]. Review of Resident #1's Care Plan with a start date of 05/24/2019 reflected she was admitted for Recurrent Right Hip Dislocation. Resident has surgical incision to right thigh. Resident #1's pain care plan reflected the goal was for the resident to verbalize relief of pain and the interventions included; Administer medications: [REDACTED]. Her ADL care plan reflected; Patient is admitted to skilled nursing for IV antibiotic therapy for infection and [MEDICAL CONDITION] reaction due to infected hardware right hip joint. Goal: Patient to discharge back home with family. A second pain care plan reflected Administer pain medication as ordered by physician and assess effectiveness. Review of Resident #1's History and Physical dated 05/27/2019 by her MD reflected; Resident is a [AGE] year old female with multiple hip revisions in the last year, which is very frustrating for her. She is depressed and anxious. Musculoskeletal: Chronic right hip pain. Review of Resident #1's Physician order [REDACTED].#1 was admitted on Friday, 05/24/19 at 10:30 PM with orders dated Saturday, 05/25/2019 for; [MEDICATION NAME] 5-325 mg tablets one every four hours as needed. [MEDICATION NAME] 5-325 mg two tablets every four hours as needed. [MEDICATION NAME] 300 mg one capsule three times a day 9:00 AM, 1:00 PM and 5:00 PM. Review of a copy of Resident #1's controlled narcotic prescription original reflected the MD had prescribed [MEDICATION NAME] 5-325 mg one or two tablets every four to six hour as needed for pain. Dispense 30 tablets. The script was dated 05/21/2019 (three days prior to admission to the facility). Review of Resident #1's Progress Notes reflected: Sunday, 05/26/2019 at 6:06 PM On Friday 05/24/2019 around 10:00 PM guest admitted . 06/07/2019 at 2:53 PM Received a new triplicate for [MEDICATION NAME] 5-325. Tylenol #3 is to be discontinued once [MEDICATION NAME] is available to be administered. (There was no note documenting exactly when Resident #1 ran out of [MEDICATION NAME] or any other attempts to notify the MD.) 06/26/2019 at 1:22 PM Called MD about needing a triplicate for her [MEDICATION NAME]. MD stated to ask the Pain Management doctor, informed MD Pain Management doctor is not following, and he stated he would send a triplicate. (There was no note documenting when Resident #1 ran out of [MEDICATION NAME] or any attempts to notify the MD.) Review of Resident #1's Nurse Treatment Administration Record reflected Resident #1 received pain medicine daily starting with [MEDICATION NAME] and Tylenol #3 with [MEDICATION NAME] on 05/25/2019 and starting her [MEDICATION NAME] for the first time on 05/27/2019. She received [MEDICATION NAME] daily except for 05/30/2019 when she did not receive any pain medication. Resident #1 took her [MEDICATION NAME] 5-325 mg on 06/01/19 and 06/02/19 and then she did not receive [MEDICATION NAME] again until 06/07/2019 at 3:03 PM. (See Progress note above - 06/07/19 received new triplicate.) Resident #1 received her [MEDICATION NAME] daily (except 06/14/2019) from 06/07/2019 until she received her last one on 06/26/2019 at 11:01 AM. The TAR reflected Resident #1 no longer had the option of taking [MEDICATION NAME] or Tylenol #3 as they were struck out on the (MONTH) 2019 TAR from (MONTH) 7, 2019 forward. In an interview on 06/27/2019 at 9:54 AM Resident #1 stated; I haven't received any [MEDICATION NAME] since the last one I got yesterday. My pain right now is about a seven. I hurt all the time. I can't lay on my right side where I have had my hip replacement. I have had nine surgeries. My back is hurting also. I hurt everywhere. I need my pain medicine. I did not sleep last night. I hurt all night. They gave me Tylenol but that was all they could give me. I take [MEDICAL CONDITION] medicine and it doesn't mix with a lot of medication. Nothing helps like two [MEDICATION NAME]. I have been on [MEDICATION NAME] since 2013. In an interview on 06/27/2019 at 4:04 PM LVN D stated Resident #1 was out of [MEDICATION NAME] and the doctor needed to write a script to refill the [MEDICATION NAME] for Resident #1. She stated the Pyxis dispenser does not show a count of narcotics for the residents and she has no way of knowing when the resident is running out of medications. In an interview on 06/27/2019 at 11:04 AM the Interim Director of Nursing (IDON) stated residents with [MEDICATION NAME] as needed and routinely received it as dispensed out of the facility on site pharmacy machine as long as the prescription was current. She stated the staff had not notified her Resident #1 was out of [MEDICATION NAME] and she did not know why the facility had not received a refill and Surveyor was the first person to bring it to her attention. In an interview on 06/27/2019 at 1:36 PM IDON stated she had researched the reason why Resident #1 did not have any [MEDICATION NAME] and reassured the [MEDICATION NAME] for Resident #1 would be delivered. She stated the MD wrote the triplicate on a script pad the pharmacy no longer recognized as adequate. The MD wrote a triplicate and the pharmacy received it on 6/21/19 but would not honor it. Resident #1's MD thinks he sent in his script, but the script pad changed on 6/01/19. The pharmacy says they notified the MD. The pharmacy system acknowledges that it received a triplicate, but the pharmacist won't allow the triplicate to be utilized. The MD says he did not receive notification. The Nurse did call the doctor and the pharmacy. The pharmacy and the doctor stood without calling the other. We need the nurses to be able to give the medicines timely. In an interview on 06/27/2019 at 2:10 PM the IDON stated she expected the Nurses to administer medications timely and the staff should have notified her about the situation with Resident #1's [MEDICATION NAME]. Review of the policy Pain Assessment and Management dated (MONTH) (YEAR) reflected: The pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Implement the medication regimen as ordered, carefully documenting the results of the interventions. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as necessary. Report to the practitioner if there is prolonged, unrelieved pain despite care plan interventions. Review of the policy Administering Medications dated (MONTH) 2012 reflected: If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of the medication is clinically advised. Review of the policy Accepting Delivery of Medications dated (MONTH) 2007 reflected; The dispensing pharmacy, consultant pharmacist and the Director of Nursing Services shall be notified of medication order errors.

Based on observations, interview, and record review, the facility failed to provide the necessary care and services and ensure a resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 (Resident #235) of 3 residents with Foley catheter in the facility. The facility did not secure Resident #235's catheter tubing to prevent pulling resulting in redness and swelling in his penile area. The facility did not have an appropriate [DIAGNOSES REDACTED].#235 for removal of the catheter as soon as possible. This failure could place residents at risk of infection and trauma. Finding included: Review of Resident #235's Face Sheet dated 01/10/19 revealed a [AGE] year old male admitted to the facility on [DATE]. His diagnoses included Retention of urine and acute pain due to trauma. There was no [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #235 had an indwelling catheter. He ambulated independently and required limited assistance with most activities of daily living(ADL) A Care Plan dated 01/10/19 indicated Resident #235 had a Foley catheter. The recommendation included catheter care every shift and prn. The Care Plan reflected effective 01/08/19 apply leg strap to secure catheter as anchor to reduce pulling. Review of physician order from 12/10/18 through 01/10/19 revealed no order for Foley catheter. Observation of Resident #235's Foley catheter on 01/08/19 at 9:45 a.m. revealed there was no leg strap to secure the catheter and mitigate pulling. The penile was red and swollen. The observation was made with the assistance of LVN P. She stated she did not know the resident was having some discomfort. She said the outgoing nurse did not pass down the information to her. Interview with Resident #235 on 01/08/19 at 12:45 PM revealed every time he does rehab his catheter pulls and causes him pain. He stated the catheter had been bleeding. He stated staff reported to him last night 01/07/19 that it was blood on his disposable diaper. He stated he had told staff it was hurting him, and they acted like they did not cared. He stated when he goes to rehab he has to put the bag up on the side of the arm rest to be able to do activities. He stated the rehab staff take it easy on him. Interview with Resident #235 on 01/08/19 at 9:50 a.m. revealed he informed the charge nurse LVN G on Thursday, (MONTH) 3, 2019 he was having discomfort on in his penile area, but she did nothing. He explained he could not fully participate in his therapy sections because of discomfort from the Foley catheter. Review of electronic time clock on 01/03/19 revealed LVN G worked from 7:02a.m to 1:32p.m. had lunch from 1:32p.m-2:02p.m. LVN G continue to work from 2:02p.m to 7:50pm Interview with LVN G on 01/11/18 at 10:25 a.m. revealed she worked on 01/03/19. She said Resident #235 did not l inform her of the discomfort from the Foley catheter. Interview with DON on 01/10/19 at 2:09 p.m. revealed she was made aware Resident # 235 Foley catheter was not secured. She said the Foley catheter was supposed to be secured as part of the protocol. Review of the facility policy on Foley catheter care revised (MONTH) 2014 revealed the purpose is to prevent catheter-associated urinary tract infections. General guidelines include: 1) Following aseptic insertion of the urinary catheter, maintain closed drainage system . 2) Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site(Note: catheter tubing should be strapped to the resident's inner thigh.)

Based on interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene for a resident who is unable to carry out activities of daily living for three (Residents #132, #133, and #2) of 14 residents reviewed for ADL care. The facility failed to provide Residents #132, #133, and #2, with scheduled showers. This failure could place residents at risk of not receiving needed services and care. Findings included: 1. Review of Resident #132's Face Sheet dated 01/10/19 revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Review of Resident #132's MDS assessment dated [DATE] revealed he had clear speech, was understood and usually understood others. He required physical help limited to transfer only assistance with bathing. Review of Resident #132's Care Plan dated 12/18/18 revealed the problem of ADL functional/rehabilitation potential. The goal was that his needs would be met by staff with his assistance. One of the identified approaches was related to bathing ability and indicated he would receive limited assistance of one staff person. Review of the facility's undated shower scheduled revealed Resident #132 was scheduled to receive showers on Mondays, Wednesdays, and Fridays during the 2:00 PM to 10:00 PM shift. Review of Resident #132's Point of Care ADL Category Report dated 12/17/18 revealed three documented showers on 12/20/18, 12/26/18 (6 days after the previous shower), and 01/03/19 (8 days after the previous shower). Interview with Resident #132 on 01/09/19 at 9:26 AM revealed he was last showered on Friday 01/04/19. He stated he asked an aide the previous day if he could have a shower. She agreed and told him later, but never returned. He stated he was told at first that his shower days were Mondays, Wednesdays, and Fridays, but was later told they were Tuesdays, Thursdays, and Saturdays. So, he did not know exactly when he should receive them. 2. Review of Resident #133's Face Sheet dated 01/10/19 revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Review of Resident #133's MDS assessment dated [DATE] revealed he had clear speech, was understood and understood others. He required physical help limited to transfer only assistance with bathing. Review of Resident #133's Care Plan dated 12/21/18 revealed the problem of ADL functional/rehabilitation potential. The goal was Resident #133 would participate in ADLs with assistance from staff as needed. One of the identified approaches was related to bathing ability and reflected he would receive extensive assistance of one to two staff persons. Review of the facility's undated shower scheduled revealed Resident #133 was scheduled to receive showers Tuesdays, Thursdays, and Saturdays during the 6:00 AM to 2:00 PM shift. Review of Resident #133's Point of Care ADL Category Report dated 12/20/18 revealed three documented showers on 12/26/18 (6 days after admission), 01/03/19 (8 days after the previous shower), and 01/07/19 (4 days after the previous shower). Interview with Resident #133 on 01/08/19 at 1:12 PM revealed he had only received one shower in two weeks and it was done by an occupational therapist. He stated he had no idea when his showers were supposed to be done. Resident #133 stated he preferred not to be named along with his concern. 3. Review of Resident #2's Face Sheet dated 01/10/19 revealed he was an [AGE] year-old male who admitted to the facility originally on 12/13/18 and readmitted on [DATE]. He was diagnosed with [REDACTED]. Review of Resident #2's MDS assessment dated [DATE] revealed he had clear speech, was understood and understood others. During the 7-day look-back period of the assessment, no bathing occurred. His functional ability and goal for showering or bathing himself was that he did it with supervision upon admission and was independently upon discharge. Review of Resident #2's Care Plan dated 12/13/18 revealed the problem of ADL functional/rehabilitation potential. The goal was ADL approaches will meet Resident #2's needs. One of the identified approaches was related to bathing ability and reflected he would receive assistance by one staff person. Review of the facility's undated shower scheduled revealed Resident #2 was scheduled to receive showers on Mondays, Wednesdays, and Fridays during the 2:00 PM to 10:00 PM shift Review of Resident #2's Point of Care ADL Category Report dated 12/18/18 revealed one documented shower on 12/29/18 (9 days after the MDS assessment was completed). Interview with Resident #2 on 01/10/19 at 10:28 AM revealed he only received one shower since he'd been in the facility. He stated he did not know his shower schedule and had not requested a shower from staff. He was observed having greasy hair. 4. Interview with LVN D on 01/09/19 at 1:20 PM revealed residents should be showered as often as they wanted. She stated the charge nurses were responsible for ensuring showers were done as scheduled. She stated she did not know residents were not being showered as scheduled. To ensure scheduled showers were completed, LVN D stated she talked to residents, asked about their showers, and tried to witness the showers if possible. She stated showers were recorded on shower sheets that were located in the binder at the nurses' stations. Interview with CNA C on 01/09/19 at 3:26 PM revealed she normally worked the 2:00 PM to 10:00 PM shift. She stated residents should be showered three times a week. She stated there was no reason why a resident did not receive a shower at least three times per week. She stated some residents were showered and others were not because she ran out of time. She stated showers were recorded on the facility's kiosks in their system. When asked about Resident #132's showers, CNA C stated she was not sure when he was supposed to be showered. She stated she showered him a couple of times but he refused a couple of times. She stated refusals were documented on the shower sheets. Follow up interview with Resident #132 with LVN E on 01/09/19 at 2:10 PM revealed he explained to the nurse that he had last received a shower on Friday (01/04/19) and asked a CNA to shower him yesterday, she agreed but did not come back. LVN E stated to ensure he and other residents received their scheduled showers, she would talk to the CNAs and receive their shower sheets. Review of the shower sheets on 01/10/19 at 11:50 AM revealed no shower sheets for Residents #132, #133, and #2. Review of the shower sheets, electronic documentation, and shower schedules revealed showers were not consistently documented by staff. Interview with the DON on 01/10/19 at 12:00 PM revealed residents should be showered Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday unless they want a shower daily. She stated the charge nurses were responsible for ensuring the showers were given as scheduled. She stated she did not know why Residents #132 and #133. Specifically regarding Resident #2, she stated she specifically had not received any complaint regarding showers from him, and was not aware of other residents not receiving regular showers. Review of the facility's Shower/ Tub Bath policy dated (MONTH) 2010 reflected, The purposes of this procedure (is) to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .the following information should be recorded on the resident's ADL record and/ or in the resident's medical record .notify the supervisor if the resident refuses the shower/ tub bath Report other information in accordance with facility's policy and professional standards of practice.

Based on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and preferences of each resident, an on-going program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident encouraging both independence and interaction in the community for five (Residents #2, #132, #134, #235, and #133) of 15 residents reviewed for activities. The facility failed to provide any planned group activities for Residents #2, #132, #134, #235, and #133. This failure could result in residents becoming displeased or bored with their residence, isolation or withdrawal and having an overall decreased quality of life. Findings included: Interview with Resident #132 on 01/08/19 at 10:37 AM revealed he did not participate in activities; just therapy. He was not aware activities should have been happening. No activity calendar was observed in the resident's room. Interview with Resident #134 on 01/08/19 at 10:25 AM revealed there were no planned activities. She stated when she wants to get out of her room, she just walked around the unit on her walker. She was not aware activities should have been happening. No activity calendar was observed in the resident's room. Interview with Resident #133 on 01/08/19 at 1:04 PM revealed there was a staff person, one day, who came in his room and asked about enhancements to the unit experience. He stated she also asked about having group and individual activities, but they have no group activities. He was not aware activities should have been happening. No activity calendar was observed in the resident's room. Interview with Resident #2 on 01/10/19 at 10:28 AM revealed there were no planned group or individual activities since he admitted to the facility (12/18/18). He stated being able to participate in activities was important so he could be around others. He was not aware activities should have been happening. No activity calendar was observed in the resident's room. Interview with Resident #235 on 01/08/19 at 12:50 PM revealed none had asked him about activities since admission. He stated he enjoys reading and planting flowers, and wished something like that was offered at the facility. He stated his wife brings him books to keep him busy when he is not in rehab. Interview with CNA C on 01/09/19 at 3:26 PM revealed as a group, she had seen residents doing puzzles and on Sundays, they gathered together to watch football games, but she had not seen daily activities being done with residents. She stated there were no posted activity calendars in the residents' rooms. Interview with CNA F on 01/09/19 at 12:59 PM revealed there were no planned group activities. She stated she saw residents gather with their family for holidays or birthday, but mostly the residents were in their rooms or therapy. Interview with LVN E on 01/09/19 at 3:09 PM revealed the facility planned activities for the holidays. She stated she recalled they polished nails a while ago, but the activities were not consistent or daily. LVN E stated when the residents were bored, staff told them about the puzzles or books they could access. Review of the undated Recreational Pursuits for Our Guests (activity schedule) revealed activities were scheduled according to days of the week and times, and place where the activity would take place on a re-occurring basis; not monthly calendar dates. The place was either in room or dining room. Observation of the dining room on 01/08/19 at 10:30 AM revealed no activity occurring. According to the activity schedule, art history discussions should have been occurring. Observation of the dining room on 01/09/18 at 11:05 AM revealed no activity occurring. According to the activity schedule, the brain works activity should have been occurring. Observation of the dining room on 01/10/18 at 8:50 AM revealed no activity occurring. According to the activity schedule, the band stretch activity should have been occurring. Observation of the dining room on 01/11/18 at 10:25 AM revealed no activity occurring. According to the activity schedule, the living a DIY life activity should have been occurring. Interview with the Activity Director on 01/09/19 at 11:05 AM revealed she had been the Activity Director since (YEAR). She stated in addition to being the Activity Director, she also performed HR and staffing functions, and was the in charge of central supplies. She stated the activities were planned out, but there was no participation. She stated they had books or the residents could go to the chapel downstairs on Sundays. The Activity Director stated there were no activities going on currently because she was busy doing a lot of things for the state survey. Interview with the DON on 01/10/19 at 12:00 PM revealed the Activity Director was very involved with residents and was trying to do individual activities. She stated, recently, activities had not been happening because of the shortage of positions and she did not have the time. Interview with the Acting ADM on 01/09/18 at 1:58 PM revealed he had not had a chance to look into activities because he was not in the facility the full five days per week because he was in transition moving from another state. He stated the Activity Director did one-on-one activities with residents, but he had not observed any group activities. Review of the facility Activity Programs policy dated (MONTH) 2006 reflected, Activity programs designed to meet the needs of each resident are available on a daily basis .Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs Scheduled activities are posted in the resident's room .

Based on interview and record review, the facility failed to provide notice to residents when changes in coverage were made to items and services covered by Medicare as soon as reasonably possible for 2 of 3 residents reviewed (Resident #1 and #2). 1. Resident #1 was not given a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when she was discharged from skilled services. 2. Resident #2 was not given a SNFABN when he was discharged from skilled services. This deficient practice could deny residents of their right to be fully informed about services covered by Medicare. Findings include: 1. Record review of Resident #1's face sheet, dated 1/10/19, revealed the resident was admitted to the facility on [DATE] and discharged [DATE]. Record review of the SNF (acronyms/define) Beneficiary Protection Notification Review (CMS- ) (put CMS in acronyms/define) form undated, revealed Resident #1 was admitted to Medicare skilled services on 12/10/18 and was discharged from skilled services on 12/28/18, prior to using up his Medicare benefits. 2. Record review of Resident #2's face sheet, dated 1/10/19, revealed the resident was admitted to the facility on [DATE] and discharged [DATE]. Record review of the SNF Beneficiary Protection Notification Review (CMS- ) form completed, undated, revealed Resident #2 was admitted to Medicare skilled services on 09/27/18 and was discharged from skilled services on 10/10/18, prior to using up her Medicare benefits. Interview on 01/10/19 at 1:02 PM with Social Services Assistant revealed she was responsible for the social worker responsibilities while there was not a social worker at the facility. She stated she never issued any SNF Beneficiary Notification forms because she couldn't find them. She stated she started doing them mid-December (YEAR). She stated she did not why Resident #2 was not given any Beneficiary notice because she did not start doing them until after she was discharged . She stated for Resident #1 she thought she did the forms but was unable to locate them. Interview with Regional Nurse Consultant on 1/09/19 at 1:57 PM revealed that the facility did not have a social worker from (MONTH) (YEAR) until (MONTH) 31, (YEAR). She stated the facility did not have the appropriate SNF Beneficiary Protection Notification forms. She stated the new social worker noticed the problem when she started, and they had plans to get the issues fixed. Interview on 01/10/19 at 12:52 PM with Social Worker revealed she just started in her position on 12/31/18. She stated she noted there was an issue with the discharge planning and beneficiary forms when she started. She stated moving forward she planned on providing the NOMNC AND ABN (Please define both or place in acronyms list) form when appropriate. Interview on 01/10/19 at 1:17 PM with Director of Revenue Integrity revealed the company does not have a SNFABN policy; they just follow regulation.