Every finding on record at Renaissance Park Multi Care Center

Based on observations, interviews and record reviews, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 of 3 rooms observed for ants. The facility failed to ensure an effective pest control program was implemented to prevent the presence of ants within the facility. This failure could place residents at risk for skin integrity issues caused by insect bites.Findings included: 1.Record Review of MDS Nursing Home dated 07/13/2026 revealed; Resident #1 is a [AGE] year-old male admitted to the facility on [DATE] with a BIMS score of 15 ( cognitively intact with normal memory and thinking skills) with an active diagnoses of Renal Failure.Record Review of Resident #1's care plan dated 07/07/2026 revealed the following focus areas:*ADL Assistance needed to maintain or attain highest level of function. Interventions assist with mobility and ADLs as needed. *Uses (1/8 bed rail type) to aid in mobility. Interventions; Complete the evaluation for use of Bed Rails, upon admission, and change of condition. Encourage resident to use bed rails to aid in repositioning and/or transfer* The resident has an ADL self-care performance deficit r/t impaired balance. Interventions; Bed Mobility; resident requires substantial/maximal assistance with one assist by staff. * Toilet Use: Resident requires partial/moderate assistance with one assist by staff. * Resident had a break in skin integrity-scar to the elbow. Intervention; Weekly skin checks. Record Review of resident medication administration record dated 07/15/2026 revealed; Resident #1 is scheduled for Triamcinolone Acetonide Ointment 0.1% Apply to skin areas/eczema topically every 8 hours as needed for Eczema.During an interview on 07/15/2026 at 11:10 AM with Resident #1 stated he observed live ants in his restroom and he thought they were coming from the wall. He stated he did not tell the staff because they should know. He stated they bit him on his back while he was lying in bed. During an observation Resident #1's in-room restroom on 07/15/2026 at 11:15 AM revealed 2 live black ants on the floor and baseboard.During an interview on 07/15/2026 at 11:30 AM with Maintenance Director revealed; during a walk-true there was an observation of three live ants in Resident #1's restroom. During a subsequent room search of neighbors restrooms did not reveal additions pest concerns. He stated the pest control treated the exterior perimeter of the building (pipes or walls) related on 07/14/2026. He stated a resolution was to contact pest control to come and treat the inside building on 07/15/2026. During an observation and interview on 07/15/2026 at 12:11 AM with DON revealed Resident #1 would not allow LVN A to perform a skin assessment for insect bites. DON conducted a skin assessment which did not reveal insect bites. Resident #1 received a room change. The risk for the resident was insect bites and skin integrity . During an observation on 07/15/2026 at 12:47 AM on hall 100 revealed; pest control treated Resident #1's room. Record Review of facility policy titled Pest Control revised: 07/09/2025 revealed; Maintain an effective pest control program so that the facility is free of pests and rodents.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for food safety The facility failed to correctly seal a bag of opened cake mix. The facility failed to separate a dented can of food.The facility failed to label and date a package of opened pasta noodles.The facility failed to defrost frozen ground beef under running water. These failures could place residents at risk for food-borne illness and cross contamination.Findings included:Observation of the dry storage room in the kitchen on 04/28/2026 at 9:15 a.m. revealedA dented can of fresh vegetables stored on the rack with other cans.A package of previously opened cake mix in a storage bag exposed to air. A package of opened powdered sugar with only one date 03/17/2026 indicating when it was placed in the storage bag was observed on the shelf. Observation of the hand dish washing area on 04/29/2026 at 10:35 a.m.Revealed a package of frozen meat siting in a pan of water in a sink with no water running over it. Observation of the dry storage area on 04/29/2026 at 10:37 a.m.Revealed a package of opened pasta noodles was observed in a storage bag with only one date 04/17/2026 written on the bag. In an interview and observation with the DM on 04/28/2026 09:15 a.m., he revealed that there was an area for dented cans. He pointed to a cart that contained more than 15 dented cans. He stated the vendor had always brought them dented cans and he recently removed dented cans in the previous days. He stated he sorted them out so that he could get credit for those dented cans. He was unaware of the single dented can left on the supply cart and was confused as how he could have missed that particular can. He stated both he and the dietitian had just gone through the inventory. He stated that someone forgot to add the discard date on the package of cake mix. In an interview with the Corporate Dietitian on 04/29/2026 at 10:35 a.m. she stated that someone must have turned the water off in the sink where the meat was defrosting. She stated that she was unaware of the labels on the pasta and powdered sugar did not list a discard date. She understood that food needed to be defrosted properly and that open packages needed dates indicating when they were opened and when they needed to be discarded. In an interview with the DM on 04/29/2026 at 10:50 a.m., he stated the the water had been running on the frozen meat before he left. He stated he was shocked someone turned the water off and began to ask who turned it off. He understood the requirement that water needed to be running to help maintain a safe temperature to help prevent food borne illness such as botulism.In an interview with the Administrator on 04/30/2026 at 2:45 p.m., she stated she was surprised with the finding in the kitchen. She stated that they have done a great job in the kitchen, food quality had improved and menu items were really good. She stated that they had an excellent health inspection and had no violations. She stated that she would look into the finding with the DM. She expected that there would have been no citations. She stated that she wanted a excellent review in the kitchen. Record Review of the facility policy .Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must legible and accurately labeled, including the date the package was opened.13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded.Review of the facility's policy, Chapter 5: Food Safety and Sanitation Food and Nutrition Services Manual, undated, revealed, Procedure1. Food is stored a minimum of six inches off the floor. 2. Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary (NSF) container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). 'Use by Date' is noted on the label or product when applicable. 3. The 'use by date' guide is easily accessible to all associates involved with resident food storage. 4. Packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water. 5. Food is stored away from all sewer and water lines, drains and condensation drippings from pipes or ceiling. 6. Dented, leaky, rusted and swelling cans that could affect food safety are returned to the vendor but stored in a designated area away from other food. These items will not be used .Thawing - Thawing some foods at room temperature may not be acceptable because it may be within the danger zone for rapid bacterial proliferation. Recommended methods to safely thaw frozen foods include:a. Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross contamination.b. Thawing the item in a microwave oven, then cooking and serving it immediatelyafterward; orc. Thawing as part of a continuous cooking process.

Based on interview and record review the facility failed to ensure the resident's right to formulate an advanced directive for 1 of 3 (Resident #45) residents reviewed for resident rights. The facility failed to ensure Resident #45's code status (a medical directive indicating the type of care a patient wants, specifically regarding CPR or life-sustaining measures if their heart or breathing stops and guides doctors to either provide all available resuscitation or to respect the patient's wish not to be resuscitated) was communicated and correctly indicated in their EHR. This failure could result in residents receiving unwanted treatment or not receiving desired treatment. Findings include: Record review of Resident #45's five day scheduled MDS assessment for a Medicare Part A stay, dated [DATE], reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #45's MDS reflected the resident had hemiplegia (form of paralysis causing total or severe loss of muscle function on one side of the body) following a cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels that supply it causing brain cells to be deprived of oxygen and vital nutrients which can cause parts of the brain to die) affecting the left nondominant side, kidney transplant status (a patient's position and priority on the kidney transplant waitlist), and cancer (any one of a large number of diseases characterized by the development of abnormal cells that divide uncontrollably and have the ability to infiltrate and destroy normal body tissue). The MDS reflected Resident #45 had a BIMS of 15, which indicated the resident was cognitively intact. The MDS indicated that the resident would receive physical and occupational therapy. Record review of Resident #45's admission Record, dated [DATE], reflected no code status. Record review of Resident #45's clinical physician orders, dated [DATE], reflected no code status. Record review of Resident #45's baseline care plan, dated [DATE], reflected no code status. Record review of Resident #45's progress notes, dated [DATE] through [DATE] indicated no code status throughout the notes. Interview on [DATE] at 1:31 PM with LVN A revealed every resident should have a code status in their EHR. LVN A was asked to locate the code status in the EHR. LVN A stated that the code status was not in the EHR where it should be documented. LVN A stated that the code status should reflect if the resident is a full code status or if they have a DNR. LVN revealed the importance of the code status was to alert the nursing staff to perform CPR if the resident stopped breathing or honor the DNR if the resident had a DNR on record. LVN A said that it was the nurse's responsibility who completed admission to ensure there was a code status in the resident's EHR. LVN A stated that any nursing staff could see the resident's missing code status in the EHR and notify administration. LVN A stated she would notify the ADON of the missing code status and ensure it was documented in the EHR. Interview on [DATE] at 2:11 PM with the ADON revealed she had been employed at the facility for about two years. The ADON stated that a resident's code status should be one of the first things entered by the admitting nurse in a resident's EHR because it was one of the most important things in a resident's EHR. The ADON revealed that the code status should be entered upon admission with the resident's orders. The ADON stated it was her and the DON's responsibility to review the admission to ensure the resident's orders, and items such as the code status, were entered correctly. The ADON revealed that if she found that there was no code status in a residents' file, she would make the correction when auditing the chart. The ADON stated that the admission was normally reviewed the following day after the admission was entered into the EHR to ensure all the orders were entered correctly and no items were missed. The ADON stated the code status was usually found on the hospital discharge documentation. The ADON stated that ultimately it was the DON's responsibility to ensure that all residents had a code status in their EHR. The ADON was unsure why the code status was not documented in the EHR. The ADON revealed that if there was no code status in the EHR, there could be a delay in care, and their advance directives' wishes would possibly not be followed. The ADON stated that she and the DON should complete chart audits on an as needed basis and when residents received new orders. Interview on [DATE] at 2:26 PM with the DON revealed he had been the DON at the facility for approximately five months. The DON stated that he expected code status to be input by the admission nurse when inputting a resident's orders. The DON revealed he or the ADON reviewed new residents' EHR the day after admissions to ensure that orders were entered correctly. The DON stated the code status should be entered upon admission to ensure the residents' requests such as a DNR would be honored. The DON stated that all nurses should be reviewing their residents' charts to ensure there is a code status in the EHR. The DON revealed that if the nurses could not find the code status, the nurse should notify the DON and/or the resident's physician as well as speak with the resident to find out their code status to ensure that it was input correctly into their EHR. The DON stated he in-serviced his nursing staff about code status, but he could not recall when it was and did not provide the documentation. Record review of the facility's policy titled, Advanced Directives and Advance Care Planning, reviewed [DATE], reflected, ProcedureResidents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the right to accept or refuse medical care, the right to accept or refuse medical/surgical treatment, organ donation requests, and the formation of advance directives upon admission.16.residents receive full resuscitative measures unless a DNR is written in the resident's medical record and is identified in the resident's advance directive.d. Social Services and/or a member of Nursing Administration reviews the DNR status with the resident and /or family and the receiving physician within 72 hours of admission.

Based on interviews, observation, and record review, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 (Resident #42) of 4 residents reviewed for resident rights. The facility failed to ensure staff did not stand while feeding Resident #42 on 04/28/26. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Review of Resident #42's face sheet, dated 04/30/2026, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that included: dementia, COPD (chronic obstructive pulmonary disease, a progressive lung disease that makes it difficult to breathe), and anxiety.Review of Resident #42's quarterly MDS assessment, dated 02/18/20263, revealed she had a BIMs score of 4 which indicated severe cognitive impairment.Observation on 04/28/2026 at 12:20 p.m. of the 2nd floor dining room revealed there were 3 staff members observed assisting or feeding residents. Resident #42 was observed sitting in a manual wheelchair while being assisted in dining by a staff member. The staff member was observed standing while feeding the resident. He stood while feeding the resident between four to five minutes until another staff member noticed and instructed him to sit while feeding the resident. The staff member gave him her seat and got another seat for herself.Interview on 04/28/2026 at 12:40 p.m. with RN B revealed he normally could get the resident to feed herself by feeding Resident #42 one to two spoonfuls of food, but that day she would not feed herself at all. He stated that the aides typically assist in feeding the residents but he knew he should have been seated while assisting residents with their meals. He stated it may make them feel awkward or even make them upset. Interview on 04/28/2026 at 1:30 p.m. with RA D revealed staff should always be sitting while feeding the residents. She stated that it would help staff keep an eye on the residents, and it would not make them feel like someone was standing over them. She stated she always sat when assisting residents with their meals and even when she assisted in feeding in their rooms. Interview on 04/29/2026 at 2:15 p.m. with LVN B, she stated she didn't always feed the resident during mealtimes, but she had to assist at times. She stated she would always prompt residents to eat and let them know what they were eating. She stated she had to be sitting while she assisted with feeding because no one wanted anyone standing over them while they ate. She stated that could be frustrating and could cause them to lash out. Interview on 04/30/2026 at 3:05 p.m. with the DON, revealed he expected all of his staff to know how to provide proper care for the residents. He stated that he had high expectations for all staff but especially the nurses. He stated that he knew this could affect the dignity of the residents involved.

Based on observation, interview, and record review, the facility failed to keep drugs and biologicals in locked compartments for 1 (Treatment Cart A) of 5 carts reviewed for medication storage. The facility failed to lock Treatment Cart A on downstairs hall while the cart was unattended on 04/28/2026. This failure could affect residents' safety and privacy. Findings included: In an observation on 4/28/2026 at 9:00am, Treatment Cart A was placed near downstair hall nurse station. The treatment cart was unlocked and unattended. There was one nurse sitting at the nurse station and one resident sitting across from the nurse station. Inside the treatment cart was wound care biologicals and a pair of scissors. In an observation on 4/28/2026 at 9:02am, the Administrator walked by Treatment Cart A and locked the cart. In an interview on 4/28/2026 at 9:05am, the administrator stated she thought Treatment Cart Awas empty. When she was informed that the treatment cart had biologicals and wound care materials, the administrator stated her staff must have forgotten to lock the cart. She stated all carts must stay locked at all times while not in use for safety. In an interview on 4/29/2026 at 8:27am, the Wound Nurse stated all carts should be kept locked when they were unattended. She stated all nurses had keys to access Treatment Cart A, and she also had a key to the treatment cart. She stated the cart did not have to be unlocked for nurses to gain access. She was not sure which nurse had the treatment cart yesterday morning. She stated if the carts were unlocked, unauthorized personnel could have access to it, which could affect residents' privacy. She also stated residents could also get ahold of biologicals there, which could affect their safety. In an interview on 4/30/2026 at 10:14am, the ADON stated she expected her staff to always keep medication and treatment carts locked when they were not using them. She stated the risks included unauthorized access, privacy issues, and safety risk. She stated she often walked the halls to make sure carts were locked, and if she saw an unlocked cart, she would lock it and remind all nurses about cart safety. In an interview on 4/30/2026 at 10:34am, the DON stated he expected his staff to be vigilant and to ensure that carts were locked at all times when not in use. He stated unlocked carts could put residents at risk for injuries. He stated the nurses were responsible for keeping carts locked. He also stated he made rounds around the facility to ensure carts stay locked. Record review of facility's Storage and expiration dating of medications and biologicals policy revised on 6/30/2025, revealed the policy stated, the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one Resident (Resident #1) of three residents reviewed for notification of changes.The facility nurses failed to notify Resident #1's physician of Resident #1's refusal of ten scheduled doses of Rifaximin 550 mg oral tablet ordered twice daily for cirrhosis during June 2025 and July 2025. The facility nurses did not notify Resident 1's physician of her refusal of 12 scheduled doses of Lactulose 30 milliliters ordered twice daily for cirrhosis in July 2025.These failures could place residents at risk of not receiving appropriate treatment.Findings include:A review of Resident #1's Face Sheet reflect Resident #1 was a [AGE] year-old female resident admitted to the facility on [DATE].A review of Resident #1's MDS dated [DATE] reflected Resident #1 had a BIMS score of 14 indicating intact cognition. Resident #1 had a diagnosis of nonalcoholic steatohepatitis (fatty liver disease unrelated to alcohol consumption) and metabolic encephalopathy (brain dysfunction due to an underlying condition). Other diagnoses included in part end stage renal disease (permanent kidney failure requiring dialysis of kidney transplant) with dependence on renal dialysis, diabetes mellitus (disease of inadequate control of blood sugar), and heart failure (the heart cannot pump enough blood to meet the needs of the body).A record review of Resident #1's Care Plan Report dated 4-01-25, reflected Resident #1 had been non-compliant with taking her lactulose and goals and interventions were identified. A review of physician orders by Physician F reflected Resident #1 was ordered Rifaximin 550 mg oral twice daily for cirrhosis with start date 5/12/25 and Lactulose (20 Grams per 30 milliliters) 30 milliliters by mouth twice daily for cirrhosis with start date 5/12/25.A review of July 2025 MAR reflected Resident #1 refused her scheduled Lactulose on 7/1/25 (once), 7/2/25 (once), 7/3/25 (once), 7/4/25 (twice), 7/5/25 (twice), 7/6/25 (twice), 7/7/25 (twice) and 7/8/25 (once). The July 2025 MAR reflected Resident #1 refused her scheduled Rifaximin on 7/1/25 (twice), 7/2/25 (once), 7/3/25 (once), 7/4/25 (twice), 7/5/25 (twice), 7/6/25 (once), 7/725 (once). A review of June 2025 MAR reflected Resident #1 refused her scheduled Rifaximin on 6/29/25 (once) and 6/30/25 (once).In an interview on 7/16/25 at 08:35 am, the ADM reported that Resident #1 had refused her Lactulose multiple times in July 2025. She stated that Resident #1 had also declined to have her Rifaximin refilled by the pharmacy and had not received multiple doses, and that the physician had not been notified of these medication refusals. She stated it was the responsibility of the nurses to notify the physician of medication refusals. She stated the risk to the resident of not reporting these medication refusals was that Resident #1's ammonia level could have increased. A record review of Resident #1's progress notes for June 2025 and July 2025 reflected no documentation that the physician or nurse practitioner had been notified that Resident #1 had refused her Rifaximin and Lactulose. In an attempted telephone interview on 7/16/25 at 1:40 pm, the primary physician for Resident #1, Physician F, could not be reached.In an interview on 7/16/25 at 2:21 pm and 5:40 pm, NP A reported that she had not been notified that Resident #1 was refusing her Rifaximin and her Lactulose until 7/08/25. She stated another provider may have been notified. She stated she had noted documentation in the medical record that Resident #1 had received teaching on the risks of refusing her medications and had signed a statement acknowledging these risks. She reported that the facility nurses should have notified her of the medication refusals but that it would not have changed her orders or treatment in the case of Resident #1. She reported that she could not relate any symptoms experienced by Resident #1 to the refusal of these medications as Resident #1 had multiple comorbidities which could all cause similar symptoms. She reported that the possible risk of not reporting medication refusal to a provider was that the resident could have gone without needed treatment.In an interview on 7/16/25 at 2:07 pm, MA B reported there had only been one day that he had worked with Resident #1 that he did not give Resident #1 her Rifaximin because it was not available. He stated he notified an agency nurse on duty but was unsure of the nurse's name. He reported that the risk of not notifying the nurse of an unavailable medication would be that the patient could miss their medication or be harmed.In an interview on 7/16/25 at 02:22 pm, LVN C stated she had provided care for Resident #1 in June and July of 2025, but she was not notified by the medication aides and was not aware that Resident #1 was refusing her Lactulose. She reported that she would have notified the nurse practitioner of this refusal if she had known. She reported that the risk to Resident #1 was that it could have caused a change in her condition.In a telephone interview on 7/16/25 at 4:09 pm, RN D reported that on 7/05/25 and 7/06/25 the medication aide had informed him that Resident #1 was refusing her Lactulose. He stated that he then provided Resident #1 with education and the medication himself. He reported that if Resident #1 had continued to refuse the medication, he would have notified the physician. He denied knowledge of other days that Resident #1 had missed her medications. However, a review of the facility Corrective Action Form for RN D dated 7/11/25 reflected he failed to notify the physician of Resident #1's missed medications from 7-01-25 to 7-06-25.In an interview on 7/16/25 at 11:45 am, RN E reported she was the Assistant Director of Nurses and was covering for the DON who was on leave under the Family and Medical Leave Act (FMLA). She stated that Resident #1 had missed doses of medications but that the physician and administration had not been notified of the missed doses. She reported that the policy was for nurses to notify the physician of missed doses. She stated the risk of the not reporting missed doses was that Resident #1 could have had elevated ammonia levels.Facility policy titled, Administration of Medications with revision date 9/16/24 reflected, Medication refusals should be documented on the MAR with the reason for the refusal and the follow up from the licensed professional.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 4 residents reviewed for care plans. The facility failed to assess and care plan for Resident #1' s primary diagnosis of sickle call pain crisis. This placed residents at risk for not receiving proper care and services due to inaccurate care plans. Findings included: Record review of Resident #1 ' s face sheet dated 06/11/2025 reflected a [AGE] year-old woman admitted to the facility on [DATE] with primary diagnosis of Sickle-Cell/HB-C Disease (genetic blood disorder of abnormal hemoglobin, resulting in blockage of blood vessels and reduced oxygen delivery in the blood. Outcomes include anemia-low hemoglobin, pain-blockage of blood flow, and risk of infection) with Crisis (characterized by painful episode caused by blockage of blood flow), with admitting diagnoses of alcoholic cirrhosis of liver without ascites (scarring of liver due to alcohol, without abnormal fluid buildup), idiopathic aseptic necrosis of bone, multiple sites (loss of blood supply to bone resulting in dying bones), fracture of right pubis (pubic bone, part of pelvis), sacrum (bone that forms base of spine, connecting the pelvis), left hip joint, and left femur (thigh bone), muscle weakness (generalize), abnormalities of gait and mobility (abnormal pattern of walking due to underlying medical condition or injury), lack of coordination, anemia, cerebral infarction (stroke), and end stage renal disease (chronic kidney failure, loss of kidney function). Record review of Resident #1 's MDS dated [DATE] reflected a BIMS score of 15, indicating cognitively intact. The resident ' s primary medical condition was indicated as Medically Complex Conditions, ICD Code: D57.219 (SICKLE-CELL/HB-C DISEASE WITH CRISIS, UNSPECIFIED). Record review of Resident #1's paper chart binder dated 05/21/25 reflected: Admitting Diagnosis: Sickle Cell Pain Crisis. Record review of Resident #1's baseline care plan initiated 05/22/25, reflected no focus, no interventions, and no goals for dx of sickle cell disease with crisis. Record review of Resident #1's order summary report dated 06/11/2025 reflected: Physician has reviewed and agrees with the plan of care (see signature); order date: 05/22/2025. Pt may be sent out to ER for higher level of care; order date: 05/30/2025. Record review of Resident #1's hospital history records (2/17/2025; 2/25/2025) reflected: Hemoglobin levels- 02/11/2025 - 7.8 g/dL 02/13/2025 - 8.2 g/dL 02/14/2025 - 8.7 g/dL 02/15/2025 - 8.4 g/dL 02/16/2025 - 8.7 g/dL 02/17/2025 - 8.1 g/dL 2/20/2025 - 7.8 g/dL 2/21/2025 - 7.8 g/dL 2/22/2025 - 7.4 g/dL 02/23/2025 - 7.0 g/dL 2/24/2025 - 7.1 g/dL 2/25/2025 - 6.6 g/dL History of multiple blood transfusions Record review of Resident #1 ' s hospital history records 05/14/2025) reflected: 05/14/2025- 7.3 g/dL (reference range 12.0-16.0 g/dL) Flag: L (low). An interview on 06/02/2025 with Resident #1 ' s family member revealed that on 05/30/2025, she had to call EMS and have Resident #1 transported to the ER because the resident was experiencing heart palpitations. Upon arrival to the ER, Resident #1 ' s hemoglobin level was 4.9 g/dL; the resident was admitted to the hospital ' s cardiac intensive care unit (specialized unit of hospital for various cardiac conditions that requires continuous monitoring and treatment). The family member stated that the resident was no longer in the cardiac intensive care unit, but the resident was still in the hospital and did not have a discharge date . An interview on 06/12/2025 with Resident #1 ' s family member revealed that the resident had not been discharged from the hospital since being admitted on [DATE]. Interview with LVN C on 06/11/2025 at 2:44PM revealed she provided care to Resident #1 prior to being discharged to the hospital. She stated that on 05/30/2025, Resident #1 ' s family called the paramedics, and she did not initially know why. LVN C was aware of Resident #1 ' s dx of sickle cell disease. She stated that when the paramedics arrived and asked what was going on, the family said the resident was having heart palpitations. LVN C discussed the physician recently changed Resident #1 ' s anxiety medications from PRN to a scheduled regimen because the resident ' s heart rate was high. She further stated the physician said the resident ' s tachycardia (heart rate over 100 beats per minute) was due to her anxiety. There was no change of condition prior to family calling EMS. LVN C was not aware of any orders for monitoring Resident #1 ' s hemoglobin levels or blood labs being ran once a week. LVN C was unable to provide examples of signs and symptoms in those with sickle cell disease. LVN C stated tiredness, fatigue, shortness of breath, pale skin, and tachycardia were the symptoms of someone with low hemoglobin. Interview with the ADON on 6/11/2025 at 3:10PM revealed Resident #1 was sent to the ER on [DATE] due to pain from sickle cell crisis. The ADON explained prior to the resident being sent out, she talked with the resident and there were no complaints of pain. A few hours later the resident said she was in a sickle cell crisis. The ADON stated orders were put into the resident ' s charts as the physician told the staff; labs were done with dialysis but that the resident should have had a lab upon admission to facility. The surveyor asked the ADON to describe signs and symptoms of someone with low hemoglobin level of 4.9 g/dL and she stated weakness, the resident wouldn ' t be very alert, cold, pale, in pain, low blood pressure, increased heart rate, shock, and blood count low. The ADON stated the importance of monitoring blood labs in someone with sickle cell disease was the hemoglobin can be low and need to make sure that blood cell count is where it should be. She stated she would have contacted the doctor to get orders if these symptoms were present. The ADON stated the importance of care plans was for staff to know how to take care of residents. An interview on 06/11/2025 at 3:59PM with the Regional Compliance Nurse revealed she was asked why Resident #1 ' s sickle cell disease was not care planned. She stated it depends on what their care is, and the disease process; she would recommend someone's most serious condition be in their care plan. The Regional Compliance Nurse was asked how Resident #1 ' s labs would be checked for low hemoglobin, and she stated they would need to talk with the physician to get the order because nurses cannot order labs. The Regional Compliance Nurse stated dialysis had Resident #1 ' s labs and dialysis would send the resident ' s labs to the facility. She further explained all residents had paper charts, and dialysis labs were kept in those charts. She stated the charge nurses are responsible to look at labs and physicians will look at the labs, she assumed dialysis staff looked at labs. The surveyor asked how staff know if labs are abnormal, and she stated the staff would just have to look at the dialysis labs. The Regional Compliance Nurse stated signs and symptoms of low hemoglobin include a bleeding episode, lethargy, and increased confusion. She stated it was important that there was lab work for the facility to monitor for low hemoglobin and to see if the resident needed a transfusion and to notify the physician if the hemoglobin was low. Record review of Resident #1 ' s paper chart binder dated 05/21/25 did not reflect dialysis lab work. An interview 06/11/2025 at 4:27PM with the ADM revealed that every nurse should show about sickle cell disease and the symptoms associated. She stated that the facility did not provide training specifically regarding sickle cell disease, but the facility had resources for nurses, and they could reach out to the physician if needed. The ADM stated the staff did not reach out about sickle cell disease. She further explained the risk of staff not using resources or the physician can result in a sickle cell episode. Record review of the facility ' s Resident Assessment Instrument and Care Plan Development policy and procedure, reviewed 09/05/2024, reflected: The information identified using the MDS and Care Area Assessment process is used to develop an individualized person-centered Care Plan that includes the patient ' s voice, the patient ' s goals while residing in the facility and for discharge that assist the patient to attain and/or maintain their highest practicable level of well-being.

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #4) of 4 residents reviewed for quality of care. The facility failed to provide treatment to Resident #4 ' s burns on both her thighs according to physician orders. This failure placed residents of risk for not receiving appropriate care and treatment and a decreased quality of life. Findings included: Record review of Resident#4 ' s face sheet, dated 06/18/2025, reflected a [AGE] year-old woman admitted on [DATE] with primary diagnoses of burns involving 10-19% of body surface with 10-19% third degree burns, burn of third-degree right hand, right thigh, left thigh, and right lower leg; other diagnoses include generalized anxiety disorder, major depressive disorder, pain in unspecified hip. Record review of Resident #4 ' s care plan dated (no date) reflected the Focus/Problem of: The resident has actual impairment to skin integrity. burn bilateral (left and right) thighs right arm surgical wound to left and right thigh; date initiated 05/16/2025. One of nine interventions included treatment as ordered. With the goal of The resident will have no complications related to skin through the review date (06/11/2025). Record review of Resident #4 ' s MDS dated [DATE] reflected a BIMS score of 13, indicating cognitively intact. Record review of Resident #4 ' s outpatient surgical specialist for wound care dated 05/21/2025 reflected: Instructions: Please bathe her and wash her bilateral lower extremities with soap and water gently washing with hands daily. Her bilateral (left and right) lower extremity wounds should be moisturized twice a day with quality lotion. Record review of Resident #4 ' s orders dated 06/11/2025 reflected: Aquaphor Advanced Therapy External Ointment (Emollient) Apply to BILATERAL (left and right) THIGHS topically two times a day for PREVENTION; order date 05/22/2025. Record review of Resident #4 ' s TAR dated 06/11/2025 reflected: Aquaphor Advanced Therapy External Ointment: Administered by LVN E Time: 06/09/25 08:44; Location: Thigh - front (left) Administered by LVN E Time: 06/09/25 08:44; Location: Thigh - front (right) Administered LVN I Time: 06/09/25 23:36[11:36 PM]; Location: Thigh - front (left) Administered by LVN I Time: 06/09/25 23:36[11:36 PM]; Location: Thigh - front (right) Administered by LVN H Time: 06/10/25 10:43; Location: Leg - both Administered by RN G Time: 06/10/25 20:07 [8:07 PM]; Location: Leg - both Administered by RN F Time: 06/11/25 10:52; Location: Leg - both. An observation and interview with Resident #4 on 06/11/2025 at 11:10AM revealed the resident had not been receiving Aquaphor treatment on her thighs for burns. The resident stated staff had not been applying Aquaphor treatment twice a day for 2 weeks. The resident showed the surveyor her burns. The burns covered both thighs, the skin had various spots including redness, fresh pink scarring, and brown peeling/flaky skin. The skin did not have a greasy or glossy coat and did not appear moisturized. She stated she takes itching medication because the burns on her legs were dry and itchy. The resident stated she saw a specialist doctor every other week for her burns. An interview on 06/11/2025 at 1:59PM with RN F revealed she was asked if she could show the surveyor Resident #4 ' s Aquaphor in the medication cart. RN F had been excused from the interview and returned at 2:09PM with a tube of Aquaphor. RN F stated that she left the Aquaphor in the resident ' s room in a bedside table drawer. The RN further discussed that the resident wants the Aquaphor that was in a tub (container with a lid that twists on and off) and not in the (squeeze) tube like the facility had and that she explained to the resident that it's the same product. RN F stated that she went to apply it that morning, but someone distracted her, and she left it there due to providing care to another resident in another room. The RN stated someone else applied the Aquaphor. When asked specifically who applied it, she proceeded to call a staff member to confirm. She then stated the ADON applied it, and she had asked the ADON to apply it. The surveyor asked RN F where the Aquaphor was to be applied and how often and she stated on the resident ' s legs for dryness, twice a day. RN F stated it was important to know residents ' orders and make sure they receive treatment, so staff know if treatment was working or to follow up with the doctor if it was not working. The surveyor asked RN F to describe what can happen to untreated burned skin and she stated the skin can crack and become infected; the body would be prone to infection. An interview with Resident #4 on 06/11/2025 at 2:57PM revealed the resident had received Aquaphor treatment after the surveyor was in her room. The resident explained someone in gray scrubs applied the Aquaphor, but she did not know who it was. She further stated the staff member did not wash her skin before applying Aquaphor treatment; they applied it all over her legs, not specifically to her thighs. She said the staff came into her room while she was sleeping, and she heard staff at the bedside table. She was unsure if staff put the tube of Aquaphor into the bedside table drawer or if they got the Aquaphor from the drawer. The surveyor asked Resident #4 if she cares if the Aquaphor was in a tube or a tub and she stated No, it doesn ' t make a difference to me. Observation and interview with the ADON on 06/11/2025 at 3:10PM revealed the ADON stated she applied Aquaphor to Resident #4 around noon on 06/11/2025 because RN F asked her to. She stated that she had not applied it previously and that it was for her burns on her legs, so they didn ' t dry out. The surveyor asked the procedure for applying the Aquaphor, and the ADON stated to put on gloves and apply to the top of the legs bilaterally; she asked the resident and the resident showed her where to apply; then she applied. The ADON was asked if she washed the area before treating, and she stated the order did not say to wash her legs first. The surveyor asked the ADON who puts orders in residents ' charts, and she stated orders go straight to the nurses, where they review orders and put them into the chart. The ADON stated it was important to apply Aquaphor as ordered to prevent drying of the skin and reopening of wound, and for healing. An interview on 06/11/2025 at 3:59PM with the Regional Compliance Nurse revealed she was aware of Resident #4 ' s burns on her legs and stated they were scared and healed. The surveyor asked who told her they were healed, and she stated she was not sure but was told the resident had healed and dried skin but had not seen the resident. The Regional Compliance Nurse was asked what the expectation was for applying the Aquaphor treatment and she stated the nurses should follow the order. The Regional Compliance Nurse stated when residents had a doctor ' s appointment outside of the facility, the nurse who received the resident back from the appointment, the DON, or ADON were responsible to review the doctor ' s notes to determine what new orders the resident had; and if orders are not transcribed like prescribed, residents will not receive treatment like prescribed. Interview with the ADM on 06/11/2025 at 4:27PM revealed the ADON and DON were expected to monitor and transcribe orders correctly in resident ' s charts. She further explained it was important to make sure when that the facility ' s orders match outside provider ' s orders so that they do not miss anything for treatment for the resident. The ADM stated that the purpose of an order was so the resident can be cared for based on their condition. Record review of the facility's Documentation of New or Changed Physician/Prescriber Orders policy, revised 07/01/24 did not address following physician orders.

Based on observations, interviews, and record review the facility failed to assess the risks and benefits of bed rails and grab bars with the resident or resident representative or obtain informed consent prior to installation for two (Resident #2 and Resident #3) of four resident rooms observed and reviewed for bed rails/enabler bars. 1.The facility failed to have evidence of informed consent, a physician's order, a side rail assessment, and a care plan of the resident's risk of entrapment for bed rails or grab bars for Resident #2. 2.The facility failed to have evidence of informed consent, a side rail assessment, and a care plan of the resident's risk of entrapment for bed rails or grab bars for Resident #3. These failures could place residents who used bed rails/grab bars at risk of the resident not being assessed for bed rails or grab bars, resident/responsible party not being aware of the risks, and informed consent not being obtained from the resident or responsible party which could place the resident at risk of harm. Findings included: Resident #2 Record review of Resident #2 face sheet, dated 06/11/25, revealed a 61-year male who was admitted to the facility on [DATE]. His primary diagnosis was dysphagia following cerebral infarction (difficulty swallowing after having a stroke). His secondary diagnoses included uncontrolled blood sugars, heart failure, blood clot in left upper leg, and muscle weakness. Record review of Resident #2's admission MDS dated [DATE], did not reflect Resident #2's BIMS score, and it did not indicate ADLs needs. Record review of Resident #2's PIR dated 06/5/25 reflected a BIMS of 10 indicating moderate cognitive impairment. Observation and interview with Resident #2's in his room on 06/11/2025 at 11:57 a.m., revealed Resident #2 was out of bed in his high back wheelchair with family at his side. The grab/mobility bar on both the left and right side of the bed were raised. Resident #2 said that when he first admitted to the facility, he had no grab bars, but after he fell, he and his family asked for them for repositioning and mobility when getting out of bed . Resident #1 said he had been asking for bed rails and he was told that they were considered a restraint and informed of the risks, but after he fell, they put them on his bed which he was happy about it. Record review of Resident #2's physician's active order for June 2025 reflected there was no orders for use of bed rails/ grab bars. Record review of Resident #2's Care Plan initiated on 06/06/25 reflected a focus area of an actual fall with minor injury to the left eyebrow area related to poor balance. The goal was the resident would resume usual activities without further incident through the review date. The interventions were floor mats as tolerated, high back wheelchair when up in bed, and PT consult for strength and mobility. The care plan did not reflect use of bedrails or grab bars for mobility. Record review of Resident #2's completed assessments from 06/04/25 to 06/11/25 reflected a fall risk evaluation completed on 06/04/25. The completed assessments did not reflect a completed assessment of side rails use. Review of Resident #2's medical record revealed no signed bed rail/grab bar consent form signed by the resident or resident's responsible party or noted to have verbal permission for the bed rails/grab bars. Record review of the Incident and Accident Tracking logs for 04/01/25 through 06/11/25, revealed Resident #2 had a fall on 06/04/25. Resident #3 Record review of Resident #3's face sheet dated 06/11/25 revealed a [AGE] year-old female with an admission of 03/01/25. Her primary diagnosis was pressure ulcer of left buttock. Her secondary diagnoses included urinary tract infection, muscle weakness, lack of coordination, back pain, and mild cognitive impairment. Record review of Resident #3's comprehensive MDS assessment, dated 05/21/25, revealed a BIMS of 00 indicating Resident #3 had severe cognitive impairment. Further review of MDS reflected Resident #3 required substantial/maximal assistance rolling left to right in the bed. The MDS reflected Resident #3 did not use bed rail. Observation of Resident #3's room and bed on 06/11/25 at 11:25 a.m., revealed a grab/mobility bar on the left side and right side of the bed were raised . Resident #3 was not in the room. Record review of Resident #3's physician's active order for June 2025 reflected use of ¼ side rails at head to enable independent bed mobility. Order start date 03/01/25. Record review of Resident #3's Care Plan, last updated on 06/11/25, reflected focus areas Combative Behavior during Incontinent Care and at Risk for Injury. Resident #3 exhibits combative behavior during incontinent care resulting in increased risk of injury hitting head on side rails. The goal was for Resident #3 remained free from further injury during care. The interventions included proved (padded) low bed with blosters (thick pillows) or floor mat and ensuring 2 people assist during incontinent care. The care plan did not reflect bedrails or grab bars for mobility. Record review of Resident #3's completed assessments from 03/01/25 to 06/11/25, did not reflect a completed assessment of side rail use. Review of Resident #3's medical record revealed no signed bed rail/grab bar consent form signed by the resident or resident's responsible party or noted to have verbal permission for the bed rails/grab bars. In an interview on 06/11/25 at 1:35 p.m., LVN C said Resident #2 was able to use a bed rail for bed mobility and transfers. LVN C said she expected the side rail assessment to accurately reflect the use of the side rail. LVN C said she did not know the risk to Resident #2 because he could use of a side rail since his he had the ability to use it safely for mobility. She said she had not worked with Resident #3, and she was not familiar with her mobility. During an interview on 06/11/25 at 3:09 p.m., the ADON revealed Resident #2 fell out of his wheelchair because he was unable to hold his upper trunk of his body when he seats rail. She said one of Resident #2's interventions were a high back wheelchair. The ADON said Resident #3 was on hospice and it was likely that her bed came with side rails from hospice. The ADON said she believed that bed rail assessments were completed for both residents. The ADON said the side rail assessment should be completed with the care plan. The ADON said nursing was responsible for obtaining bed rail orders, consents, and updating the assessment to accurately reflect the use of a side rail as an enabler. The ADON said Resident #2 and Resident #3 could be injured without an accurate assessment of the use of side rail. ADON said nurse managers were responsible for ensuring the side rail assessment, orders, and care plans were completed and completed accurately. The ADON said it was considered a restraint if they did not have the required assessments, care plans, consents , and orders in place. During an interview on 06/11/25 at 4:26 p.m., the Administrator said she expected the side rail assessment to be updated with changes in condition, as a part of the care planning process. The Administrator said nursing was responsible for getting physician's orders and completing the side rail assessment. She said the DON and ADON were responsible for monitoring that orders, care plans, and assessments were completed. The Administrator said her facility did not have consents for bedrails because it was not in their policy. She said the risk to the residents was that the residents could hurt themselves when turning. Review of facility policy titled: Bed Rails-Safe and Effective Use of Bed Rails revision date 11/16/2021, reflected Bed rails should only be used when identified need outweighs the potential risk. 1. Residents will be assessed upon admission, readmission or upon initiation utilizing use of Bed rails. 3 the facility should use Med-Pass Consent for use of Bed Rails. 5. A person- centered care plan will be developed within 48 hours of admissions to address the bed rail (s), if indicated 7 a physician's order and signed restraint physical assessment is required

Based on observation, interview, and record review, the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 2 (Resident #1 and #4) of 7 for accuracy of records. The facility failed to accurately transcribe orders for the admitting diagnoses for Resident #1 and #4. The failure can affect residents by putting them at risk for physical pain, decline in current health condition(s), and negative psychosocial impact. Resident #1 Record review of Resident #1 ' s face sheet dated 06/11/2025 reflected a [AGE] year-old woman admitted to the facility on [DATE] with primary diagnosis of Sickle-Cell/HB-C Disease (genetic blood disorder of abnormal hemoglobin, resulting in blockage of blood vessels and reduced oxygen delivery in the blood. Outcomes include anemia-low hemoglobin, pain-blockage of blood flow, and risk of infection) with Crisis (characterized by painful episode caused by blockage of blood flow), with admitting diagnoses of alcoholic cirrhosis of liver without ascites (scarring of liver due to alcohol, without abnormal fluid buildup), idiopathic aseptic necrosis of bone, multiple sites (loss of blood supply to bone resulting in dying bones), fracture of right pubis (pubic bone, part of pelvis), sacrum (bone that forms base of spine, connecting the pelvis), left hip joint, and left femur (thigh bone), muscle weakness (generalize), abnormalities of gait and mobility (abnormal pattern of walking due to underlying medical condition or injury), lack of coordination, anemia, cerebral infarction (stroke), and end stage renal disease (chronic kidney failure, loss of kidney function). Record review of Resident #1 ' s MDS dated [DATE] reflected a BIMS score of 15, indicating cognitively intact. Record review of Resident #1 ' s paper chart binder dated 05/21/25 reflected: Admitting Diagnosis: Sickle Cell Pain Crisis. Record review of Resident #1 ' s order summary report dated 06/11/2025 reflected: Physician has reviewed and agrees with the plan of care (see signature); order date: 05/22/2025 OXYcontin RF 60mg give 2 tabs to =120mg every 8 hours for sickle cell disease; order date: 5/28/2025 Record review of Resident #1 ' s physician orders for May 2025, reflected no physician orders for monitoring Resident #1 ' s hemoglobin levels or lab work. Record review of Resident #1 ' s baseline care plan initiated 05/22/25, reflected no focus, no interventions, and no goals for dx of sickle cell disease with crisis. Interview with LVN C on 06/11/2025 at 2:44PM revealed she provided care to Resident #1. LVN C was not aware of any orders for monitoring Resident #1 ' s hemoglobin levels or blood labs being ran once a week for the resident ' s sickle cell disease condition. LVN C was asked to describe signs and symptoms of someone with a low hemoglobin level of 4.9 g/dL, she stated tiredness, fatigue, shortness of breath, pale skin, tachycardia (fast heart rate) Interview with the ADON on 6/11/2025 at 3:10PM revealed orders were put into the residents ' charts as the physician told the staff; and labs were done with dialysis but that the resident should have labs upon admission to facility. The ADON was asked to describe signs and symptoms of someone with a low hemoglobin level. She stated weakness, the resident wouldn ' t be very alert, cold, pale, in pain, low blood pressure, increased heart rate, shock, and the blood count low. The ADON stated the importance of monitoring blood labs in someone with sickle cell disease was the hemoglobin could be low and need to make sure that blood cell count is where it should be. She stated she would have contacted the doctor to get orders if those symptoms were present. Interview with the ADM on 06/11/2025 at 4:27 PM revealed the ADON and DON were expected to monitor and transcribe orders correctly in resident ' s charts. The ADM discussed that it was important that a resident ' s orders were transcribed correctly to care plan for their admitting diagnosis and to get the right order to the doctor. She further explained the purpose of an order is so a resident can be cared for. Resident #4 Record review of Resident #4 ' s face sheet, dated 06/18/2025, reflected a [AGE] year-old woman admitted on [DATE] with primary diagnoses of burns involving 10-19% of body surface with 10-19% third degree burns, burn of third-degree right hand, right thigh, left thigh, and right lower leg; other diagnoses include generalized anxiety disorder, major depressive disorder, pain in unspecified hip. Record review of Resident #4 ' s care plan dated (no date) reflected the Focus/Problem of: The resident has actual impairment to skin integrity. burn bilateral (left and right) thighs right arm surgical wound to left and right thigh; date initiated 05/16/2025. One of nine interventions included treatment as ordered. With the goal of The resident will have no complications related to skin through the review date (06/11/2025). Record review of Resident #4 ' s MDS dated [DATE] reflected a BIMS score of 13, indicating cognitively intact. Record review of Resident #4 ' s outpatient surgical specialist for wound care dated 05/21/2025 reflected: Instructions: Please bathe her and wash her bilateral lower extremities with soap and water gently washing with hands daily. Her bilateral lower extremity wounds should be moisturized twice a day with quality lotion. Record review of Resident #4 ' s orders dated 06/11/2025 reflected: Aquaphor Advanced Therapy External Ointment (Emollient) Apply to BILATERAL THIGHS topically two times a day for PREVENTION; order date 05/22/2025 The orders did not mention the instructions to bathe and wash Resident #1 ' s bilateral lower extremities with soap and water prior to applying the Aquaphor. Interview with Resident #4 on 06/11/2025 at 2:57PM revealed the resident had received Aquaphor treatment after the surveyor was in her room. The resident explained someone in gray scrubs applied the Aquaphor, but she did not know who it was. She further stated the staff member did not wash her skin before applying Aquaphor treatment; they applied it all over her legs, not specifically to her thighs. She said the staff came into her room while she was sleeping, and she heard staff at the bedside table. She was unsure if staff put the tube of Aquaphor into the drawer if they got it from the drawer. An interview with the ADON on 06/11/2025 at 3:10PM revealed the ADON stated she applied Aquaphor to Resident #4 around noon on 06/11/2025 because RN F asked her to. She stated that she had not applied it previously and that it was for Resident #4 ' s burns on her legs, so they didn ' t dry out. The surveyor asked the procedure for applying the Aquaphor, and the ADON stated to put on gloves and apply to the top of the legs bilaterally; she asked the resident, and the resident showed her where to apply; then she applied. The ADON was asked if she washed the area before treating, and she stated the order did not say to wash her legs first. The surveyor asked the ADON who puts orders in residents ' charts, and she stated orders go straight to the nurses, where they review orders and put them into the chart. The ADON stated it was important to apply Aquaphor as ordered to prevent drying of the skin and reopening of wound, and for healing. An interview on 06/11/2025 at 3:59PM with the Regional Compliance Nurse revealed she was aware of Resident #4 ' s burns on her legs and stated they were scared and healed. The surveyor asked who told her they were healed, and she stated she was not sure but was told the resident had healed and dried skin but had not seen the resident. The Regional Compliance Nurse was asked what the expectation was for applying the Aquaphor treatment, and she stated the nurses should follow the order. The Regional Compliance Nurse stated when resident had a doctor ' s appointment outside of the facility, the nurse who received the resident back from the appointment, the DON, or ADON were responsible to review the doctor ' s notes to determine what new orders the resident had; and if orders were not transcribed like prescribed, residents would not receive treatment like prescribed. An interview with the ADM on 06/11/2025 at 4:27PM revealed the ADON and DON were expected to monitor and transcribe orders correctly in residents ' charts. She further explained it was important to make sure the facility ' s orders match outside provider ' s orders so that they do not miss anything for treatment for the resident. Record review of the facility ' s Documentation of New or Changed Physician/Prescriber Orders policy, revised 07/01/24 reflected: 6. Authorized facility staff should enter new electronic medication orders in the electronic medication ordering system as soon as they are received . 6.3 Once the drug is chosen, staff should carry on with the order process by completing the directions, administration schedule, reason for use, and any other information required to complete the order.

Based on interview and record review the facility failed to allow the resident's Next-of-Kin to obtain a copy of the records upon request and upon two working days advance notice to the facility for one (Resident #1) of four residents whose records were reviewed in that: -The facility failed to provide Resident #1's next of kin copies of medical records after a request was submitted to the facility on [DATE]. This failure could place residents' responsible parties at risk of violation of their rights by not receiving copies of resident medical records. The findings were: Closed Record Review of Admission Record dated [DATE] reflected Resident #1 was a [AGE] year-old male, initially admitted to the facility on [DATE]. Resident #1 was listed as his own Responsible Party. Resident #1's Next-of-Kin was listed as his Emergency Contact #2. Closed Record Review of Resident #1's progress note, dated [DATE] at 5:29 PM, reflected Resident #1 had been found unresponsive and with no detectable pulse. The note reflects LVN A called for assistance and performed CPR on Resident #1 until EMS arrived and took over, until Resident #1 was pronounced dead at 5:55 PM on [DATE]. An interview on [DATE] at 8:56 AM with Resident #1's Next-of-Kin revealed the medical records had still not been received at the time of the interview . Resident #1's Next-of-Kin stated they had attempted to get the person who had been Resident #1's Medical and Durable Power of Attorney to request the records, but was informed the [NAME] of Attorney became null and void the moment the resident passed away, so Resident #1's next of kin had requested the records. After over two months Resident #1's Next-of-Kin had still not received the records. Resident #1's Next-of-Kin stated a phone conversation (time and date unknown) had taken place between them, and the DMR , and it had been pushed to the company's legal department, and they were the ones standing still on it. An interview on [DATE] at 12:43 PM with the DMR revealed she had been working in medical records for [AGE] years, and had never had a problem with the legal department approving the records and sending them to the requestor. She said as soon as she received a request, she passed it to the legal department, and they told her if she could release them from the facility, or they would do it from the corporate office. She said if they were to be released at the facility level, she had 72 hours to send them, but she normally got them done faster. She said she had to make sure the legal documents were in place, and she remembered that Resident #1's next of kin said the resident had no estate, and sent documents to show kinship. She said Resident #1's Power of Attorney requested the records, but they could not release them because the resident had passed away, so the Power of Attorney documents were no longer in play. She said she did not think the legal department took very long to send records normally, because she did all of the leg work to prepare the records in the facility. The DMR said she did not like to make anyone wait, and she had assumed legal had taken care of sending the records. She said it was a right for people to receive medical records for themselves, for someone they had Power of Attorney over if that resident was still alive, or for the Next-of-Kin. She said they could not send some of the things Resident #1's Next-of-Kin was asking for, like the staff records, but all of Resident #1's medical records should have been available. She said they had 30 days to get the records to the requestor. An interview on [DATE] at 1:57 PM with the DMR and Administrator revealed they had learned that the attorney who was handling the request for Resident #1's clinical records was no longer working for the company, and the current attorney had not been made aware of any pending requests, so the request had not been fulfilled. The Administrator said it had been addressed at the time of this interview, and the records would be sent out within a day or so. The DMR said she had been doing her job for a long time, and had never had a problem like this with their corporate, but now knew she needed to keep checking on the records, until she knew they had been sent. Review of documentation provided by Resident #1's Next-of-Kin reflected the following: - Resident #1's death certificate, certified [DATE], showing the date of death to be [DATE]. - Resident #1's Next-of-Kin's driver's license, and birth certificate. - An email, dated [DATE], from the Admissions Director to Resident #1's Next-of-Kin, providing the Next-of-Kin with the Authorization for Release of Medical Information form, in response to an emailed request from Resident #1's medical records from his Next-of-Kin. - An email, dated [DATE], from Resident #1's Next-of-Kin to the Admissions Director and the DMR (Director of Medical Records) with the Authorization for Release of Medical Information form attached. - A letter, dated [DATE], from Resident #1's Next-of-Kin requesting records related to Resident #1. - An Authorization for Release of Medical Information signed by resident #1's Next-of-Kin on [DATE] for the request of Resident #1's entire medical record, and additional information including incident reports, emergency response records related to [DATE], policies and procedures related to emergency response, and staffing records for [DATE] through [DATE]. - An email dated [DATE] from Resident #1's Next-of-Kin to the Admissions Director and the DMR requesting a time frame for the records to be delivered. - An email dated [DATE] from the DMR to Resident #1's next-of kin requesting a document showing the executor of Resident #1's estate. - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR replying to explain the resident did not have to go through probate, and being Next-of-Kin had been appropriate when requesting other medical records. - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR inquiring about the status of the medical records request. The email reflected the initial request was made on [DATE], and the last correspondence received was on [DATE]. The email refers to the birth certificate attached to prove status as Next-of-Kin, and expresses frustration over the facility's lack of communication and failure to follow HIPAA regulation requiring the provision of records within 30 days. The letter states a request for a formal response with a definitive timeline on receiving the records, and delivery of the records by the close of business on [DATE]. The letter stated failure to comply would be reported to US DHHS, TX HHSC, and the Attorney General's Office (enforcer of state consumer protection laws.) - An email, dated [DATE], from the DMR to Resident #1's Next-of-Kin requesting a copy of who was the executor of Resident #1's estate. - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR which reflected there was no executor to Resident #1's estate, and the Next-of-Kin had a right to the medical records. - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR requesting an update on the release of records. - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR again requesting an update on the release of records, and a reminder of non-compliance with regulations. - An email, dated [DATE], from the DMR to Resident #1's Next-of-Kin apologizing for the length of time, and stating there should be information from the legal department on that day ([DATE].) - A final email, dated [DATE], from Resident #1's Next-of-Kin to the DMR requesting corporate contact information, and stating that unless the records were received by close of business on [DATE] complaints would be filed. Review of the facility policy, dated [DATE], for Disclosure of Protected Health Information (PHI)- Release of Information reflected Policy: ( .) Each resident has the right to access his or her protected health information contained in the medical record. The resident is assured confidential treatment of his or her medical records and may approve or refuse their release to any individual outside the facility, except in the case of his or her transfer to another health care institution, or as required by law or third-party contract. If there is a state-specific law with more stringent requirements, the facility must comply with the state statute(s). ( .) Procedure: 2. When a request is made by a current resident or another party to view or copy the medical record, those requests should be directed to the Health Information Management Director/Privacy Official. ( .) Handling a Request for Copies of Medical Records: All requests for copies should be handled by the HIMD to ensure uniform application of the facility policy and adherence to applicable laws and practice to standards. The request for copies should be put in writing on an Authorization for Release of Information form and signed by the resident or personal representative. The request should specifically state which records are to be copied. In accordance with 42 CFR S483.10(b)(2), a request may be made orally by the resident/ legal representative. ( .) Note: The maximum turnaround time to respond to a valid request for a discharged or expired resident's information is 30 days from the date of request unless otherwise required by state law. ( .) In general, the resident is incompetent or cannot authorize the disclosure, the following individuals may serve as the resident's personal representative (in order of priority). a. Legal guardian or attorney b. Agent named in a directive, durable power of attorney for health care, other durable power of attorney c. Next of kin (in the following order): a. Spouse from a marriage recognized by law b. Adult son or daughter c. Father or mother d. Adult brother and sister.

Based on interview and record review, the facility failed to ensure that a resident received care, consistent with professional stands of practice, to prevent pressure ulcers for 1 of 4 residents (Resident #95) reviewed for quality of care. 1. The facility failed to implement interventions to prevent Resident #95 from developing a stage 3 pressure injury to the sacral area. The facility did not assess Resident 95's skin to determine if she had pressure ulcers due to resdient refusal and did not identify a Stage III pressure ulcer to her sacrum which was identified when she was transferred to the hospital and was infected. Resident #95 was diagnosed with sepsis at the hospital. 2. The facility failed to accurately assess the skin of Resident #95. RN A did an incomplete skin assessment and documented Resident #95's skin was intact with no skin issues. 3. The facility failed to document Resident #95's refusal of skin assessments. An Immediate Jeopardy (IJ) situation was identified on [DATE] The IJ template was provided to the facility on [DATE] at 12:14 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopordy and a scope of Pattern due to the need for monitoring of corrective measures and the effectiveness of its corrective plan. These failures could place residents at risk of inaccurately assessing resident's condition, preventing pressure injuries, a decreased quality of life, hospitalization , and death. Findings included: Review of Resident #95's admission record, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of colon (cancer of large intestine), systemic lupus erythematosus (autoimmune disease), Parkinson's disease (a movement disorder of the nervous system) and neuralgia (nerve pain) and neuritis (nerve inflammation). Review of Resident #95's admission MDS, dated [DATE], revealed occasional urinary incontinence. Review of Resident #95's quarterly MDS dated , [DATE], revealed a BIMS score of 15, indicating intact cognition. Further review of the MDS revealed Resident #95 was at risk of developing pressure ulcers/injuries, had pressure reducing device for bed and turning/repositioning program and did not have pressure ulcers/injuries. The MDS section GG functional abilities revealed Resident #95 was independent with eating, toileting, transferring and required supervision with showering/bathing self. Review of Resident #95's care plan, dated [DATE] revealed Resident #95 was at risk for unavoidable pressure injury development or decline of skin integrity with a goal to maintain intact skin with no skin breaks. Interventions included: Clean and apply moisture barrier after each incontinent episodes . Educate resident/family/caregivers of causative factors and measures to prevent skin injury . Encourage/Assist with turning and repositioning . Pressure redistribution mattress . Weekly skin checks . Review of Resident #95's weekly skin assessment, dated [DATE], comleted by LVN X, revealed the following: no alteration in skin; skin color was normal, skin temperature was warm, skin moisture was normal, and turgor was fair. Review of Resident #95's weekly skin assessment, dated [DATE], completed by LVN y, revealed the following: no alteration in skin; skin color was normal, skin temperature was warm, skin moisture was normal, and turgor was good. Review of Resident #95's weekly skin assessment, dated [DATE], completed by RN A, revealed the following: no alteration in skin; skin color was normal, skin temperature was warm, skin moisture was normal, and turgor was good. Review of nurse note dated [DATE] at 08:50 AM, written by LVN P (Agency Nurse) revealed, nurse was notified by CNA that resident was needing extensive assistance to transfer to w/c. nurse came into patients room and noticed that she was lethargic. Ask resident if she was in any pain and she stated 'no'. Vitals were taking at this time ,d+[DATE] B/P, p103, t 98.6, r16, O2 93. Family was visiting in facility and wanted [Resident] to be sent out. Explained DON and Doctor would need to be notified and they would decide transfer. While monitoring O2 sat pulse was noted as elevated to 130 bpm. DON and Doctor was notified and the OK to send patient to hospital. [Family members] of resident was notified. They requested resident to be sent to [Hospital Name]. Resident was able to verbally respond to nurse. She was unable to dress herself and two watery stools were notated by staff. EMS was called and resident sent to hospital. Review of Resident #95's Nursing Home to Hospital Transfer From dated [DATE] completed by RN F, revealed reason for transfer: unresponsive. Review of Resident #95's hospital admission history and physical, dated [DATE] revealed mild discomfort in her buttocks. Review of Resident #95's hospital records dated [DATE] revealed problem list included Sepsis (a serious condition in which the body responds improperly to infection) due to methicillin resistant Staphylococcus aureus (MRSA - bacteria that has become resistant to many antibiotics) with acute renal (kidney) failure and tubular necrosis (damage to tiny tubule cells of the kidneys) without septic shock, lactic acidosis (buildup of lactic acid in bloodstream), diarrhea of presumed infectious origin, pressure injury (a sore that develops under pressure) of sacral region stage 3, and cellulitis (bacterial skin infection) and abscess (a painful, collection of pus) of buttock. Review of Resident #95's hospital Admission History and Physical dated [DATE] revealed in part: The patient is a [AGE] year-old female who presents with diarrhea and acute renal failure with possible buttock cellulitis. She reports experiencing diarrhea but has not had any episodes today. She also reports no associated symptoms of fever or chills. There have been no instances of vomiting. Additionally, she mentions mild discomfort in her buttocks. Negative for fever, chills, or vomiting. Review of Resident #95's hospital CT abdomen and Pelvis WO contrast results, dated [DATE], revealed in part: Addendum #1 Also noted on the exam but not mentioned in the exam report is considerable asymmetric edema (swelling) involving the right labial area without soft tissue gas or drainable abscess. This is an asymmetric finding in the labial region. Very subtle fat-containing direct inguinal hernias (a bulge or lump that occurs in the groin region) also evident previously and currently but not significant. Also history included symptoms of right and left lower abdominal pain .Impression .7. New superficial subcutaneous mass like density in the posterior left inferior buttocks area which could represent fibrotic or active inflammatory sequelae of a left decubitus ulcer. No soft tissue gas or ulceration evident. 8. Diffuse reticular edema throughout the subcutaneous tissues of the posterior buttocks areas and in the presacral pelvic cavity areas could relate to a left inferior buttocks decubitus ulcer but no drainable fluid or abscess noted. Review of Hospital records wound care flow sheet revealed in part: Wound - Date First Assessed:[DATE] Time First Assessed:1515 Primary Wound Type: Other (comment) Properties Group inflamed and tender Side: Right Location Specific: buttocks Drainage amount: scant Drainage Characteristic: blood, bright Odor: Odor Current Dressing: none; open to air Dressing Applied: ABD pad; gauze fluffs (Kerlix Fluffs) Dressing Appearance: clean, dry and intact Wound Base: edematous; moist; pink; red Periwound Area: edematous; redness; moist; swelling Wound Edges: Open . Date First Assessed:[DATE] Time First Assessed:1517 Location Specific: labia Drainage amount: small Drainage Characteristic: purulent; tan; thick Odor: none Current Dressing: ABD pad; gauze fluffs (Kerlix Fluffs) Dressing Applied: ABD pad; gauze fluffs (Kerlix Fluffs) Dressing Appearance: clean, dry and intact Wound Base: edematous; red; ecchymotic; moist Periwound Area: ecchymotic; edematous; redness; swelling; moist Wound Edges: Open . Review of Resident #95's hospital records revealed, Consult notes dated [DATE] [AGE] year-old with staph sepsis now with tachycardia. admitted 3 days ago with abdominal pain and diarrhea. She is found to have cellulitis. Blood cultures positive for MRSA. She has had a sinus tachycardia since admission. She was being taken for debridement this afternoon and noted to have a heart rate of 200. Telemetry suggestive of SVT. No EKG performed. Surgery has been postponed. Heart rate improved. No chest pain or shortness of breath. Review of Resident #95's hospital discharge summary dated [DATE] revealed in part: Discharge diagnosis: Bacterial pneumonia, unspecified Acute hypoxemic respiratory failure secondary to PNA and volume overload Septic shock secondary to PNA Perineal wound, POA SSTI secondary to MRSA, POA MRSA bacteremia secondary to perineal wound, SSTI, POA Acute exacerbation of diastolic CHF AKI Acute lactic acidosis . Briefly, this is a 79 y.o. year old female who presented with on [DATE] with a perineal wound. Blood cultures were positive for MRSA. She underwent I&D on [DATE] and [DATE]. Additionally, she underwent robotic colostomy placement on [DATE]. On [DATE], she was noted to be more hypoxemic requiring escalation to HFNC. CXR demonstrated worsening bilateral pleural effusions. TPCCC was consulted for acute hypoxemic respiratory failure. Her antibiotics were escalated but her hypoxemia continue to worsen. She was eventually placed on BPAP and transferred to the ICU because of hypotension. Vasopressors were initiated. She remained DNR and her clinical deterioration was discussed with the[family members] at bedside. They elected to transition to comfort care. Condition at the time of discharge: deceased . A phone interview on [DATE] PM at 12:26 PM with CNA D revealed Resident #95 did pretty much everything for herself and staff just brought her meals. CNA D stated Resident #95 would sometimes go to the dining room and walk or take herself in her w/c and was very independent. She said when Resident #95 was in the bathroom she would offer her help and Resident #95 would say no. CNA D stated she did not see Resident #95's skin because the resident would not allow it. An interview on [DATE] at 12:51 PM, RN F stated he only worked weekends downstairs on the rehab hall. RN F stated he admitted Resident #95 before she went upstairs for long term care. RN F stated on [DATE], the DON had asked him to go upstairs because the restorative aide had gone to do restorative with Resident #95, and she was lethargic and had a change of condition. RN F stated when he got upstairs, LVN P had called the doctor. RN F stated he did not see Resident #95 and helped with the transfer paperwork then went back to work downstairs. An attempted phone interview with LVN P (agency nurse) was unsuccessful on [DATE] at 12:58 PM. An interview on [DATE] at 1:01 PM, the DON stated facility nurses did their own wound treatments and went through training with herself or another nurse, and she had done in services on wound care, infection control and wound stages. The DON stated the risk to residents if wound care was not done was infection, they could become septic, and it would be harmful to the resident. She stated nurses were supposed to assess skin weekly and they were trained through Lippincott's which taught them wound care. The DON stated she also trains the nurses and would bring in the nurse during an assessment and explain what they were supposed to do, and when to notify the wound care doctor. She said nurses reported to her any skin changes because it was a change in condition, an incident report would be completed, and she would contact the wound Doctor and he then took over from there. The DON stated the CNA's were to report skin changes to their nurse. The DON stated she hired a wound care treatment nurse today because they had wounds and she felt like they could keep an eye on the skin, and the skin assessments would be consistent with one person doing them. She said everybody is going to document different and it would be consistent with a would care nurse. The DON stated Resident #95 was alert and oriented x 4 and did everything for herself. She said Resident #95 would shower herself and staff did set up and got towels. She said Resident #95 was modest and because of her culture would not staff look at her skin. The DON stated Resident #95's refusals were documented and should be in the EHR. She said the day the agency nurse worked the day Resident #95 was sent out did a paper progress note because she could not get logged into the EHR. The DON stated she was not at the facility when Resident #95 was sent out but LVN P had called her and she had called RN F to go help with the transfer. The DON stated LVN P described Resident #95 as lethargic and was not herself according to the CNA. The DON stated she asked for Resident #95's vitals and told LVN P to contact the Doctor. The DON said there was no change in Resident #95's condition the day before ([DATE]) and she had come down to the Christmas Party and got her gifts. The DON stated Resident #95 was not acting different and did not make any complaints. An interview and record review on [DATE] at 2:12 PM with RN A revealed the weekly skin assessment dated [DATE] indicating skin intact with no issues was not based on an actual assessment but what Resident #95 would report to her. The ADON stated she saw Resident #95 every day. On [DATE] Resident #95 was getting off the toilet, and normally did not need help. The ADON stated she talked with Resident #95 about the pain in her feet and when Resident #95 stood up she pulled up her pants and did not have anything on her skin or redness to her left. The ADON demonstrated where she could see Resident #95 skin and stated Resident #95 only had her lower back exposed. The ADON stated she did not wipe Resident #95 because she did not need the help. The ADON stated she could not see Resident #95's buttocks or peri area because Resident #95 was ready to pull her pants up, and she would not have even seen that. Interview on [DATE] at 2:37 PM, Resident #95's family member stated they were not aware Resident #95 refused skin assessments and stated facility staff did not inform them of refusals. An interview on [DATE] at 1:03 PM with CNA G revealed she was a restorative aide, and the other CNAs and the nurses would sometimes ask her to help them out. CNA G remembered it was morning, because she was going to get Resident #95 to go work out in the gym, where she normally went to do her exercises, and that was when CNA I asked her to help with the resident. She said CNA I told her that Resident #95 was weak, had had loose bowels, and she needed help with her. CNA G said they did not normally need to help Resident #95, and she knew as soon as CNA I asked for help with her, something was wrong. She said she was surprised when she saw her and knew something was not right with her. CNA G said on Saturday ([DATE]), Resident #95 was sitting in her chair, slouching, when normally she was sitting upright in her chair, and reading, or praising God. The resident told CNA G she didn't feel good. CNA G told her she was there to help clean her up. Resident #95 agreed to let her help. She immediately went and told LVN P (an agency nurse) to come right now because the resident had a big change in condition. She said that LVN P went to Resident #95 and took her vitals. Resident #95 normally did her own care, but she looked bad and she was weak and had BM on her. Soiling herself was something Resident #95 never did. CNA G said she had never seen Resident #95 naked, because normally she just got her set up for her shower and she stood outside the door while she showered herself. She said Resident #95 would shower, dress, and come out, then CNA G would go and clean up the shower. CNA G said when Resident #95 came to the facility initially, she was weak, but therapy got her better and she was self-caring after that. CNA G said she thought CNA I asked her to help on a Saturday, but on the Friday before ([DATE]) she was up, and moving around, but she did mention to her that she thought she might have a flu or something, because she was not feeling well, and she thought someone tested her for the flu. CNA G said before that Friday ([DATE]) Resident #95 was fine, and was in activities, singing along, and she had only complained on that Friday. CNA G said she saw Resident #95 playing bingo earlier that week, and she was functioning as she normally did, and carrying on her daily routine. She said the resident went from that, to on Saturday ([DATE]) too weak to care for herself. CNA G said she and the other CNA put Resident #95 on the bed to clean her up, because she was so heavily soiled. She said they tried to assist her to stand, but she could not even do that, so they laid her down, and cleaned her the best they could. She said the skin looked intact, nothing that would be a red flag to alarm them, like redness or excoriation. She said that Resident #95 was more comfortable with her than she was with most people, but nobody was getting up in there. because Resident #95 was so modest she would never allow them to spread her legs, to get to everything. CNA G said because the resident would not allow them access to her entire body she could not be 100% sure Resident #95 was 100% clean. CNA G stated Resident #95 would not let anyone clean her peri area. She said LVN P got orders to send Resident #95 to the hospital, and everyone expected her to come back. She said when the staff learned she passed away, they were shocked, and it brought everyone down. She said everyone loved Resident #95, and she missed her. CNA G said normally if someone would not let you do care, or wouldn't let you do it right, you would tell the nurse, and the nurse would document it in the notes. She said she was sometimes present when the DON did skin assessments, and she was able to describe what she herself looked for when doing care, and what the nurses did for a skin assessment, and that they documented in detail about the skin, and contacted the physician. She said when she assisted nurses, she held up legs, and all of the other body parts, any skin folds, genitalia, breasts, so the nurse could see into all of their cracks and crevices. She said if they did not report a skin concern to the nurse, something the size of a pea could turn into a big problem, and a wound could lead to a serious infection if it was not treated and could kill someone. Review of facility policy Nursing Documentation Issued: [DATE], Reviewed: [DATE], reflected 1The medical record must contain an accurate representation of the actual experience of the resident-and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions. Review of the [NAME] Procedures adopted as facility policy for Documentation: Long-Term Care retrieved on [DATE] at 9:59 AM from https://procedures.lww.com/lnp/view.do?pld=4139796&disciplineld=7169 , reflected Introduction: ( .) Accurate, detailed documentation shows the extent and quality of the care that nurses provide, the outcomes of that care, and the treatment and education that the resident still needs. It also decreases the risk of miscommunication and errors and promotes continuity of care. Documentation helps demonstrate that a nurse has applied nursing knowledge, skills, and judgment according to professional nursing standards. ( .) These records must also be complete, accurate, readily accessible, and systematically organized and must provide documentation of the resident's assessments and the care plan and services provided. ( .) Implementation: ( .) Document only the care actually provided. Don't document care, treatments, or medications that you intend to administer. ( .) Special Considerations: Never tamper with documentation or any part of the clinical record. Tampering includes ( .) inserting inaccurate information in the record ( .) Review of the policy Refusal Care or Treatment, Issued: [DATE]; Reviewed: [DATE], reflected: Policy: It is the policy of the facility to allow the resident to be informed and made aware of the risks, benefits and procedures to be used in providing treatment as well as alternatives, any, and to give Informed consent or refuse treatment. This includes the initiation of treatment and the continued application of treatment. ( .) Procedure: ( .) 4. If a resident refuses medication or treatment, the facility will notify the resident and/or the resident representative of the risks versus benefits of the refusal. a. The facility should explore the reasons for the refusal and possible alternatives with the resident and/or resident representative. ( .) 6. If the resident refuses other care activities such as bathing, the facility should speak with the resident and/or resident representative to determine if the preference or tolerance for this care activity has changed. The interdisciplinary team should work with the resident and or resident representative to develop alternative options to provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. 7. Documentation of the refusal and ( .) notifications should be present in the resident's medical record. Review of the facility policy Skin Integrity & Pressure Ulcer/Injury Prevention and Management, Effective Date: [DATE]; Revised: [DATE], reflected: Policy: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards ( .) Procedure: ( .) 2. Per regulation a standardized risk assessment tool should be completed upon admission/readmission, weekly for 4 weeks, quarterly, and as needed based upon each resident's specific needs. The standardized risk assessment tool being used is the Braden Scale ( .). The score and additional risk factors are documented on the tool. 3. A skin assessment/inspection should be performed weekly by a licensed nurse. a. Skin observations also occur throughout points of care provided by CNAs during ADL care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the Nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed. Review of the [NAME] Procedures adopted as facility policy for Skin Assessment: Long-Term Care retrieved on [DATE] at 10:05 AM from https://procedures.lww.com/lnp/view.do?pld=4138690&disciplineld=7169, reflected Critical Notes! (Facility Corporation Name) has approved the following information as an addendum to the Lippincott procedure. Please reference the Skin Integrity & Pressure Ulcer/Injury Prevention and Management policy and include the following information: - Skin inspections are performed frequently by CNAs during ADL care. Any changes or concerns are reported to nursing. -Showers may be optimal time for coordinated skin inspections. Introduction: Skin inspections offers [sic] insight into a resident's physical condition. Visual inspection of the resident's skin provides objective data; information gathered during the interview process directly from the resident or a family member in their own words, including thoughts and observations on the resident's health, provides subjective data. Physical assessment focuses on inspection and palpation. During inspection, the exposed area should be observed for color, moisture, texture, and the presence of lesions. ( .) Implementation: ( .) Assist the resident with putting on a resident gown to gain access to the resident's skin and to facilitate assessment. ( .) Inspecting and palpating the skin: - Expose the resident's skin adequately to facilitate assessment. ( .) Documentation: Document your assessment findings, including the risk assessment score and identified risk factors as well as findings communicated to other health care providers. Document teaching provided to the resident and family (if applicable), their understanding of that teaching, and any need for follow-up teaching. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:14 PM due to the above failures. The facility Administrator, DON and Regional RN were notified. The Administrator was provided the IJ template on [DATE] at 12:14 pm and a plan of removal was requested. An interview on [DATE] at 12:14 PM with the Administrator, Regional RN, and DON revealed they had been expecting an IJ to be called, and where near completion on their Plan of Removal (POR.) The DON stated that they could ask a resident if they had skin issues, and that Resident #95 was fully alert and oriented, and able to say if she was having any pain. The DON likened asking an alert and oriented resident if they had any pain to a physician asking an alert and oriented patient if they were having any issues with their skin at an appointment. The Administrator stated she could give documentation from [DATE] that the resident had a wound, but it was not a DTI or a pressure ulcer. The Regional RN stated she also reviewed the documents from [DATE], and the diagnoses contraindicated each other, and she saw the photo from before Resident #95 died . The DON stated that if Resident #95 was having pain, she would have alerted someone. She said she understood the nurse should have done the full assessment, and did not do it, but Resident #95 did not want her to, and they could not, if she did not want them to. The following plan of removal submitted by the facility was accepted on [DATE] at 2:56 PM. Plan of Remediation: [Facility Name] Re: Pressure Ulcers Failures: o The facility failed to identify and implement interventions for a pressure ulcer, that was identified in the hospital after she had been transferred to the hospital Corrective Action for Those Found to Have Been Affected by the Deficient Practice: o Identified resident no longer resides in the facility o Education will be completed regarding conducting thorough skin assessments, Braden assessments, updating care plans, documenting of refusal of resident care, and implementing resident specific interventions related to pressure ulcers. This education will be provided to all licensed nursing staff by the Director of Nurses or Regional Nurse Consultant. This training will be completed prior to staff working and by [DATE]. Identification of Other Residents Having the Potential to be Affected: o On [DATE] Infection Prevention Nurse, Director of Nurses, Staff nurse and Regional Nurse conducted a skin sweep on all residents in the facility o No negative outcomes identified o All residents that reside in the facility will have a completed skin data collection tool, Braden and updated care plan by the Infection Nurse, Director of Nurse, Staff nurse or Regional Nurse this will be completed by [DATE] Measures/Systemic Changes to Ensure the Deficient Practice does Not Recur: o The DON and IP nurse and Regional Nurse began immediate in servicing on [DATE] of current licensed nursing staff on the following and will be completed on [DATE] or prior to the staff working shifts: o Completion of a thorough skin assessment upon admission within 24 hours by charge nurse weekly o Completion of Braden assessment upon admission and then weekly X4 weeks and then monthly. o Completion of care plan upon admission and updated on any significant change o Completion of implementation of interventions upon identifying any wound areas o How to Document refusal of skin assessments by residents, notifying DON of any skin assessment refusals immediately Current licensed staff will not be allowed to work until completion of education as noted above and completed by [DATE] Ongoing Monitoring: o Director of Nurses, Infection Nurse and Regional Nurse will complete the following until substantial compliance has been achieved and maintained: o Review and documented audits for completion of weekly skin assessments for residents o Review and documented audits for completion of refusal skin sheets o Review and documented audits for completion of Braden assessments audits o Review and documented audits for care plans for residents with pressure ulcers identified o Review and documented audits for interventions for residents with pressure ulcers identified o The facility will continue to provide on-going in-services as noted above to newly hired licensed nursing staff, annually and as needed. o All components of this plan of correction will be submitted to the facility QAPI meeting and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Executive Director, Director of Nurses, IP nurse, Regional Nurse and RVP are responsible for the corrections and continued monitoring. Completion Date: [DATE]. Surveyor Monitoring: Interviews with RN B, RN F, LVN J, LVN L, RN M, LVN T, RN V, LVN W on [DATE] between 12:15 PM and 6:00 PM revealed nurses had been in-serviced on how to perform head-to-toe skin assessments, the Braden Scale (a tool for determining pressure wound risk), who to notify, and what to document, which included description of skin issues, and documenting refusals or partial skin assessments. The nurses were able to talk surveyors through a detailed description of how they would perform a skin assessment. Nurses confirmed that they knew that asking even an alert and oriented, independent resident about their skin did not constitute a skin assessment. All nurses were able to express understanding of the risks of not performing thorough skin assessments. An interview on [DATE] at 4:53 PM with RN A revealed she was in-serviced on [DATE] on skin, wound care, and abuse and neglect. She described the head-to-toe skin assessment in detail, including how to look at areas of the body which were normally not exposed. RN A stated she would look for anything abnormal about the skin, which could include rashes, raised skin, redness, pressure injuries, wounds, darkened areas, and would include inspecting bony prominences and low blood flow areas. She said it would be documented in the EHR, with the size, any signs of infection or odor, location on the body, who was notified, and any new orders. She said they were to notify the physician and DON and would notify the family of any findings and new orders. She said she would then care plan it the skin issue. She said they did skin assessments weekly at this facility, as well as on admission, and with any change. She said the CNAs knew how to use the skin data sheet, and the nurses followed up on any findings they had, as well. RN A said if the resident refused the assessment, that was to be documented, and if they allowed only a partial assessment, they would document which specific parts of the body were assessed, and which were not, then notify the physician of the partial skin assessment. She said the procedure was the same for any resident, regardless of how oriented and independent they were, and any verbal information a resident gave about their skin was subjective data and would not be considered reliable information to replace a skin assessment, and would not be documented as such. RNA said the risk of not doing thorough skin assessments was not finding skin problems in [TRUNCATED]

Based on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure the Dietary Manager wore a beard restraint while in the kitchen on 02/25/2025. This failure could place residents at risk for food contamination. Findings included: Observation and interview on 02/25/25 between 8:53 AM to 9:07 AM in the facility kitchen revealed the Dietary Manager was not wearing a beard restraint. He was observed walking through the kitchen when the Surveyor walked in. He stated he was not required to wear a beard restraint because he was not cooking food and it was required if he was cooking. He stated hair could get in the food if hair restraints were not worn. Interview on 02/27/25 at 12:07 PM, the Administrator stated her expectation was employees follow the company wide uniform policy. She stated if hair restraints (including beard restraints) were not worn, hair could contaminate the food. Record review of the facility's policy, titled Associate Conduct and Dress Code revised 04/30/2024 revealed in part: .Hair Restraints/Jewelry/Nail Polish - Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food . Procedure 1. Associates present a neat and clean appearance at all times. This would include; e. All facial hair including moustaches and beards should be trimmed and covered . 3. The Food and Nutrition Services associates wear a hair covering, which covers all unpinned hair, including all facial hair while on duty .

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 (Resident #23) resident personal refrigerators reviewed for food safety. The facility failed to ensure Resident #23's personal refrigerator was cleaned, and items discarded per facility policy. This failure could place residents at risk of not having an environment that is clean/comfortable. Findings included: Record review of Resident #23's admission record, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Record review of Resident #23's Quarterly MDS assessment revealed a BIMS score of 15 indicating intact cognition. Observation and interview on [DATE] at 10:07 AM in Resident #23's room revealed a personal fridge on top of a nightstand next to the bed. Inside the fridge were protein shakes, small yogurt cups and an ice tray on a shelf. Above the ice tray was a small white box with a temperature control knob. A rounded buildup of ice was attached from the bottom of the white box to the ice tray. Inside the ice appeared to be grapes and a paper towel. Resident #23 stated staff did not clean her fridge. Interview on [DATE] at 6:05 PM, CNA O stated CNA's were responsible to check resident's personal fridges and the temperatures. Interview on [DATE] at 12:07 PM, the Administrator stated housekeeping cleaned all resident personal fridges. She stated if they had to defrost the fridge, the CNA's would remove the food and put the food in the nutrition room. She said if the CNA's saw food that was expired, they should take the food out and let housekeeping know to go in and clean. The Administrator stated if the resident's fridges were not cleaned out it the risk could be infection control and the residents could get sick. Record review of facility policy titled, Resident Refrigerators revised [DATE] revealed in part: Procedure 1. Residents who choose to maintain refrigerators in their rooms will be provided with a copy of this policy and procedure upon admission and agree to the terms and conditions . 5. Facility staff will check individual food items for expiration dates and discard outdated food promptly from the residents' personal refrigerator. a. Food will be labeled and dated to monitor for food safety . d. Food items in unmarked or unlabeled containers should be labeled with contents, and the date the food item was stored. e. Any food suspected to be contaminated or with visible signs of contamination should be discarded immediately .

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 (Resident #143) of 2 residents reviewed for enteral nutrition. RN R failed to check g-tube placement before administering medication. RN R pushed medication and water with a syringe and plunger instead of using gravity gentle flow (this is a method used by attaching a feeding syringe without the plunger to allow water, medications, and food to enter the stomach via G-tube gently without force of pushing) to administer medications and water via G-tube for Resident #143. This deficiency practice would affect residents who receive tube feedings by not receiving the appropriate nutrition and causing G-tube complications. Findings included: Review of Resident #143's face sheet, dated 2/27/2025, revealed that resident was a [AGE] year-old female admitted on [DATE] with diagnoses of Anterior displaced type 2 dens fracture (fracture of the C2 bone of the spine), Type 2 diabetes, Chronic kidney disease, Acute cholecystitis (inflammation of the gallbladder). Review of Resident #143's physician orders, dated 2/25/2025, revealed that Resident #143 has Enteral feed order to verify position of Enteral Access Device by comparing the documented length or numerical marking at the exit site of the device to the previously documented length. Review of Resident #143's Care plan, dated 2/19/2025, showed that the resident was care planned for tube feeding. One of the interventions documented on 2/25/2025 stated feeding tube length 8.4cm from feeding port cover to stoma. Observation on 2/27/2025 at 09:20am, RN R was preparing PRN pain medication (Oxycodone) to administer to Resident #143. After crushing medication, preparing water, RN R performed hand hygiene, put on PPE and went in Resident #143's room. RN R lifted Resident #143's shirt to expose g-tube site which showed dressing labeled 2/26/2025, RN R paused continuous feeding. Without checking for g-tube placement, RN R proceeded to use the syringe plunger to flush the g-tube line with 10mL of water. He then drew the medication mixture from the medication cup using the same syringe and proceeded to push medication mixture directly in the g-tube. He flushed the line with 10mL of water, closed the port and restarted the continuous feeding. He performed hand hygiene before exiting the room. In an interview on 2/27/2025 at 09:30AM, RN R stated that pushing medication directly to the line has been the method he has been using. He does not use gravity method. He did not know which method was the correct method. In an interview on 2/27/2025 at 1:00PM, the DON stated that gravity was the only method to administer medication via g-tube, the nurses should never force the medication in the tube. She stated that the risk of peritonitis can happen if medication is forcefully pushed into the tube. She also stated if the nurses notice medication does not flow down the line while using gravity, they should notify the physician to get the tube changed. She also stated that the nurses have been trained to measure the g-tube length with the measuring tape and they should do it every time they are giving medication. Review of facility's procedure called Medication Administered through an Enteral tube, revised on 11/15/2024, revealed that the staff administering medication should confirm feeding tube placement per facility policy. The procedure guide also stated the procedure is done by inserting medication syringe into the appropriate port and pour each medication through the syringe, . Allow the drug to flow by gravity. If the medication does not flow easily, reposition resident and milk the enteral tube or give gentle boosts with the plunger. Do not forcibly push medications through the tube.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 9 (Resident #143 and Resident #115) residents reviewed for infection control. RN R failed to perform hand hygiene and use clean gloves while providing wound care on Resident #143. Facility staff failed to ensure visitors for Resident #115 followed facility infection control policy during COVID19 outbreak. These deficient practices could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings included: Review of Resident #143's face sheet, dated 2/27/2025, revealed that resident was a [AGE] year-old female admitted on [DATE] with diagnoses of Anterior displaced type 2 dens fracture (fracture of the C2 bone of the spine), Type 2 diabetes, Chronic kidney disease, Acute cholecystitis (inflammation of the gallbladder). Review of Resident #143's physician orders, dated 2/16/2025, revealed that resident has right heel DTI (Deep tissue injury), the order stated to paint with betadine and apply dressing in the morning. Observation on 2/27/2025 at 9:00 am revealed, RN R, ADON, and MA S provided wound care to Resident #143. All staff performed hand hygiene before entering room, put on PPE. ADON and MA S assisted in holding Resident #143's right leg up to expose her right heel. RN R removed old dressing, which was labeled 2/26/2025, proceeded to open 2 packs of betadine sticks to paint on wound. RN R then applied border gauze dressing to wound and labeled 2/27/2025. RN R did not change gloves after old dressing was removed and did not perform hand hygiene after touching soiled dressing. He only performed hand hygiene before leaving Resident #143's room. In an interview on 2/27/2025 at 9:30am, RN R stated he only used one pair of gloves while providing wound care. He stated he did not know why he forgot to change gloves. He stated the risk of not changing gloves and performing hand hygiene was transmission of infections. In an interview on 2/27/2025 at 9:35am, ADON agreed RN R should have removed soiled gloves, perform hand hygiene and put on a new pair of gloves. She stated the risk of not doing that was infection. She stated the DON provided in-services monthly for infection control & hand hygiene. Observation on 02/25/2025 at 12:09 PM outside Resident #115's room revealed a visitor wearing an N95 mask entered the room, came back out of the room to fill a water pitcher from down the hall, and returned to the room. Visitor did not use hand sanitizer before entering or when leaving the room and did not put on PPE before going into Resident #115's room. Signage posted on the door read Droplet Precautions Everyone must: clean their hands, including before entering and when leaving the room . and Contact Precautions Everyone must: clean their hands including before entering and when leaving the room . Record review of undated list provided by the facility on 02/25/2025 revealed 9 of 10 residents on Transmission Based Precautions were positive for COVID19. In an interview on 02/26/2025 at approximately 6:30 PM, the ADON stated when a resident was on Transmission Based Precautions for COVID, gowns, masks, eye protections and gloves were required for staff. She stated they encourage family members to wear gowns and gloves and dress out, but unfortunately could not catch them all. In an interview on 2/27/2025 at 1:00pm, the DON stated that RN R did not follow infection control procedure by not changing gloves and washing hands after he touched the soiled dressing. She stated since the facility does not have a treatment nurse, nurses do their own wound care. She stated the nurses go through trainings provided by the DON, including those that are related to wound care and infection control. She stated residents who were positive for COVID19 required droplet and contact isolation which was posted on the resident's door and family members or visitors could see. The DON stated she expected for visitors to wear masks and encouraged them to wear gowns, but it was their choice. She said Resident #115's visitor/family should not have gotten ice, and she should have asked someone. She stated the risk of not practicing infection control are infection, sepsis, harm to residents. Review of facility's Hand hygiene procedure, last revised on 7/15/2022, showed that Associates perform hand hygiene (even if gloves are used) in the following situations: a. Before and after contact with the resident b. After contact with blood, body fluids, or visible contaminated surfaces c. After contacts with objects and surfaces in the resident's environment d. After removing personal protective equipment, .

48520 Based on interviews and record review the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of seven residents reviewed for medication errors. The facility failed to ensure Resident #1 got his own medications instead of receiving Resident #2's medications, which included a narcotic medication, on [DATE] by MA D. This failure could place residents at risk of medical complications, and reactions to increased dosages of medications or unfamiliar medications, including potentially death. The noncompliance was identified as PNC. The IJ began on [DATE], and ended on [DATE], as the facility had corrected the non-compliance by in-servicing all Medication Aides prior to the visit. Findings included: Review of Resident #1's face sheet, dated [DATE], reflected he was a [AGE] year-old male, most recently admitted to the facility on [DATE]. He had diagnoses of repeated falls, anxiety disorder, chronic kidney disease, diabetes, and heart disease. Review of Resident #1's admission MDS, dated [DATE], reflected he was usually able to understand others, and was understood by others. He had a BIMS score of 15, indicating intact cognition. He had no behaviors or indicators of psychosis during the assessment period but had a depression indicator score of 13 out of 27, indicating moderate depression. He used a walker and a wheelchair. He required only set-up help for eating, and substantial to maximal assistance (helper does more than half the effort) for toileting, dressing, and hygiene. He required partial to moderate assistance (helper does less than half the effort) for getting in and out of bed, moving himself in bed, and transfers. He did not receive PRN or scheduled pain medication in the past five days and reported no pain in that period. Review of Resident #2's face sheet, dated [DATE], reflected he was a [AGE] year-old male, admitted on [DATE]. He had diagnoses of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute respiratory failure, type 2 diabetes with chronic foot ulcer, urinary catheter, unspecified psychosis, paraplegia (paralysis of the lower body), hemiplegia and hemiparesis following cerebral infarction (one-sided weakness following a stroke), multiple sclerosis (an autoimmune disorder which attacks nerve cells), chronic kidney disease, neuropathy (nerve pain), heart disease, emphysema (this is a lung diseases that causes air sacs destruction), and chronic obstructive pulmonary disorder (both conditions which make breathing difficult). Review of Resident #2's quarterly MDS, dated [DATE], reflected he was able to be understood by others, and usually understood others. He had a BIMS score of 11, indicating moderate cognitive impairment. He had no indicators of psychosis, or behaviors, during the assessment period, and a depression indicator score of 16 out of 27, indicating moderately severe depression. He had range-of-motion impairment in his upper and lower extremities and used a wheelchair for locomotion. He was dependent on staff for most ADLs and movement in bed. He did not transfer, stand, or walk during the assessment period. He received scheduled and PRN pain medications in the past five days, and had frequent pain, which frequently affected his sleep and interfered with his day-to-day activities. He rated his worst pain in that period as a nine on a one-to-ten scale. Review of Resident #2's MAR for [DATE] reflected the following medications/dosages were administered to him on the morning of [DATE]. - Sertraline HCl Tablet 100 MG Give 2 tablet by mouth one time a day for depression - Ascorbic Acid Tablet 1000 MG Give 1000 mg by mouth one time a day for Supplement - Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for prophylaxis - Bumetanide Tablet 1 MG Give 1 tablet by mouth in the morning for fluid retention - Calcium Oral Tablet 500 MG (Calcium) Give 1 tablet by mouth one time a day for supplement - Cholecalciferol Oral Capsule 125 MCG (5000 UT) (Cholecalciferol) Give 1 capsule by mouth one time a day for supplement - Depakote Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day related to unspecified psychosis not due to a substance or known physiological condition - Famotidine Tablet 20 MG Give 1 tablet by mouth one time a day for acid indigestion - Flecainide Acetate Tablet 50 MG Give 1 tablet by mouth two times a day for irregular heartbeat - Gabapentin Tablet 600 MG Give 1 tablet by mouth three times a day for Neuropathy - HydrALAZINE HCl Tablet 25 MG Give 3 tablet by mouth three times a day for hypertension - Magnesium Oxide Tablet 400 MG Give 1 tablet by mouth one time a day for supplement - Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day related to essential (primary) hypertension - Multi-Vitamin/Minerals Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for Supplement - Senna Tablet 8.6 MG (Sennosides) Give 2 tablet by mouth one time a day for constipation - OxyCODONE HCl Tablet 15 MG Give 1 tablet by mouth every 12 hours for moderate to severe pain Review of Resident #1's MAR for [DATE] reflected the following morning medications were held on [DATE]: - Clopidogrel Bisulfate (Plavix) Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention -Order Date- [DATE] 2331 [blood thinner/Antiplatelet agent] - Rivaroxaban Oral Tablet 10 MG Give 1 tablet by mouth in the morning for MI-Order Date-[DATE] 2331 [blood thinner/Anticoagulant] -Duloxetine HCl Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth two times a day for depression-Order Date-[DATE] 2331. - Amlodipine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day for HTN -Order Date- [DATE] 2331. -Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime for high Cholesterol -Order Date- [DATE] 2331. - Calcium Oral Tablet 500 MG (Calcium) Give 1 tablet by mouth two times a day for Supplement -Order Date- [DATE] 1853 - Carvedilol Tablet 12.5 MG Give 1 tablet by mouth two times a day for Hypertension Hold if SBP less than 100 Order Date- [DATE] 2331 - Cilostazol Tablet 100 MG Give 1 tablet by mouth two times a day for blood thinner -Order Date- [DATE] 2331. - Finasteride Tablet 5 MG. Give 1 tablet by mouth one time a day for bladder Gloves should be worn by person handling or administering this product if they suspect or anticipate pregnancy -Order Date- [DATE] 2331. - Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 30 MG (Isosorbide Mononitrate) Give 1 tablet by mouth in the morning for Angina [chest pain] -Order Date- [DATE] 2331 - Multi-Vitamin/Iron Tablet (Multiple Vitamins-Iron). Give 1 tablet by mouth one time a day for Supplement multivitamin with iron-Ca-FAmin ,d+[DATE].4mg -Order Date- [DATE] 2331. - Pregabalin Oral Capsule 75 MG (Pregabalin). Give 1 capsule by mouth three times a day for Diabetic complication causing injury to some body nerves -Order Date- [DATE] 2331. -Rosuvastatin Calcium Tablet 20 MG Give 1 tablet by mouth one time a day for lipid control -Order Date [DATE] 2331. - Vitamin D (Ergocalciferol) Oral Capsule 50 MCG (2000 UT) (Ergocalciferol). Give 1 capsule by mouth one time a day for supplement -Order Date- [DATE] 1855. - Acetaminophen Tablet 325 MG Give 2 tablets by mouth three times a day for pain -Order Date- [DATE] 1951. Review of Resident #1's MAR for [DATE] reflected the following medications/dosages that were administered to him on of [DATE] at 12:05 PM: - Naloxone HCl Injection Solution 0.4 MG/ML (Naloxone HCl) Inject 1 ml intramuscularly as needed for opioid overdose until [DATE] 10:05 Inject in shoulder or thigh. Repeat after 3 minutes if no or minimal response. Order Date- [DATE] 1205. Also known as Narcan. Review of Resident #1's MAR for [DATE] reflected his 8:00 PM medications were not administered, because he was sleeping. Review of nursing progress note by LVN C, dated [DATE] at 5:08 PM, reflected [direct quotation] Type: Event Note LATE ENTRY Note Text: The resident was in therapy when this nurse was notified, therefore this nurse immediately ran down to report the incident to the DON. ADON and Administrator. When we arrived back to the floor therapy had just brought him back and reported him being sluggish. Upon getting a assessment and verifying ABC's and he was lethargic and could not answer basic questions. The doctor was notified and orders were given to administer IM injection of Narcan 2mg and check vitals every 15 mins x 1 hour and if no improvement send him to the ER. Review of Resident #1's vital signs during the acute assessment reflected the following. Blood pressure, oxygen saturation, and Pulse vital summary: [DATE] at 11:40 AM BP ,d+[DATE], pulse 108, oxygen 98 % by LVN C, [DATE] at 11:55 AM BP ,d+[DATE], pulse 105, oxygen 96 % by LVN C [DATE] at 12:10 PM BP ,d+[DATE], pulse 105, oxygen 97 % by LVN C [DATE] at 12:25 PM BP ,d+[DATE], pulse 105, oxygen 97 % by LVN C [DATE] at 12:40 PM BP ,d+[DATE], pulse 105, oxygen 96 % by LVN C [DATE] at 01:40 PM BP ,d+[DATE], pulse 96, oxygen 97 % by LVN C In an interview with Resident #1 on [DATE] at 11:20 AM, Resident #1 was in his room in his bed. He stated he could not recall being given any wrong medications. He stated he cannot remember a lot of things. He stated that he was fine and had no complaints. An interview on [DATE] at 11:29 with CNA A revealed she heard about Resident #1 having to have Narcan [this is a medication that is used to treat narcotic overdose in an emergency] through the grapevine on [DATE]. She heard a med aide gave a resident the wrong medicine. She said she thought the med aide was working upstairs at the time of this interview, but she was agency or something and she did not know her. She said the nurse on duty when it happened was the same one on duty at the time of this interview. She said she had never heard of anyone getting the wrong medications here before. She said Resident #1 seemed a little sleepy and needed a little more help in the shower on [DATE], but he seemed more like his normal self on the day of this interview. She did not know if he was sent to the hospital, and she thought the CNA on duty that day was CNA B, and she might know more. In an interview with MA D on [DATE] at 12:16 PM, MA D stated that on Monday [DATE], she had given Resident #1 medicine that belonged to Resident #2. She stated that therapy had come to get Resident #1 and at the time she had popped into a medicine cup all morning medicines belonging to Resident #2, but at the time, she thought it belonged to Resident #1. She stated she forgot whose medications they were, but she thought they belonged to Resident #1. She stated after administering the medicine that she had in the cup to Resident #1, he went to therapy. She stated she then took out medications that she thought were for Resident #2 and popped them into another medicine cup and took them to Resident #2 but Resident #2 refused to take them. MA D stated that after Resident #2 refused to take the pills she went to nurse LVN C to let her know that Resident #2 was refusing his medicine saying it was not his. MA D stated that she was confused on which resident was in bed A, and which one was in bed B. She stated that she should have asked someone to verify the bed arrangements so that she could have been sure that bed A was for Resident #1, and it was close to the entry way and bed B belonged to Resident #2 and it was close to the window. She stated she realized that she had given Resident #1 medicine that should have been given to Resident #2. MA D stated that she was confused by trying to rush before therapy took Resident #1, and not being familiar with the residents, the bed numbers, and having only worked at the facility for 4 days. MA D stated she was very upset (observed crying), and she had messed up. MA D stated she had a one-on-one in-service after the incident with the DON and that she had done a medication check return demonstration. MA D stated that the medication error was reported to the nurse, the DON, the ADON, and the Administrator the same day it happened. She stated that she worked the rest of her shift after being in-serviced. She stated that when giving medication it was important to remember the medication rights practice (Right patient, Right medication, Right dose, Right route, Right time). She stated the risk to Resident #1 getting medicine that did not belong to him was adverse medication reactions and she stated he could have died . An interview on [DATE] at 12:26 PM with LVN C revealed that on [DATE] she had been on the opposite end of the hall when MA D came to her and said she could not get a resident to take his medications. She went with her to check, and when she walked in Resident #1's bed was empty, and Resident #2 was in his bed. Resident #2 said those were not his medications, because there were not enough pills in the cup to be his medications. She asked MA D who she was trying to give the meds to, and she and MA D looked at each other and she could see on her face she realized she had given Resident #2's medications to Resident #1. MA D said she had given Resident #1 the other medications before he went downstairs to therapy, and she thought the beds were switched and the A bed was by the window. LVN C went to get the DON Immediately and told her that they needed to go to therapy to check on Resident #1. She, the DON, and the ADON were heading downstairs to therapy room to find Resident #1, at the same time, therapy was bringing Resident #1 back upstairs. She stated she did not know which therapist it was and the DON got the physician on the phone and explained that a med error had occurred while she (LVN C) took Resident #1's vital signs. She said Resident #1 was starting to seem confused and lethargic, but his vital signs were not bad. She said therapy had said he was lethargic, but she felt he was more sleepy than lethargic. The physician ordered two doses of Narcan, 2ml, and for her to check vitals every 15 minutes for one hour. She administered the Narcan, which was 1ml in each of the two bottles, and he became more alert, more easily roused, and less confused. His vital signs remained stable. She said the medication they were most concerned about was oxycodone every 12 hours. She said Resident #1 did occasionally take Tylenol with codeine, but nothing as strong as Resident #2. At first the Administrator asked her to count MA D out (count the medications in the cart so MA D could end her shift.) The DON said MA D was about to go on her lunch, and she did not need to count to go out to lunch. Then she came back and worked the rest of her shift. LVN C said after it happened, she did not know what happened with MA D, in terms of training or disciplinary action. It was her responsibility to oversee her on the floor, but the rest was the administration's responsibility for disciplinary action. She said she thought MA D was from an agency, and [DATE] was the first time she had ever seen her. She said MA D seemed to know what she was doing, and had asked her questions when she had them, but after this incident she was breaking down and crying a lot. She said MA D was very upset, because she knew that her error could have caused the resident to die. Resident #2 understood what happened, and he did receive his medications and did not have any problems with it. An interview on [DATE] at 1:19 with PT E revealed she had worked with Resident #1 on [DATE]. She said he was not as alert as usual, and not able to participate a lot, so they cut the treatment short. His blood pressure was a little low, she thought 91 or 92, over 62. She thought a few minutes of exercise might raise it, so they worked on his legs, and it came up a bit, but went right back down. At that point he said he was not dizzy or anything, but he was seeing blue stars, so she took him to his nurse, who checked his vitals and put him back in bed. She said she saw him on [DATE] working with OT F and he was not able to follow instructions, and was easily roused, but was dozing. She said she was PRN, so she had limited contact with Resident #1, but she had worked with him before. She said he was usually talkative and engaged more. She said it did not happen often that a resident who was normally able to participate showed up not able to. An interview on [DATE] at 1:33 PM with OT F revealed when he worked with Resident #1 on [DATE]. He required maximum assistance to sit on the edge of his bed, and the week before that it took only contact assistance. He said Resident #1's family member had watched him in therapy the previous week, he had a great day, and he barely had to touch him. OT F said that Resident #1 had been experiencing some decline in the week before that day. He said when he went to Resident #1's room to get him, he was sitting on the edge of his bed to taking his medication. He stated after that he took Resident #1 to therapy and for the first 30 minutes, he was OK, but then, in addition to requiring maximum assistance, he started falling asleep and could not follow all of the commands. He said he took his blood pressure, which was fine. He thought maybe the resident was having blood sugar problems, which he did sometimes and, which he could not check. He went to look for a nurse downstairs and did not see one. He took Resident #1 upstairs, and an aide told him that Resident #1 had taken the wrong medications. They put him in bed, and the nurse came, and PT O left the room. He was not sure what happened after that. He heard they might send him out to the hospital, but he did not know if they did. He said on [DATE] Resident #1 did much better in therapy. An interview on [DATE] at 2:08 PM with the Administrator revealed Resident #1 was going to therapy and MA D was in the middle of passing Resident #2 his medications, and because the therapist was waiting, and said they needed to take Resident #1 right then she stopped and dispensed Resident #1's medication and. She stated MA D was going to give Resident #2 his medications afterwards. She accidentally gave Resident #1 the wrong medications. She said it was an honest mistake, and they pulled her off the floor. She stated they did an in-service with her, and a medication competency, to make sure she knew what she was doing, and that she knew how to identify a resident before she administered medications. She said they did an in-service with all the other Medication Aides. She said MA D was borrowed from a sister facility. ADM stated Resident #1 did not suffer any harm from the incident. An interview on [DATE] at 2:18 PM with the DON revealed the medication error happened on Monday [DATE] between 11 AM and 12 PM. She stated the nurse informed her the med aide got two residents medicines mixed up. She stated Resident #1 received Oxycodone and that was the only medication that was concerning at the time. The DON stated she went upstairs to assess Resident #1 while LVN C was on the phone with the doctor. She stated the doctor ordered Narcan to be given to Resident #1 to help reverse the effects of the oxycodone (an opioid medication). She stated vitals were given to the doctor as they were being done and she could not recall the exact numbers. She stated once Resident #1 was stable and easier to arouse the doctor gave orders to monitor Resident #1 for one hour checking his vitals every 15 minutes. The DON stated that they investigated MA D's medication error right away and did training and a competency check with her. They did in-services with the other aides right away, so there was no reason to suspend her. She said the new medication aides normally went through training with another medication aide to make sure they understood what they were doing, their job description, and she and their HR also do their parts of the orientation. She went over the expectations they needed to meet with each new aide. She in-serviced the new staff, and she in-serviced all of her staff a lot. She said when they come in from a sister facility, they did orient them to the floor, but they already have the same training as they would in this facility. She said MA D had not worked in this building in the time she had been here. She said the medication aides just did the med count with the oncoming aide at the end of the shift but did not round like nurses and CNAs did. She said getting the wrong medication could potentially result in death, lethargy, or having a reaction to the medication. An interview on [DATE] at 3:56 PM with MA G revealed he worked in the facility PRN. He said he had not heard about the incident with the wrong medication given, but when he arrived for his shift, the DON did a training and competency with him on medication pass, and she talked about the Five Rights (of medication administration). He said he did not work at the facility often, because he was in nursing school, so they did it right when he came in on this day. He said she went over a lot of things, including how to make sure you erre giving the right resident the medication, giving it the right way, and how to know when to hold it. He said that he would talk to the resident, and ask them, and if they were not able to answer or seemed confused, he would check the picture in the computer, and check with the nurse, or another staff member who would know the resident. He said he would ask the nurse or other staff if he had any questions about anything. An interview on [DATE] at 3:59 PM with MA H revealed that she worked with Resident #1 on Monday after the medication incident. MA H stated that Resident #1 appeared very drowsy, and she asked the night nurse RN M if they could hold his night shift medications that were due on her shift at 8PM. She stated that Resident #1 medicines were not given on nightshift on [DATE]. MA H stated that it was her responsibility to always double and triple check residents' identity before medication administration. She stated that being careful during medication administration was vital. She stated the risk to a resident receiving the wrong medication was reaction a to medicine and other serious medicine effects. An interview on [DATE] at 4:52 PM with the Administrator and the DON revealed the DON had gone over the med pass in-service on [DATE] in-person with MA D, MA H, and MA I, and talked to the other aides, and was still talking to them about it. The DON said she was planning to start having the medication aides round at shift change, but today they were still just doing the count. She said she felt like they did what they could when it happened and did not think of what happened as actual harm. When asked what might have happened if Resident #2 had not been alert and oriented and able to identify that he was being offered the incorrect medications, which alerted them immediately to the error, the DON said that even if Resident #2 had not noticed the medications were wrong, they would have noticed his change in condition and sent him to the hospital. She said after they identified the error LVN C was taking Resident #1's vitals and writing them down and providing them to the physician. She said the physician had come to check on Resident #1 on [DATE], and the resident was doing well, and there were no new orders. The DON said she had checked on him in the middle of the night and they talked about him in their morning meeting. The DON said that the risk to the resident when getting the wrong medications depended on the interventions put in place, and they put the intervention of the Narcan in place. She stated the risk could potentially include actual harm, and that a resident could get sick or die. The Administrator confirmed that she had self-reported the medication error, after the state surveyors started asking about it, and they were doing competency checkoffs with all of the medication aides, as well as the in-servicing they had already done when it happened. An interview on [DATE] at 11:21 AM with Resident #2 revealed MA D was a temp and he had not seen her before. He said they did not really have regular people passing medications like they used to have, and the people often changed. Resident #2 said he knew all of his medications, and he knew the ones she tried to give him on [DATE] were not his. He said his roommate's (Resident #1) medications probably would not have hurt him any if he had taken them, but they probably would not have helped him either, and his medications played havoc with his roommate. He said Resident #1 was normally kind of confused and that he seemed more normal on [DATE] than he had for a couple of days after he got the wrong medications. Resident #1 said he did get his own medicine that morning ([DATE]) and did not have any problems because of what happened. He said that the medication aides did make mistakes on his medications sometimes, and it happened fairly regularly (he was not able to say when it last happened before this, or how often it happened), but he always checked, them so he knew he was getting the right ones. An interview on [DATE] at 12:22 PM with the NP revealed the facility had reached out to the Physician on [DATE] about Resident #1, not her, but she had checked on the resident on [DATE] and [DATE]. She said she did not know what acute monitoring the facility was doing, but they should have been monitoring him routinely for 24 hours. She said that during the acute monitoring the vital signs the facility sent her were good, except for a little bit of tachycardia (fast heartbeat), which was normal for Resident #1. She said even if the staff had not become aware of the medication error, any time they noted a change in condition, like altered mental status, they would have notified the physician, and they would do STAT vitals, ordered STAT labs as appropriate to the situation, and taken any precautions ordered by the physician. She said she did not know exactly what Resident #1's orders were at the current time, but he had been in and out of the hospital, and in the facility before, and had taken narcotic medication, so his body was not naive to narcotics. She said the strength difference could make a difference in how it affected someone, but he would not be as likely to have to have a serious reaction as someone who had not taken any medications of the same type in the past year or so. She said any time they started someone on a medication, especially a geriatric patient, she started them on a low dose , and went slow in working their way up (raising the dosage), so of course they would be concerned about it, and monitor him and act as needed, but she did not feel it was likely to have caused lasting harm to him. An interview on [DATE] at 12:49 PM with the Physician revealed the facility did notify her about the medication error with Resident #1, and she had been made aware of the IJ. She said with narcotics, any negative effect would be relatively immediate. She said when Narcan was given, it's done (the effect is immediate), and it puts a stop to the possibility that a person will stop breathing because of the narcotic. She said she only knew Narcan to work for the opiates, not the other medications, and she listed a long list of possible symptoms. She stated the mixture of those medications could do anything under the sun, and that the combination of the psych meds and opiate could potentially cause a full-on out-of-body experience in some people, and that you never knew how an individual would respond to them. She said with the narcotic 99% of people would just be sleepy, and the next thing they watched for, which would only be .08% would be an allergic reaction. She said when someone got the wrong medication, and they sent them to the hospital, all they do was observe them. The Physician stated that many people got the same combination of medications (narcotic and psych med), and there would be no reason to try to get it out of (by inducing vomiting) someone who got them mistakenly. She said she told them to keep monitoring him, because in the emergency room all they would do would be monitor him for signs of anything besides sleepiness. She felt that even if they had not caught the medication error, she did not feel the resident would have experienced a negative long-term outcome. She said the most likely outcome would be somnolence (sleepiness), and an allergic reaction could have been possible, which was a serious thing, but also only had a very small chance of occurring. She said she was not downplaying the situation, and that this was a serious thing, and they gave him a serious drug (Narcan), but she felt that it was highly unlikely he would have suffered any serious consequences of the error. Review of facility's policy titled Medication-Related Errors, revision date [DATE], reflected . read in part .3.2 Dose Error-dispensing to the resident of a dose that is greater than or less than the amount ordered by physician/prescriber. 3.4. Rate Error-Dispensing the incorrect rate of administration of the medication to a resident other than the amount ordered by physician/prescribe. 3.6. Frequency Error- dispensing to the residents of a medication at an incorrect interval of administration other than that is ordered by physician/prescriber. 3.8. Medication Error-Dispensing to the resident a medication other than that ordered by the physician/prescribe. 3.9. Resident/Facility Error-Dispensing to a resident or facility other than the one intended. 3.12. Monitoring Error-Failure to review a prescription regimen for appropriateness.4. In the event of an administration error, facility staff should follow facility policy relating to medication administration errors . Interviews from [DATE] at 12:00 PM to [DATE] at 10:00 AM with MA D, MA G, MA H, MA I, MA J, and MA K revealed they had all been in-serviced on medication administration topics, including making sure the correct resident received the medications, by the DON, and were able to answer questions about the five rights of medication administration (right patient, right drug, right time, right dose, and right route). They stated they would ask the nurse about any concerns or questions they had about anything, including the identity of a resident, in order to be absolutely sure they were giving the medications to the right person. They all explained how they would go about identifying a resident and knew how to do so if the resident was able to be interviewed reliably, or if they were not. They were all able to explain potential risks of a resident receiving medications which were meant for another resident. Review of an undated staff roster, and an interview on [DATE] at 1:50 PM with the DON and the Administrator reflected MA D, MA G, MA H, MA I, MA J, and MA K were the current medication aides at the facility, and there was one medication aide listed on the roster who was no longer an employee of the facility. Review of staff competency for MA D reflected medication administration check off completed on [DATE]. Review of an in-service signature form dated [DATE] reflected the DON in-serviced MA D, MA G, MA H, MA I, MA J, and MA K on Medication Administration, how to identify the resident before administering medications, and medical discrepancies. Review of a Medication Pass Review competency check-off sheet for MA D, dated [DATE] reflected she passed all areas of the competency and was able to demonstrate passing medications per physician orders. The competency included Was a system of resident identification utilized? Review of Medication Pass Review competency check-off sheets dated [DATE] for MA G, MA H, MA I, MA J, and MA K reflected they all passed the review, and were able to demonstrate passing medications per physician orders. The competency included Was a system of resident identification utilized? The noncompliance was identified as PNC. The IJ[TRUNCATED]

Based on interviews and record review, the facility failed to ensure that an incident of possible neglect was reported to Health and Human Services for one (Resident #1) of seven residents reviewed for abuse and neglect reporting. The facility failed to report a significant medication error, in which MA D administered Resident #2's morning medications to Resident #1, including a narcotic medication, and a psychoactive medication, on [DATE]. This failure could place residents at risk of being neglected and lack of oversight by a state agency. Findings included: Review of Resident #1's face sheet, dated [DATE], reflected he was a [AGE] year-old male, most recently admitted to the facility on [DATE]. He had diagnoses of repeated falls, anxiety disorder, chronic kidney disease, diabetes, and heart disease. Review of Resident #1's admission MDS, dated [DATE], reflected he was usually able to understand others, and was understood by others. He had a BIMS score of 15, indicating intact cognition. He had no behaviors or indicators of psychosis during the assessment period but had a depression indicator score of 13 out of 27, indicating moderate depression. He used a walker and a wheelchair. He required only set-up help for eating, and substantial to maximal assistance (helper does more than half the effort) for toileting, dressing, and hygiene. He required partial to moderate assistance (helper does less than half the effort) for getting in and out of bed, moving himself in bed, and transfers. He did not receive PRN or scheduled pain medication in the past five days and reported no pain in that period. Review of Resident #2's face sheet, dated [DATE], reflected he was a [AGE] year-old male, admitted on [DATE]. He had diagnoses of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute respiratory failure, type 2 diabetes with chronic foot ulcer, urinary catheter, unspecified psychosis, paraplegia (paralysis of the lower body), hemiplegia and hemiparesis following cerebral infarction (one-sided weakness following a stroke), multiple sclerosis (an autoimmune disorder which attacks nerve cells), chronic kidney disease, neuropathy (nerve pain), heart disease, emphysema (this is a lung diseases that causes air sacs destruction), and chronic obstructive pulmonary disorder (both conditions which make breathing difficult). Review of Resident #2's quarterly MDS, dated [DATE], reflected he was able to be understood by others, and usually understood others. He had a BIMS score of 11, indicating moderate cognitive impairment. He had no indicators of psychosis, or behaviors, during the assessment period, and a depression indicator score of 16 out of 27, indicating moderately severe depression. He had range-of-motion impairment in his upper and lower extremities and used a wheelchair for locomotion. He was dependent on staff for most ADLs and movement in bed. He did not transfer, stand, or walk during the assessment period. He received scheduled and PRN pain medications in the past five days, and had frequent pain, which frequently affected his sleep and interfered with his day-to-day activities. He rated his worst pain in that period as a nine on a one-to-ten scale. Review of nursing progress note by LVN C, dated [DATE] at 5:08 PM, reflected [direct quote] Type: Event Note LATE ENTRY Note Text: The resident was in therapy when this nurse was notified, therefore this nurse immediately ran down to report the incident to the DON. ADON and Administrator. When we arrived back to the floor therapy had just brought him back and reported him being sluggish. Upon getting a assessment and verifying ABC's and he was lethargic and could not answer basic questions. The doctor was notified and orders were given to administer IM injection of Narcan 2mg and check vitals every 15 mins x 1 hour and if no improvement send him to the ER. Review of Resident #2's MAR for [DATE] reflected the following medications/dosages were administered to him on the morning of [DATE]. - Sertraline HCl Tablet 100 MG Give 2 tablet by mouth one time a day for depression - Ascorbic Acid Tablet 1000 MG Give 1000 mg by mouth one time a day for Supplement - Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for prophylaxis - Bumetanide Tablet 1 MG Give 1 tablet by mouth in the morning for fluid retention - Calcium Oral Tablet 500 MG (Calcium) Give 1 tablet by mouth one time a day for supplement - Cholecalciferol Oral Capsule 125 MCG (5000 UT) (Cholecalciferol) Give 1 capsule by mouth one time a day for supplement - Depakote Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day related to unspecified psychosis not due to a substance or known physiological condition - Famotidine Tablet 20 MG Give 1 tablet by mouth one time a day for acid indigestion - Flecainide Acetate Tablet 50 MG Give 1 tablet by mouth two times a day for irregular heartbeat - Gabapentin Tablet 600 MG Give 1 tablet by mouth three times a day for Neuropathy - HydrALAZINE HCl Tablet 25 MG Give 3 tablet by mouth three times a day for hypertension - Magnesium Oxide Tablet 400 MG Give 1 tablet by mouth one time a day for supplement - Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day related to essential (primary) hypertension - Multi-Vitamin/Minerals Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for Supplement - Senna Tablet 8.6 MG (Sennosides) Give 2 tablet by mouth one time a day for constipation - OxyCODONE HCl Tablet 15 MG Give 1 tablet by mouth every 12 hours for moderate to severe pain Review of Resident #1's MAR for [DATE] reflected the following morning medications were held on [DATE]: - Clopidogrel Bisulfate (Plavix) Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention -Order Date- [DATE] 2331 [blood thinner/Antiplatelet agent] - Rivaroxaban Oral Tablet 10 MG Give 1 tablet by mouth in the morning for MI-Order Date-[DATE] 2331 [blood thinner/Anticoagulant] -Duloxetine HCl Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth two times a day for depression-Order Date-[DATE] 2331. - Amlodipine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day for HTN -Order Date- [DATE] 2331. -Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime for high Cholesterol -Order Date- [DATE] 2331. - Calcium Oral Tablet 500 MG (Calcium) Give 1 tablet by mouth two times a day for Supplement -Order Date- [DATE] 1853 - Carvedilol Tablet 12.5 MG Give 1 tablet by mouth two times a day for Hypertension Hold if SBP less than 100 Order Date- [DATE] 2331 - Cilostazol Tablet 100 MG Give 1 tablet by mouth two times a day for blood thinner -Order Date- [DATE] 2331. - Finasteride Tablet 5 MG. Give 1 tablet by mouth one time a day for bladder Gloves should be worn by person handling or administering this product if they suspect or anticipate pregnancy -Order Date- [DATE] 2331. - Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 30 MG (Isosorbide Mononitrate) Give 1 tablet by mouth in the morning for Angina [chest pain] -Order Date- [DATE] 2331 - Multi-Vitamin/Iron Tablet (Multiple Vitamins-Iron). Give 1 tablet by mouth one time a day for Supplement multivitamin with iron-Ca-FAmin ,d+[DATE].4mg -Order Date- [DATE] 2331. - Pregabalin Oral Capsule 75 MG (Pregabalin). Give 1 capsule by mouth three times a day for Diabetic complication causing injury to some body nerves -Order Date- [DATE] 2331. -Rosuvastatin Calcium Tablet 20 MG Give 1 tablet by mouth one time a day for lipid control -Order Date [DATE] 2331. - Vitamin D (Ergocalciferol) Oral Capsule 50 MCG (2000 UT) (Ergocalciferol). Give 1 capsule by mouth one time a day for supplement -Order Date- [DATE] 1855. - Acetaminophen Tablet 325 MG Give 2 tablets by mouth three times a day for pain -Order Date- [DATE] 1951. Review of Resident #1's MAR for [DATE] reflected the following medications/dosages that were administered to him on of [DATE] at 12:05 PM: - Naloxone HCl Injection Solution 0.4 MG/ML (Naloxone HCl) Inject 1 ml intramuscularly as needed for opioid overdose until [DATE] 10:05 Inject in shoulder or thigh. Repeat after 3 minutes if no or minimal response. Order Date- [DATE] 1205. Also known as Narcan. Review of Resident #1's MAR for [DATE] reflected his 8:00 PM medications were not administered, because he was sleeping. In an interview with Resident #1 on [DATE] at 11:20 AM, Resident #1 was in his room in his bed. He stated he could not recall being given any wrong medications. He stated he cannot remember a lot of things. He stated that he was fine and had no complaints. An interview on [DATE] at 11:29 with CNA A revealed she heard about Resident #1 having to have Narcan [this is a medication that is used to treat narcotic overdose in an emergency] through the grapevine on [DATE]. She heard a med aide gave a resident the wrong medicine. In an interview with MA D on [DATE] at 12:16 PM, MA D stated that on Monday [DATE], she had given Resident #1 medicines that belonged to Resident #2. MA D was visibly distraught when she talked about her error. MA D stated she had a one-on-one in-service after the incident with the DON and that she had done a medication check return demonstration. MA D stated that the medication error was reported to the nurse, the DON, the ADON, and the Administrator the same day it happened. She stated that she worked the rest of her shift after being in-serviced. She stated the risk to Resident #1 getting medicine that did not belong to him was adverse medication reactions and she stated he could have died . An interview on [DATE] at 12:26 PM with LVN C revealed that on [DATE] there had been an incident in which MA D gave all of Resident #2's morning medications to Resident #1, and Resident #1 had a change in condition, becoming lethargic and confused. She said Resident #1's vital signs were stable, and the physician ordered the administration of Narcan because one of the medications was a stronger dose of oxycodone (an opiate) than Resident #1 was used to taking. She was not aware of how the administration handled MA D once they dealt with the immediate concerns about the resident, but MA D did continue to work the rest of her shift after she left the floor for her lunch break. An interview on [DATE] at 2:08 PM with the Administrator stated the medication error in which MA D administered Resident #2's medications to Resident #1 happened because MA D was in the middle of passing Resident #2's medications, and a therapist was waiting to take Resident #1 to therapy. She stated so MA D switched to giving Resident #1 his medications, but got the cups switched. She said they pulled her off the floor and did an inservice with her, and a medication competency, to make sure she knew what she was doing, and that she knew how to identify a resident before she administered medications. She said MA D was borrowed from a sister facility. The Administrator said that she always told their corporate about incidents and took direction from them about whether to report things. They did an incident report, and addressed the issue with their staff, but because they considered this a medication error, they did not consider it as reportable. She said Resident #1 did not suffer any harm from the incident. An interview on [DATE] at 3:15 PM with the Regional RN revealed they did not report it because it was not considered a reportable. She said there was no harm or injury to the resident. She said that having Narcan would not be considered harm, and it would be like if a resident had an allergic reaction to a medication and they were ordered Benadryl. She said that their corporate staff did talk with the Administrators about whether or not to report, but at the end of the day, it was the Administrator's decision. An interview on [DATE] at 4:52 PM with the Administrator and the DON revealed the Administrator had gone ahead and self-reported the medication error to HHSC on [DATE] and would have done so earlier if she had known she needed to. She said they were also doing competencies with all other Medication Aides, in addition to the in-servicing they had already done. The DON said they did not think of what happened as actual harm, because they monitored the resident, his vitals were stable, he did not need to go to the hospital, and he was only affected for a short time. She did not feel like he was at a high risk for harm even if they had not been alerted to the medication error so quickly, because they would have used their nursing judgment, monitored him, and the physician would have sent him out to the hospital if they needed to. She said the physician had seen the resident, the resident was fine, and there were no new orders. She said the risk of a medication error like this one could be the resident potentially getting sick and dying but she felt it was highly unlikely in this case. Review of the facility policy Abuse: Identification of Types, issued [DATE], reflected Neglect: Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. a. Neglect includes cases where the facilities indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. b. Neglect of goods or services may occur when staff are aware, or should be aware, of resident care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an intervention (e.g. Suctioning, transfers, use of equipment), lack of sufficient staffing to be able to provide the services, lack of supplies, or staff lack of knowledge in the needs of the resident. Review of the facility policy for Incident and Reportable Event Management, issued [DATE], reflected Policy: the facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. ( .) ( .) Federal Regulations: F609: 483.12(c)(1) Reporting of Alleged Violations: 483.12(c)(1) ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made if the events that caused the allegation evolve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the state survey agency and adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures. ( .) Definitions: accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. This does not include other types of harm, such as adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current professional standards of practice (e.g., drug side effects or reaction). ( .) Event Management includes but is not limited to the following types of events: ( .) - Alleged Neglect ( .) Medication Discrepancy ( .) External Notifications: ( .) 3. Refer to state specific guidelines for reporting of events other than injuries of unknown origin, abuse, and Elder Justice Act. 4. The facility should be aware that external reporting may include; ( .) Adult Protective Services ( .) 48520

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 one (Residents #1) of seven residents reviewed for infection control. LVN A failed to change gloves and perform hand hygiene during wound care for Resident #1. LVN A failed to follow wound care procedures that prevented spread of infection and cross contamination when he reused same gauze to wipe wound three times and placed the soiled items on the bed next to Resident #1's wound area during wound care. This failure could place residents at risk of cross contamination and spreading infections. The finding included: Review of Resident#1's face sheet dated 06/18/24, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, history of falling, pubic bone fracture, fracture of the pelvis, wedge compression fracture of T1 and T11-T12 of the vertebrae, sepsis is an infection in the whole body, seizures, high blood pressure, elevated white blood count, sleep disorder while sleeping (obstructive sleep disorder), macular degenerative is an eye disease that causes vision loss and legal blindness. Review of Resident #1's quarterly MDS dated [DATE], reflected a BIMS of 6 which indicated severe cognitive impairment. Resident #1 required partial/moderate assist with the helper does less than half the effort. The helper lifts or holds, or support trunk or limbs and provides more than half the effort to roll left and right for bed mobility. The MDS indicated that Resident #1 skin treatments were a pressure reducing device bed and it indicated Resident #1 had no open wounds. Review of Resident #1's order summary dated 06/18/24, reflected Santyl Ointment 250 UNIT/GM (Collagenase) Apply to open area to sacrum topically every shift for wound care. Before applying, clean with Normal Saline. Cover with border dressing. Change dressing daily. Order active 05/31/24. Review of Resident #1 care plan on 06/18/24, reflected Resident #1 had been at risk for break in skin integrity r/t impaired bed mobility and incontinence. Goal was to maintain intact skin with no skin breaks through next review. Interventions included to clean and dry skin after each incontinent episode. Care plan initiated on 04/16/24. Observation of wound care on 06/18/24 at 12:14 PM, revealed Resident #1 in bed with family at bedside. LVN A washed his hands then wore blue gloves pulled from out of his bag. He then gathered wound care supplies for Resident #1 provided by LVN B. The supplies contained some wax papers, wet five-by-five inches of white gauze, a couple of five-by-five inches of dry white gauze, Santyl wound ointment with two application sticks inside a small medication cup, dated dressing, and a clear bull eye wound measuring tool and placed them on a side table next to Resident #1's bed. The side table contained a clipboard with papers and pen, a cup, and socks on top of it. LVN A did not clean the side table and placed the wound care supplies on the wax paper next to the items on the side table. LVN A positioned himself on the left side of the bed. He attempted to position Resident #1 by pulling the sheet underneath her bottom to turn her on her right side but Resident #1 barely moved her body to the right side of the bed. LVN A then positioned his hand on her pelvic bone/hip area and pushed her to expose her band aid wound on the sacrum. LVN A held his left hand on Resident #1 left buttock to stabilize her in place. With his right-hand, he removed the old wound dressing on Resident#1's sacrum. He then placed the old, soiled dressing on the bed next to Resident#1 right buttock. He reached with his right hand on the side table and took the wet gauze and wiped Resident #1's wound 3 times with same gauze. He placed the soiled gauze on the bed next to Resident#1's right buttock. He then reached again on the side table and took one of the dry gauze and pat dry the wound. LVN A then placed the used gauze on the bed next to Resident #1's right buttock. LVN A did not change his gloves nor perform hand hygiene. At this time Resident #1 could not hold in place and slightly lied on back with the soiled dressing and gauze touching her left buttock. LVN A then adjust Resident #1's position. He took the measuring tool with his left hand and positioned it on Resident #1 wound on the sacrum. He used his right hand to hold the wound measuring tool and reached on the clip board with his left hand and took a pen. He then proceeded to measure the wound. Resident #1 was uncomfortable, and she expressed herself to LVN A. He then let go of Resident #1 and she laid on her back on top of the soiled items. LVN A again attempted to adjust Resident #1's position. He placed his hand again on her left buttock pushing her and reached on bedside table for the Santyl wound ointment and with both application sticks he took one scope and applied it to the wound and then went back into the cup with the Santyl wound ointment and applied more to the wound. He then placed the application sticks and cup on the wax paper next to the clean outer dressing. He let go of Resident #1 and she rolled on top of soiled wound items. With both hands, LVN A removed the plastic cover from the sticky part of the dressing and then with right hand he pushed Resident#1 on her right side. He attempted to apply the dressing, but the dressing rolled on the edges due to Resident #1 being unstable in position. He let go of Resident #1 and with both hands he unrolled the dressing. He then pushed Resident #1 on to the right side. At this time the resident was very uncomfortable and family at bedside asked if it was meant to go this way. LVN A continued to push Resident #1 more on the right side and applied the dressing. In an interview with LVN A on 06/18/24 at 12:48 pm, he stated he should have asked for assistance during wound care. He stated had he gotten help, he could examine Resident #1's wound better, he would have measured the wound correctly and applied the Santyl wound ointment correctly. He stated he was busy focusing on holding Resident #1 in place that he did not think about infection control or cross-contamination during the wound care. He stated he was an experienced nurse, and he should have known better. He said the risk to the resident was that her wound would get worse due to infection. In an interview with LVN B on 06/18/24 at 1:29 PM, he stated he had asked LVN A if he needed assistance with wound care, but LVN A declined stating that he was comfortable performing the wound care on Resident #1 by himself. He stated the risk to the resident for improper wound care was spread of infection and cross contamination. He said that it may cause resident's wound to get worse. In an interview with the cooperate DON on 06/18/24 at 5:10 PM, she stated LVN A was not employed by the facility. She said he was contracted from an agency for hospice. She stated she had banned LVN A from coming back to the facility. She stated facility would start checking off competencies and training before agencies can provide patient care. She stated she expected all nursing staff to follow infection control policy. She also stated she expected LVN A to have asked to assistance for resident's safety. She stated the risk to Resident #1 was spread of infection and cross contamination. In an interview with the ADM on 06/18/24 at 5:10 PM, she stated she expected all staff to follow the facility's infection control policy. Review of the facility's policy dated November 9, 2022, and titled Standard Precautions revealed .Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .hand hygiene is performed with soap (anti-microbial or non-antimicrobial) or alcohol-based hand rub before and after contact with the resident .

Based on observation, interview, and record review, the facility failed to maintain a safe environment for residents, staff, and the public for one (Dining room [ROOM NUMBER]) of two dining room and one of one employee restrooms reviewed for physical environment. The facility failed to ensure the ceiling in the dietary department's employee restroom was free from unknown stains. The facility failed to ensure the ceiling tiles outside the dietary department in the dining room were not stained. The facility failed to ensure the walls outside the dietary department in the dining room were not damaged with drooping, sagging, and bubbled paint. This could place residents at risk for an unsafe environment. Findings included: Observation on 06/18/24 at 11:00 a.m revealed walls in dining room outside the dietary department had several drooping, sagging, and bubbled paint. The ceiling tiles above the wall were stained and brown from a leak. Interview on 06/18/2024 at 11:00 a.m. with the DM revealed there was an unidentified black substance in the dietary department's employee restroom. Observed the unidentified black substance in the employee restroom inside above, the door facing and on the ceiling. The color was scattered specks of a black substance. The DM revealed the area was treated by the Maintenance Director. The DM revealed the Maintenance Director informed her there has been a water leak from the air conditioner. Interview on 06/18/2024 at 11:15 a.m. with the Maintenance Director revealed he had been employed at the facility for one month. The MD revealed that he had treated the outside the dietary department area with [mold spray]. The MD revealed the mold was gone. Surveyor revealed to the MD the black substance was still in the dietary department's restroom. The MD revealed the area would be treated. again. The MD revealed the air conditioner had been leaking and causing moisture to form in the wall. The MD revealed the damage to the wall was there when he started work at the facility. The MD revealed he thought the Administrator was going to hire contractors to repair the wall. The MD revealed he had not completed any testing or observed any black substance on the wall. Record review of the Maintenance Repair Log, there was an entry dated 05/28/2024 informing AC Leaking in Dining Room, requesting repair by the Administrator. Review of the policy/procedure for Preventative Maintenance Services dated 01/11/2023 revealed Coordinate adequate resources and complete the required preventive maintenance on time. The facility must be designed, constructed, equipped, and maintained to protect health and safety of residents, personnel, and the public. The Plant Operations/Maintenance Department will respond to and correct identified problems withing the scope of their operations or arrange for the correction by a qualified individual in a timely manner.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for one (hallway 100) of two hallways checked for pest control, so that the facility was free of pests. The facility did not maintain an effective pest control program to ensure Residents #3, #4, and #2 were not bitten by horse flies and to ensure the facility was free of gnats and horse flies for Residents #1, #2, #3, and #4. This could place residents at risk for an unsanitary environment. Findings included: Record review of Resident #3's Face Sheet, dated 4-18-2024, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of hemiplegia (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left non-dominant side and secondary diagnosis of urinary tract infection, inflammatory reaction due to indwelling urethral catheter, and morbid obesity. Record review of Resident #3's MDS, dated [DATE], revealed a BIMS score of 14, which indicated he was cognitively intact. In an observation/interview, with Resident #3, in his bedroom, on 4-18-2024, at 1:12 PM, revealed Resident #3 has been dealing with gnats and horseflies for 3 weeks. Resident #3 stated what bothered him the most, was while sleeping and using the toilet, the horseflies have bitten him. Resident #3 said when he has been bitten, it was painful. Resident #3 showed a mark on his left forearm stating it was from a horsefly bite. Resident #3 stated he has been complaining to the facility for a few weeks about the bugs, while residing in the room next door (room [ROOM NUMBER]), and just 3 days ago moved him into his current room next door. While speaking with Resident #3, a fly was observed crawling on Resident #3's pie, which was covered with a plastic lid. A video was captured of this observation. Record review of Resident #4's Face Sheet, dated 4-18-2024, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of urinary tract infection, and secondary diagnosis of Parkinson's disease, repeated falls, and cerebral infarction (stroke). Record review of Resident #4's MDS, dated [DATE], revealed a BIMS score of 15, which indicating he was cognitively intact. In an observation/interview, with Resident #4, on 4-18-2024, at 3:15 PM, revealed Resident #4 has been dealing with insects in his room since he admitted to the facility. Resident #4 stated that he has been bitten by the flies and it hurt. Observation of Resident #4's room revealed 4 gnats flying, and 1 horse fly. Record review of Resident #2's Face Sheet, dated 4-18-2024, revealed a [AGE] year-old male, admitted to the facility on [DATE], with a primary diagnosis of acute kidney failure, and secondary diagnosis of hypertension (high blood pressure), hyperkalemia (high potassium level in the blood), type 2 diabetes, and congestive heart failure. Record review of Resident #2's MDS, dated [DATE], revealed a BIMS score of 15, which indicated he was being cognitively intact. In an observation/interview with Resident #2, on 4-18-2024, at 12:48 PM, 4 gnats and 3 horse flies, were observed flying in Resident #2's room. One horse fly was observed landing on Resident #2's leg while he was talking. Resident #2 stated that he has dealt with the insect problem since he admitted to the facility. Resident #2 stated he has been bitten by a bug while he was in bed. Resident #2 said he has not told a staff member he has been bitten. Record review of Resident #1's Face Sheet, dated 4-18-2024, revealed a [AGE] year-old male, admitted to the facility on [DATE], with a primary diagnosis of displaced fracture of shaft of the left tibia (the larger of the two shinbones in the lower leg) and secondary diagnosis of fracture of the upper end of the left tibia, necrosis (death of body tissue) of the left femur, and alcoholic liver disease. Record review of Resident #1's MDS, dated [DATE], indicated a BIMS score of 15, which indicated he was cognitively intact. In an observation/interview with Resident #1, on 4-18-2024, at 12:20 PM, 3 gnats and 2 horse flies, were observed in Resident #1's room. Resident #1 stated he noticed a bug problem in his room, since he had admitted into the facility, and he wished he would have stayed home, and not been admitted to this facility. In an observation, on 4-18-2024, at 1:09 PM, in the 100-hall hallway, 8 gnats were observed flying around. In an observation, on 4-18-2024, at 1:10 PM, in room [ROOM NUMBER], in the 100-hallway, approximately 6 large horse flies were video recorded flying in the window and approximately 30-50 dead gnats on the floor. An observation was made, on 4-18-2024, at 2:20 PM, of 25 gnats in the hallway by the kitchen on floor one. In an interview with RN A, on 4-18-2024, at 2:45 PM, revealed RN A has worked at the facility since 3-28-2024. RN A stated the flies and gnats have been here since she started working at the facility. RN A said residents have complained about the bugs to her. RN A stated another nurse uses an electronic bug zapper to kill the bugs at times. RN A stated she has not witnessed anything being done about the bug problem. In an interview on 4-18-2024, at 3:40 PM, with the Administrator, revealed the facility did not have a Maintenance Director, but were seeking to hire one. The Administrator stated that the Maintenance Director would be responsible for ensuring the facility was free of insects. The Administrator stated the facility used the Maintenance Director from a sister facility. In a phone interview with the Maintenance Director, of a sister facility, on 4-18-2024, at 3:51 PM, it was revealed that a pest control company was contracted for the facility, and they come out to the facility every two weeks to exterminate it. The interim Maintenance Director stated the pest control company treats the facility for gnats, flies, ants, roaches, spiders, and rodents. In an interview with the ADON, on 4-18-2024, at 5:05 PM, it was revealed the facility has had a flying insect problem since December 2023. The ADON stated the pest control company comes out to the facility, but they still have a problem with insects. The ADON stated the potential risk, to the residents, was for infections to occur for the ones who have IV lines, wounds, and colostomy bags. The ADON stated everywhere one goes, there seems to be a fly following you around. The ADON stated that residents on the first floor have complained about the insect problem. In an interview with the DON, on 4-18-2024, at 6:10 PM, revealed that residents have been complaining about the insect problem for a while. The DON stated the first time she noticed the insect problem occurring was 2 months ago. The DON stated that a few residents stated they had been bitten by large horse flies. The DON stated the potential risk to residents having insects in the facility, in their food, and residents being bitten by insects, is infection control. The DON stated that her expectation was for the facility to be free from flies. The DON stated the person responsible for pest control was the Maintenance Director. The DON stated the facility did not have a Maintenance Director but were seeking to hire one. The DON stated they were using a Maintenance Director from another facility. In an interview with the Administrator on 4-18-2024, at 6:50 PM, revealed that her expectation was for the facility to be free from flies. The Administrator believed the insects were coming from a drain and she has plumbers working on the problem. The Administrator said left over food in a resident's room can attract flies. The Administrator stated if a resident has left over food in their room, they have an aide throw the food away. The Administrator stated if a resident gets bitten by an insect, it can cause a skin problem and infection control. The Administrator stated that the Maintenance Director was responsible for maintaining pest control in the facility, but they did not have one. The Administrator stated they were in the process of hiring a Maintenance Director but were using one from their sister facility. The Administrator stated that only one resident has complained about the insect problem in the facility and as soon as he complained, they moved him to another room immediately. The Administrator stated that the facility contracts with a pest control company and they are working on the problem. The Administrator stated that the risk for insects getting into a resident's food was they could get sick. Record Review of the facility's pest control log indicated: 3-8-2024 - 11:05 AM to 12:44 PM - Insect Maintenance Service given flies, gnats, ants, and rodents. 4-9-2024 - 12:08 PM to 1:30 PM - Insect Maintenance Service given for flies, gnats, ants and rodents. Pest control company check in with Maintenance Director from sister agency and performed preventative treatment on the front entry way doors and in kitchen. Inspected 3 rooms and performed a treatment in drains in kitchen. Checked rodent traps and changed bait in bait stations. Removed a rat from a ceiling void in conference room. Record review of the facility's pest control policy, dated 6-4-2023, stated: The facility will maintain an effective pest control program that provides frequent treatment of the environment for pest so that the facility is free of pest and rodents. It will allow for additional visits when a problem is detected. 48520

Based on interview and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers that were avoidable for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. 1. The facility failed to perform weekly skin assessments for Resident #1 from 09/25/2023 to 10/07/2023. 2. The facility failed to notify the physician during the admission process of the resident's pressure ulcers to obtain wound treatments, and failed to obtain orders to help prevent facillity acquired pressure ulcers to develop. Resident #1 developed stage 3 pressure ulcers to right heel, left heel, and right buttock, one deep tissue injury to right ankle, one deep tissue injury to left ankle, and two deep tissue injury to left foot while at the facility. An Immediate Jeopardy (IJ) was identified to have existed from 09/25/2023 to 10/13/2023. The IJ was determined to be at past non-compliance as the facility had implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures could place residents with impaired skin integrity at risk of developing wounds or deterioration of existing wounds and a decrease in quality of life. Findings included: Review of Resident #1's face sheet, dated 11/09/2023, revealed a [AGE] year-old-male who admitted [DATE] from an acute care hospital and discharged on [DATE] to an acute care hospital. Resident #1's diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #1's admission assessment, dated 09/25/2023, completed by LVN A, reflected in part, skin was not intact and areas marked included bruise, skin tear and open area/wound. The assessment indicated his upper mid back had opening area from boney prominence, left elbow with weeping scabbed area, back of left hand had weeping open area, other with left arm 7 cm skin tear and other right back of shoulder area with no description. Further review of the admission assessment revealed Resident #1 required maximum assist x2 with toileting, transfers and x1 for bed mobility. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #1 did not have unhealed pressure ulcers/injuries and did have skin tears. Review of Resident #1's care plan, dated 09/26/2023, revealed he was at risk for a break in skin integrity with interventions that included clean and dry skin after each incontinent episode, and treatment as ordered. No other interventions were documented. The open areas/skin tears found on admission were not documented. Review of Resident #1's physician orders, and TAR from 09/25/2023 through 10/07/2023 revealed no assessment, treatment or monitoring for skin. Review of Resident #1's Braden scale (for predicting pressure sore risk), dated 09/25/2023, revealed a score of 12 indicating high risk. Review of Resident #1's Braden scale, dated 10/06/2023, revealed a score of 12 indicating high risk. Review of Resident #1's nursing notes dated 10/07/2023 written by RN B revealed At approximately 11:40am a change of condition was noted in resident mental status while conducting an assessment, open area on right heel also noted, NP notified and tele-visit conducted with resident, while [family member] at bedside, based on NP's evaluation of resident order received to transport resident out for more extensive evaluation. Further review of nursing notes from 09/25/2023 revealed no documentation of skin issues, assessment, or treatment for skin. Record review of Resident #1's EHR revealed no evidence that the resident's pressure ulcers were clinically unavoidable. Review of ED to hospital admission records dated 10/07/2023 through 10/27/2023, revealed Resident #1 had a diagnosis of severe anemia. Review of ED HPI dated 10/07/2023 at 2:15 pm reflected in part. [AGE] year-old male with a past medical history of hypertension, arthritis, lung cancer in remission who presents for failure to thrive via EMS. Patient is at a SNF and was brought in by [family member's] request. Per EMS, the [family member] state he was not getting proper care for his right foot and ankle. Patient has a pressure ulcer on his ankle that is bandaged Pressure wound right heel. Dried Necrosis. Further review of hospital records revealed the following wounds: - forearm anterior; right. Assessed on 10/07/2023. Present on admission. 2 cm Length by 3 cm Width by 2.2 cm depth. Wound bed color: pink; yellow; bright red; black. Texture: spongy. Slough (yellow-tan dead tissue): 1-25%. Eschar (brown or black, dry, dead tissue): 1-15%. Granulation: 26-50%. Wound thickness: full thickness. Moderate drainage. Odor: none. - forearm anterior; left. Assessed on 10/07/2023. Present on admission. 4 cm Length by 2.2 cm Width by 0.2 cm depth. Wound bed color: pink. Texture: non-blanching; spongy. Slough: none. Eschar: none. Granulation: 76-100%. Wound thickness: partial thickness. Moderate drainage. Odor: none. - Pressure Injury Heel; right. Assessed on 10/07/2023. Present on admission. 5.5 cm Length by 4 cm Width by 0.2 cm depth. Wound bed color: bright red. Texture: spongy. Slough: none. Eschar: 1-25%. Granulation: 26-50%. Epithelialization: 26-50%. Wound thickness: Eschar Cover. Drainage: small. Odor: none. Pressure injury staging: U - Pressure injury Back: Mid. Assessed on 10/07/2023. Present on admission. 2 cm Length by 1.8 cm Width. Wound bed color: black; purple. Texture: spongy; non-blanching. Slough: none. Eschar: none. Granulation none. Epithelialization: none. Wound thickness: full thickness. Drainage: none Odor: none. Pressure injury staging: DTPI - Pressure injury Scapula: Right. Assessed on 10/09/2023. Present on admission. 2 cm Length by 1.8 cm Width. Wound bed color: purple; black. Texture: non-blanching. Slough: none. Eschar: none. Granulation: none. Epithelialization: none. Wound thickness: full thickness. Drainage: none Odor: none. - Pressure injury Buttocks: Right. Assessed on 10/09/2023. Present on admission. 5 cm Length by 3 cm Width by 2.3 cm depth. Wound bed color: pink. Texture: spongy; non-blanching. Slough: none. Eschar: none. Granulation: 76-100%. Epithelialization: none. Wound bed exposed: Adipose Exposed. Wound thickness: full thickness. Drainage: small. Odor: none. Pressure injury staging: 3. - Pressure injury Foot: Lateral. Assessed on 10/09/2023. Present on admission. Wound bed color: purple; black; pale. Texture: spongy. Drainage: none. Pressure injury staging: DTPI. Notes: two DTI wounds on left lateral foot: distal measures 2.8 by 2, proximal 2.5 by 1.8. - Pressure injury Ankle left: lateral. Assessed on 10/09/2023. Present on admission. 2 cm Length by 1.8 cm Width by 0.1 cm depth. Wound bed color: purple; bright red. Texture: firm; Leathery. Slough: 1-25%. Eschar: 51-75%. Granulation: none. Epithelialization: none. Wound thickness: eschar cover. Drainage: none. Odor: none. - Pressure injury Ankle right: anterior. Assessed on 10/09/2023. Present on admission. 4 cm Length by 10.5 cm Width by 0.1 cm depth. Wound bed color: purple. Texture: non-blanching. Slough: none. Eschar: none. Granulation: none. Epithelialization: none. Wound bed exposed structure: Tendon Exposed. Drainage: none. Pressure injury staging: DTPI. - Pressure injury Ankle left: anterior. Assessed on 10/09/2023. Present on admission. 2 cm Length by 1.8 cm Width by 1 cm depth. Wound bed color: purple. Texture: non-blanching. Slough: none. Eschar: none. Granulation: 76-100%. Epithelialization: none. Drainage: none. Odor: none. Pressure injury staging: DTPI. - Pressure injury Heel: Left. Assessed on 10/09/2023. Present on admission. 2 cm Length by 2 cm Width by 0.1 cm depth. Wound bed color: purple; black. Texture: non-blanching. Slough: none. Eschar: none. Granulation: none. Epithelialization: none. Wound thickness: full thickness. Drainage: moderate. Odor: none. Pressure injury staging: Unstageable. Skin assessment performed per consult. Patient presents with multiple wounds, some due to previous falls (seen on previous admission) and new pressure injuries to bilateral ankles, feet, heel, back, sacrum and buttocks. Review of hospital documentation clarification by hospital MD dated 10/21/2023 revealed patient has an unstageable pressure injury located on bilateral heels .patient has Stage 3 pressure injury on right scapula and right buttock. Interview with Resident #1's family member on 11/08/2023 at 9:27 am revealed Resident #1 was currently in another nursing facility. The family member stated RN B took pictures of Resident #1's foot, did a virtual visit with the doctor and showed the wound on his right heel and was sent to the hospital. The family member stated he was not turned while at the facility and did not have pressure ulcers before he admitted . A request was made with the Executive Director from sister facility on 11/09/2023 at 11:17 am, of all documentation related to Resident #1's skin assessments, treatment, and wound care. She stated the DON was getting all wound care notes together. Interview with the DON on 11/09/2023 at 1:58 pm revealed she talked with LVN A who admitted Resident #1. The DON stated LVN A said she did the initial assessment but could not initiate treatment since Resident #1 did not come with orders, and she stayed within her scope as an LVN and could not initiate treatment. The DON stated she in-serviced the nurses to call the doctor and get some kind of treatment order. The DON stated Resident #1 had skin tears on his back and on both arms, but no other skin issues were documented. The DON stated she did not remember that Resident #1 had wounds. When asked why the weekly skin assessment was not completed, the DON stated when LVN A identified the skin issue, it should have triggered a weekly skin assessment in the EHR. The DON stated the nurses were responsible for completing weekly skin assessments, and it automatically populated. The DON stated had LVN A completed the wound observation tool and skin assessment tool, it would have populated every week to be completed. The DON stated she was responsible to oversee that assessments were completed. The DON stated part of their Plan of Correction (facility was cited for not completing skin assessments on 10/13/2023) was getting CNAs involved with their shower sheets. So when any skin issue was brought to her attention, depending on the type of wound, they would get a wound consult from Dr. [Name]. The DON stated the wound doctor came every Monday. The DON stated nurses from a sister facility have been over to do the skin assessments and she hired a nurse, LVN G, who would start Monday (11/13/2023) to round with the wound doctor and to complete weekly skin assessments. The DON stated the risk for not completing assessments would be a negative outcome for the resident, worsening of wounds. Phone interview on 11/09/2023 at 10:53 am, LVN A stated Resident #1 had bruising, scabs, bony prominences almost like bone would stick out, it was not open but had a foam dressing to protect it. She said she put the dressings back like they were because they should not be open. LVN A stated Resident #1 had quite a bit of issues going on with his skin. LVN A stated when a resident admitted , she completed an initial assessment, took vitals, and if there was a dressing, she would take it off and see what was underneath and put them back on just like they were, finish charting, then send to the provider to get any updated orders. She stated LVN's could not initiate orders and could not diagnose so she would give the assessment to the provider, and they would initiate any type of dressing. LVN A stated skin assessments should have completed weekly. She stated each nurse had their own assessments due, the day shift nurses have even numbered rooms and the night nurses have odd numbered rooms. LVN A stated there was no wound nurse and the former ADON would round with the wound doctor but she left in September. LVN A stated she had been in-serviced on wound treatment, technique and have competency checks about every 6 months. Phone interview on 11/09/2023 at 11:27 am, RN B stated he thought Resident #1 had a couple of wound orders, and treatment for both of his arms, but he could not really remember and would have to look at the MAR. He stated he could not remember if Resident #1 had something on his bottom. He stated Resident #1's family member talked about a small reddened area on one of his heels; it was not open. He stated a week before Resident #1 went to the hospital, Resident #1 would not eat and would not let staff feed him. RN B stated a tele-visit with the NP was on done on Saturday or Sunday and the NP said to send him out. RN B stated when a resident admitted , a head-to-toe assessment was done and usually get a skin report (from the hospital) when they come, but nurses were supposed to do an assessment. He stated if he identified something new like a reddened or opened area, he would let the physician know and get an order. He stated nurses were responsible for doing skin assessments every week. Phone interview on 11/09/2023 at 11:39 am with LVN C was unsuccessful. Surveyor left voicemail and no return call was received. Interview on 11/09/2023 at 12:02 pm, the DON stated since they audited on 10/13/2023, 3 residents were found to have new skin issues but no pressure ulcers. She stated the RDCS, Nurse management at the facility and from the sister facility, completed the skin sweep. The DON stated a skin assessment should be done upon admission for a new admit, and at the time of the assessment, the nurse should document any open areas or any issues and complete the wound observation tool in the EHR. She stated that automatically triggers the skin review every week. She stated if any skin issues were found, then the nurse should contact the NP or doctor to get orders. She stated her expectation was for nurses to assess and measure wounds, and then notify the doctor. She stated Resident #1's family member did not make her concerns known about the wound on the ankle to her. Interview on 11/09/2023 at 12:31 pm with the RDCS revealed she did not remember Resident #1, had not talked with Resident #1's family member, and Resident #1's nurse note said he was sent out for change of condition and she believed RN B sent him out over the weekend. She stated the process to ensure skin assessments were completed for new residents admitted to the facility was the skin assessment was populated on admission, and if there was a skin issue, a wound observation tool was generated in the EHR. She stated the nurses completed those on a weekly basis. She stated the DON was overseeing that they were completed, and she oversaw the DON. She stated it turned red on the EHR if it was late or missing. She stated since the nurses did the wound treatments, she and the DON in-serviced nurses on pressure ulcers and treatments. Interview on 11/09/2023 at 2:31 pm with CNA D revealed she was from agency, and it was her first time working at the facility. She stated if she saw any redness/skin breakdown/new skin issue she would report it to the nurse. Interview on 11/09/2023 at 2:34 pm with CNA E revealed she was from agency and it was her first time working at the facility. She stated if she saw any redness/skin breakdown/new skin issue she would report to the nurse. Interview on 11/09/2023 at 2:36 pm with CNA F revealed he had worked at the facility for 3 weeks. He stated if he saw any redness/skin breakdown/new skin issue he would inform the nurse, because they needed to do an intervention, and call the wound doctor to see what was going on. Interview on 11/09/2023 at 1:25 pm with DON and LVN A by phone revealed LVN A stated she did not remember speaking with a provider about Resident #1 but had sent in her assessment and did not receive any treatment orders from the NP or doctor. The DON stated if LVN A gave report to the provider, and they did not give any recommendations and there was no treatment orders to move forward with. The DON stated LVN A should have documented any treatment provided. Record review of in-service dated 10/12/2023 revealed nurses were educated on pressure ulcers - changing and dressings to wounds, following MD orders, and weekly skin completion. Record review of weekly skin audit dated 10/27/2023 and 11/02/2023 revealed weekly skin assessments completed. Record review of facility policy titled Documentation & Assessment of Wounds revised 03/31/2023 reflected in part: to guide the associates and licensed nurse in the assessment of wounds to include pressure ulcer/injuries, venous, arterial, diabetic, dehisced surgical wounds, and other (not otherwise specified) Procedure 1. A wound assessment/documentation is required to occur at a minimum 'weekly'. Nurses performing the treatment would perform a prn assessment/documentation if noted change has occurred i.e., wound has healed/resolved, appears infected, or appears to have declined. It may not be practical for the 'weekly' assessment to occur on the 7th day deadline due to dressing not required to be changed on due date, wound round or MD schedule changes, follow-up appointments, or resident's refusal. For those purposes would obtain wound assessment/documentation prior to if able or within the calendar week to maintain assessment and documentation compliance. Record review of facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management revised 08/25/2021 and reviewed 03/31/2023 revealed in part: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy, Continent Nurses Society) . Procedure 1. A comprehensive skin inspection/ assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present . 3. A skin assessment /inspection should be performed weekly by a licensed nurse 4. Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services . a) skin inspections with particular attention to bony prominences; e) minimize injury due to shear and friction through proper positioning, transfers, and turning schedules (if indicated); . 5. Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: a) reposition at least every 2-4 hours (per NPIAP standards) as consistent with overall patient goal and medical condition; b) utilize positioning devices to keep bony prominences from direct contact; c) ensure proper body alignment when side-lying; d) heel protection/suspension if indicated; .

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for four (Residents #1, #3, #4, and #5) of 17 sampled residents. 1) Resident #1 fell from a disposable mechanical lift sling and fractured a cervical vertebra. 2) Residents #3 and #5 were transferred on a mechanical lift without properly securing the waist safety belt. 3) Resident #4 was transferred in a manner that bumped her left foot and lower leg on the mechanical lift. These failures resulted in major injury to Resident #1 and could potentially affect the facility's seven other residents who utilized mechanical lifts by placing them at risk for injury. Findings included: 1) Resident #1's MDS assessment, dated 03/24/14, revealed she was a [AGE] year-old female admitted on [DATE], with [DIAGNOSES REDACTED]. Functional status for transfers indicated total dependence with two or more persons' physical assistance. Falls history indicated one fall since admission with major injury. Resident #1's height was 63 inches and weight was 238 pounds. Review of Resident #1's Care Plan, dated 03/20/14, reflected the resident required a Hoyer lift for transfers and did not indicate the newly implemented system of checking the sling for wear or double checking sling straps prior to lifting the patient. The nursing staff corrected the care plans once this was discovered by the surveyor. Observation during initial tour on 04/01/14 at 9:10 AM, revealed Resident #1 had a cervical collar on her neck. A floor mat and pressure relieving bed were being utilized. Resident #1 was talkative but confused and expressed she had sustained her neck injury in a car accident during "orientation." The nurse in attendance (LVN F) stated Resident #1 was not in a car accident, but was dropped from the Hoyer lift sling last week. Nursing Progress Notes for Resident #1, dated 03/19/14 reflected: "...CNA stated that while transfer resident oob (out of bed) the sling ripped on one side and resident fell to floor." Review of the Provider's Investigation Report, dated March 2014, revealed during a two-person assist Hoyer transfer, the strap on the sling broke and Resident #1 fell to the floor. The two CNAs attempted to catch and guide the resident. The resident's cervical vertebra was fractured. The provider response was: "Instructed resident not to move, Norco (pain reliever) 5/325 mg tablet was given for pain, physician and power of attorney notified, and 911 called." Action taken post-investigation included: "Hoyer In-service, Implementation of check and log system for slings, and Inspection of all Hoyers and slings." Witness statement, dated 03/19/14 and signed by CNA G, reflected the Hoyer lift connecting belt tore in half. Witness statement, dated 02/19/14 and signed by CNA I, reflected one of the connecting belts tore in half. Review of Treatment Summary from the hospital Emergency Department, dated 03/19/14, revealed a [DIAGNOSES REDACTED]. In-service on Hoyer Lifts and Inspections was done on 03/20/14. Interview on 04/02/14 at 8:20 AM with the DON and Administrator revealed the CNAs and laundry aides were responsible for visually inspecting the mechanical lift slings prior to each use and after being laundered. The DON stated the strap of the sling snapped in half during a mechanical lift transfer of Resident #1. The DON stated after the accident involving Resident #1 all of the slings were inspected for wear and new slings were ordered. The Administrator stated prior to the incident slings were laundered and dried on the low heat setting. The Administrator stated now the slings were being line-dried. During the interview, the DON revealed the sling used on Resident #1 was brought into the facility with the resident at the time of admission. Interview on 04/02/14 at 9:30 AM with LVN F, along with LVN N and the DON, revealed all the slings were Invacare brand except for one resident on Hall 100. LVN F stated the slings are washed, air-dried, and set aside until they are inspected. The DON stated maintenance inspected the mechanical lifts every month and documented the results of the inspection. The laundry person inspects the lift slings for rips, tears, frayed or worn straps and initials a sheet, then a nurse inspects again and initials before placing them in the area for access for CNAs to use them. The DON further stated when residents come in with their own equipment, the therapy department checks the equipment and switches it out. Resident #1 was using a lift sling not owned by the facility, so that was "one that we missed." The DON did not know the brand name of that sling and the sling had been discarded. In an interview on 04/02/14 at 11:45 AM with Resident #1's guardian he/she stated, "Here they have Hoyer transfers down to an art. The sling that broke was worn out and they replaced it." An interview on 04/02/14 at 1:00 PM with LVN F revealed no one currently had their own equipment except maybe a walker. Equipment was tagged with their name after therapy inspected and replaced the equipment with facility-owned equipment while they were here. LVN F did not think the sling belonged to Resident #1, but was not 100% sure. LVN F stated the resident's inventory sheet was missing from Resident #1's chart but was probably not returned from the resident's family member. LVN F stated, "I was here (when Resident #1 was injured) and the strap (on the sling) was white." In an interview on 04/02/14 at 2:16 PM with CNA G, he stated he, CNA I, and LVN J were lifting Resident #1 from the bed into a chair with the mechanical lift. After placing the resident on the sling and elevating a little from the bed, CNA G checked the hooks and gave them a tug. After moving Resident #1 out from above the bed, the sling strap snapped and broke in two. It was the right upper strap which was white and braided. The facility got rid of the white ones after Resident #1 fell . CNA G stated, "We found out the white ones wear out." CNA H checked and did not notice anything wrong with the strap. There was no history of the facility using worn-out equipment according to CNA G. Since the incident, the facility got all new slings and re-educated everyone on checking the slings even more frequently. After they are washed, the slings are inspected. Now the slings have nylon material with straps that are thicker and stronger. The new ones have color-coded loops and extra black back-up loops. The old sling looked a little worn but not to the point of any thought of danger, just a little "thready." The old white slings belonged to the facility and it was in use before Resident #1 was admitted . After Resident #1 fell , CNA I stayed with Resident #1 and CNA G ran for the charge nurse, supervisor, and the DON. The ambulance came and took Resident #1 to the hospital. In an interview on 04/02/14 at 3:00 PM, LVN J stated when she got to the room, Resident #1 was on the floor and the sling was not under her. The sling was still on the lift. The strap was torn from the sling. LVN J thought the strap was flat with double stitching and did not remember what color, but thought it may have been black and could not remember any threads showing. Since the incident, the facility inspects all slings and checks for rips, tears, threads, anything coming loose, or does not look right. The sling Resident #1 fell out of was a facility sling. We received new slings of the same kind. We used to have white ones and blue ones. We were in-serviced for lift transfers and sling inspections. LVN J stated she does the inspection when in the room helping and she guessed the CNAs inspected them when they get them to use. In an interview on 04/02/14 at 3:25 PM, CNA I stated CNA G had asked her for assistance. Both CNAs got the sling under Resident #1 and hooked the top and bottom. CNA I further stated, "Just as we pulled (Resident #1) over, the strap snapped. We tried to hold her but it was not possible. The left top strap broke." It was a white sling with colored loops. The purple loop snapped. It frayed apart. The strap was flat nylon and not braided. It just ripped in half with no loose threads seen. Currently, we are not to use the white slings. We are only to use the blue ones. The sling used did not belong to the resident; it belonged to the facility. The facility had two white slings and both were thrown out. The slings were now inspected by the laundry and the charge nurse. In an interview on 04/03/14 at 10:15 AM, Laundry Aide K stated, "We trashed the white ones. We didn't know they were the one-time use disposable ones. We were washing them and re-using them." In an interview on 04/03/14 at 10:25 AM, the DON stated, "We don't have disposable slings." In an interview on 04/03/14 at 11:00 AM, Resident #18 stated, "They (the slings) are not always blue. They once used a white one and it wasn't good. It was disposable. That's the one that broke that time." In an interview on 04/03/14 at 11:40 AM, the Rehabilitation Director stated if residents bring their own equipment, the therapy department inspected rolling walkers and other equipment was inspected by the maintenance department. The mechanical lift slings would be included with the mechanical lift inspection as far as she knew. At 11:45 AM, the Rehabilitation Director said Central Supply ordered the lift slings and she had never heard of disposable slings. The Rehabilitation Director then stated, "I've heard of disposable slings now! My DON told me about the disposable slings. We got rid of them because of the fall." On 04/04/14, website http://www.liftran.com/disposable-slings/disposable-universal-slings-p216.html for a disposable sling manufacturer reflected: "Do not wash and discard if they (disposable slings) are accidentally washed..." indicating the integrity of the sling would be compromised if laundered. Review of the Lift and Sling Safety in-service, dated 04/02/14, revealed competency tests including sling inspections and immediately discarding slings with even a small tear and double checking slings/sling straps when there was tension on the sling, prior to lifting the patient. The Invacare Patient Slings Owner's Operator and Maintenance Manual, dated October 2008 reflected: "Invacare slings are made specifically for use with Invacare lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers." Review of the Invacare Reliant 600 Manual/Electric Portable Patient Lift User Manual, dated May 2011 reflected: "...Invacare slings and patient lift accessories are specifically designed to be used in conjunction with Invacare patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of Invacare's patient lift system...After each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately." 2) Resident #3 was observed on 04/02/14 at 10:10 AM, during a sit-to-stand lift transfer from the bed to the chair. A sling was placed on Resident #3, but was not fastened at the waist. The strap dangled to each side from the sling. CNA B checked the back of the sling for positioning but did not fasten the belt around Resident #3. Resident #3 was lifted to a standing position and transferred to the wheelchair. Resident #3 was lowered into the wheelchair. On initial rounds conducted on 04/01/14 at 8:55 AM, interview with LVN M revealed all lifts used in the facility required two people to operate the lifts. This practice was for safety reasons. Resident #3's MDS assessment, dated 02/20/14, and physician monthly orders, dated March 2014, reflected [DIAGNOSES REDACTED]. Resident #3's MDS assessment, dated 02/20/14, reflected a BIMS score of "15." Resident #3 under section G Functional Status had a score of "4/2." This indicated Resident #3 was totally dependent for staff performance and required the assistance of one person for transfer. Review of the section Balance During Transitions and Walking revealed Resident #3 for surface-to-surface transfer was not steady, only able to stabilize with staff assistance. Review of Resident #3's Care Plan under the problem section, dated 02/17/14, revealed the resident had ADL Self-Care Deficit. As evidenced by needs assistance with (specify self performance): "...2. Transfer Standing Lift x (times) 2 ( Requires two people to use lift)." Goal for Resident #3 was to continue to participate as able with daily ADLs with assistance of staff. The Approaches were provide adaptive/safety equipment such as standing lift. 3) Resident #5 was an [AGE] year-old female admitted to the facility on [DATE], per her quarterly MDS assessment, dated 01/28/14. Further review revealed she had [DIAGNOSES REDACTED]. Resident #5's MDS further reflected she was always incontinent of bowel and bladder, and was totally dependent on two staff members for transfers and one staff member for incontinent care. On 04/02/14 at 1:10 PM, during an observation of CNAs A and B using the sit-to-stand lift to change Resident #5, CNA A steered the sit-to-stand lift in front of Resident #5's wheelchair and placed the green sling around her chest under her left arm and fastened it to the lift while CNA B on the right of Resident #5 placed the sling under her right arm and attached it to the right side of the lift. CNA A grasped the belt part of the sling and pulled it around Resident #5's waist and buckled it but when she tried to tighten the slack she stated, "I can't tighten it, the thing is as old as I am," and left it hanging loosely around Resident #5's waist. CNA A instructed Resident #5 to hold on to the lift bars the sling was attached to and she began to push the button to lift Resident #5 to a standing position. (Neither CNA used the calf strap to secure Resident #5's lower legs to the machine as they were supposed to do.) Once Resident #5 was in a half-standing half-sitting position with her knees bent and her buttocks extending backwards towards CNA B and her arms extended over her head with the sling sliding almost to her elbows and the belt around her waist hanging loosely, the CNAs continued with changing Resident #5's incontinent brief. (During this entire procedure Resident #5 was hanging from the sling which had slipped to around her upper arms and she was still holding the bars with her hands.) Review of the facility's sit-to-stand lifts "Sabina II Instruction Guide," undated, provided by the DON on 04/03/14 revealed the following: "Place the SupportVest around the patient according to the instruction guide...Tighten the calf strap...." Review of the initial tour rounds conducted with LVN M on 04/01/14 from 8:45 AM through 10:50 AM, revealed there were 38 incontinent residents on Unit Two. Review of the list of residents who require the use of the Sit to Stand lift provided by LVN M on 04/03/14, revealed there were three residents on Unit Two who required the use of the Sit to Stand lift. 4) Resident #4 was a [AGE] year-old female admitted to the facility on [DATE], per her quarterly MDS assessment, dated 11/11/13. Further review of Resident #4's MDS revealed she had [DIAGNOSES REDACTED]. This document further reflected Resident #4 was always incontinent of bowel and bladder, was totally dependent on two staff members for transfers and one staff member for incontinent care. On 04/01/14 at 2:10 PM, the surveyor observed CNAs A and B performing a Hoyer lift transfer with Resident #4 from her Geri-chair to her bed. CNA A, with the Hoyer legs open, positioned the Hoyer lift in front of Resident #4 and together both CNAs attached the sling straps to the Hoyer lift. CNA A controlled the Hoyer and lifted Resident #4 up then CNA B pulled the Geri-chair back and CNA A put the Hoyer lift legs together and pulled back on the lift causing Resident #4's left foot to hit the machine. Resident #4 complained of hurting. CNA A continued to maneuver the lift backwards and then turned it to the right still with Resident #4 facing the machine and her left foot and lower leg hitting the lift. The Hoyer lift legs were still together as CNA A was maneuvering it about and Resident #4 was still facing the machine until CNA A got her almost over the bed and then CNA B swiveled Resident #4 so her side was closest to the machine and when they got her over the bed CNA A lowered her to the bed. On 04/02/14 at 1:10 PM, before the surveyor was to observe CNAs A and B work the sit-to-stand lift for Resident #5, CNA A asked the surveyor how they had done the previous day demonstrating the Hoyer lift with Resident #4. The surveyor informed her they had hit Resident #4's left foot and lower leg into the lift. The surveyor asked her if they could not have swiveled Resident #4 so her side was against the lift and avoided hitting her foot, and CNA A said that would make the lift tip. CNA A then turned to CNA B and said they had better do better this time because they had failed the Hoyer lift transfer. On 04/02/14 at 2:35 PM, the surveyor asked CNA G about the sling for the sit-to-stand lift. CNA G stated it should be snug about the chest of a resident before lifting. When asked about the legs position on the Hoyer lift when he had a resident up in it, he said the legs should be together while maneuvering it about the room. (The legs should be apart to prevent tipping of the Hoyer lift.) On 04/02/14 at 3:40 PM, the surveyor asked CNA I when she used the sit-to-stand lift how was the belt on the sling supposed to be fastened, and she stated it fastened in front of the resident about their torso snuggly, but not too tight. When asked which position the Hoyer lift legs should be in when she had a resident up in the sling and was maneuvering the machine, CNA I stated the legs were to be open to give it a wider base because the narrower it was the more likely it would be to tip. CNA I said the resident can be pivoted so their side is against the machine while maneuvering the Hoyer lift as long as the legs were apart. On 04/03/14 at 1:40 PM, the surveyor asked CNA H about the sit-to-stand sling, and CNA H stated the belt should be fastened firmly about the resident's waist. When asked about the Hoyer legs, she replied the Hoyer legs should be in the closed position or together when maneuvering it in a room with the resident up in it. On 04/03/14 at 9:46 AM, when the surveyor asked RN P about the sit-to-stand lift sling, he stated he would have to think about it or look at it, and then LVN M who was sitting nearby in the nurses' station stated the belt should be firm about the resident's waist. When asked about the Hoyer leg position when the resident was in it and it was being maneuvered around, RN P stated the legs should be together, and LVN M stated when a resident was in it the legs should be apart while maneuvering it. RN P said he thought the surveyor meant when there was no one in the Hoyer lift. LVN M stated it was also okay to pivot the resident so their side was against the lift while up in the sling to prevent their feet from hitting against the machine as long as the legs on the Hoyer were spread. 5) The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 04/02/14 and signed by LVN L, reflected the census was 83. A list of residents utilizing mechanical lifts provided by LVN M on 04/02/14 and 04/03/14, reflected eight residents. Two residents on the first floor utilized mechanical lifts, and six residents on the second floor utilized mechanical lifts. .