Every finding on record at Rolling Hills Care Center

Based on record review and interview, the facility failed to ensure medication was administered according to physician orders for 1 (#1) of 3 sampled residents reviewed for medication administration. The administrator identified 55 residents resided in the facility. A quarterly assessment for Resident #1, dated 03/27/26, showed the resident was severely cognitively impaired for daily decision making with a brief interview for mental status score of 0. An admission record for Resident #1, dated 04/18/26, showed the resident had diagnoses which included Alzheimer's disease, dementia, hypertension, and depression. A physician order for Resident #1, dated 05/14/26, read in part, Risperdal oral tablet 1mg. Give one tablet by mouth two times a day. A physician order for Resident #1, dated 05/14/26, read in part, metoprolol succinate extended-release oral tablet 24-hour 50 mg. Give one tablet by mouth one time a day. On 06/02/26 at 11:13 a.m., CMA #2 stated they did not crush medications for Resident #1 because they did not have an order to crush the medications. On 06/02/26 at 11:17 a.m., CMA #1 stated they crushed the medications for Resident #1 on two occasions because Resident #1 appeared to have a slight problem swallowing upon returning from the hospital. CMA #1 stated there was not an order for Resident #1 to have their medications crushed. On 06/02/26 at 2:00 p.m., the director of nursing stated medications should not be crushed without an order. On 06/05/26 at 3:30 p.m., Pharmacist #1 stated if Risperdal or metoprolol succinate were crushed, they would not cause clinical harm.

Based on observation, record review, and interview, the facility failed to ensure 1 (treatment cart #1) of 3 treatment carts observed were locked.The DON reported 50 residents resided in the facility.On 12/02/25 at 10:57 a.m., treatment cart #1 was observed to be South of the nurse's station, unlocked and unattended. On 12/02/25 at 10:58 a.m., LPN #1 was observed sitting on the North side of the nurse's station with their back to treatment cart #1. The cart was observed to be unlocked and unattended. On 12/02/25 at 3:03 p.m., treatment cart #1 was observed to be unlocked and unattended on the South side of the nurse's station. On 12/02/25 at 3:04 p.m., LPN #2 was observed to walk out the of the storage closet on Hall A, toward treatment cart #1 located on the South side of the nurse's station. Treatment cart #1 was observed to be unlocked and unattended. On 12/02/25 at 3:06 p.m., RN #1 was observed to stand in room A1 on Hall A. Treatment cart #1 was observed to be unlocked and unattended. On 12/08/25 at 12:51 p.m., treatment cart #1 was observed to be unlocked and unattended located on the South side of the nurse's station. On 12/08/25 at 12:52 p.m., LPN #1 was observed to walk away from treatment cart #1, the cart remained unlocked. A facility policy titled Security of Medication Cart, revised 04/2007, read in part, 1. The nurse must secure the medication cart during pass to prevent unauthorized entry .4. Medication carts must be securely locked at all times when out of the nurse's view .5. When the medication cart is not being used, it must be locked and parked.On 12/02/25 at 11:00 a.m., LPN #1 stated treatment carts were to be supervised and locked. They stated, they could not see the treatment cart while facing the opposite direction of the cart.On 12/02/25 at 12:13 p.m., the DON stated they used the medication cart policy for their treatment carts procedures. On 12/02/25 at 12:14 p.m., the DON stated treatments carts were to be secured and supervised. On 12/02/25 at 3:07 p.m., LPN # 2 stated treatment cart #1 was out of their sight while they were in the storage closet. On 12/02/25 at 3:07 p.m., RN #1 stated they had gotten a bandage from the treatment cart and had left the treatment cart unlocked. They stated all nursing staff were responsible to lock the treatment carts. On 12/02/25 at 3:08 p.m., RN #1 stated nursing staff were to lock the treatment cart after every use. RN #1 stated they could not see the treatment cart from the resident's room. On 12/08/25 at 12:53 p.m., LPN #1 stated they had left treatment cart #1 unlocked and unattended.

Based on record review and interview, the facility failed to ensure assessments were accurate for 1 (#26) of 2 sampled residents reviewed for indwelling urinary catheters.LPN #1 identified four residents had indwelling urinary catheters.Findings: Based on record review and interview, the facility failed to ensure assessments were accurate for 1 (#26) of 2 sampled residents who were reviewed for indwelling urinary catheters. LPN #1 identified four residents who had indwelling urinary catheters. Findings: On 12/03/25 at 9:38 a.m., Resident #26 was observed in their room. An indwelling urinary catheter bag was observed to hang from their chair. On 12/09/25 at 11:30 a.m., LPN #1 and CNA #1 were observed to provide care to the resident's suprapubic catheter. A policy titled, MDS Assessment Coordinator, dated November 2019, read in part, Each individual who completes a portion of the assessment [MDS] must certify the accuracy of that portion of the assessment by: a. Dating and signing the assessment [MDS]; and b. Identifying each section completed. A physician order, dated 08/02/25, showed Resident #26 was to receive catheter care for indwelling urinary catheter every shift. A medication administration/treatment administration record, dated November 2025, showed Resident #26 had received care for their indwelling urinary catheter. A quarterly assessment, dated 11/12/25, showed Resident #26 had an indwelling urinary catheter and was always incontinent of urine. A care plan, dated 11/13/25, showed Resident #26 had an indwelling urinary catheter. On 12/09/25 at 11:59 a.m., the DON stated Resident #26 was admitted with an indwelling urinary catheter and they were responsible to complete assessments. They reviewed the quarterly assessment, dated 11/12/25, and stated they should have coded the assessment as 'not rated' rather than always incontinent of urine.

Based on record review and interview, the facility failed to close out trust accounts and convey funds within 30 days for three (#115, #116, and #18) of three residents reviewed for open trust accounts and had been discharged from the facility over 30 days. The Business Office Director identified five residents who no longer resided in the facilty and trust accounts were not closed out within 30 days. Findings: 1. Resident #115 discharge summary documented the resident had been discharged from the facility on 10/11/23. Resident #115 trust account ledgers, dated 05/07/23, documented the resident had an open trust account balance of $$3,577.07. 2. Resident #116 discharge summary documented the resident had been discharged from the facility on 08/02/23. Resident #116 trust account ledgers, dated 05/07/23, documented the resident had an open trust account balance of $2,617.85. 3. Resident #118 discharge summary documented the resident had been discharged from the facility on 07/14/23. Resident #118 trust account ledgers, dated 05/07/23, documented the resident had an open trust account balance of $93.41. On 05/09/24 at 9:30 a.m., the businesss office manager stated Resident #115, Resident #116 and Resident #118 were no longer in the facility and had open trust accounts. The business office manager then stated the home office was responsible for making sure the trust accounts were closed out within 30 days. On 05/09/24 at 10:17 a.m., the administrator stated Resident #115, Resident #116 and Resident #118 trust accounts had not been closed within 30 days.

Based on record review and interview, the facility failed to ensure residents who received medicaid and had money in the trust account were notified of balances within $200 of the social security resource limit of $2,000 for three (#9, #13 and #45) of three sampled residents reviewed for trust account balances. The business office manager identified 33 residents who had a payer source as medicaid and had money in the resident trust account. Findings: An undated Accounting of Resident Funds policy, read in part, .a representative of the business office informs the resident if the balance in personal funds account reached $200 less than the .resource limit . 1. Resident #9 trust account ledger, documented they had a current balance of $2,063.56 on 05/07/24. The admission summary documented Resident #9 had a payer source of medicaid. 2. Resident #13 trust account ledger,documented they had a current balance of $2,650.20 on 05/07/24. The admission summary documented Resident #13 had a payer source of medicaid. 3. Resident #45 trust account ledger, dated 05/07/24, had a current balance of $4,694.08 on 05/07/24. The admission summary documented Resident #45 had a payer source of medicaid. There was no documentation in the trust account records of the clinical record Resident #9, Resident #13, and Resident #45 had received notices when they were within $200 of the resource limit for medicaid residents in the trust account. On 05/09/24 at 9:30 a.m., the business office manger stated Resident #9, Resident #13, and Resident #45 all had a payer source of medicaid. They further stated their was no documentation the facility had provided notices to Resident #9, Resident #13, and Resident #45 when they were within $200 of the $2,000 resource limit. On 05/09/24 at 10:17 a.m., the administrator stated the facility did not provide notices to Resident #9, Resident #13, and Resident #45 when they were within $200 of the $2,000 resource limit.

Based on record review and interview, the facility failed to ensure summaries of the admission care plan was provided to residents for three (#35, #51 and #114) of three newly admitted residents reviewed for base line care plans. The facility form 802 matrix identified four residents who had been admitted to the facility in the past 30 days. Findings: 1. Resident #35 admission summary documented they were admitted to the facility on [DATE]. Resident #35 base line care plan was completed on 02/22/24. There was no documentation on the base line care plan or in the clinical record to indicate Resident #35 received a summary of their care plan. 2. Resident #51 admission summary documented they were admitted to the facility on [DATE]. Resident #51 base line care plan was completed on 02/21/24 There was no documentation on the base line care plan or in the clinical record to indicate Resident #51 received a summary of their care plan. 3. Resident #114 admission summary documented they were admitted to the facility on [DATE]. Resident #114 base line care plan was completed on 04/24/24. There was no documentation on the base line care plan or in the clinical record to indicate Resident #114 received a summary of their care plan. On 05/06/24 at 10:12 a.m., Resident #114 stated they did not receive a summary or a copy of the care plan completed on admission. On 05/06/24 at 10:42 a.m., Resident #51 stated they had not participated or received a copy or summary of their care plans. On 05/06/24 at 1:56 p.m., Resident #35 stated they did not receive a summary or a copy of the care plan completed on admission. On 05/08/24 at 9:19 a.m., the director of nursing stated the social service director was responsible for providing copies of or the summary of the care plans. On 05/08/24 at 10:01 a.m., the social service director stated summaries and copies of the base line care plan was not provided unless the family or resident requested it.

Based on record review and interview, the facility failed to document on a preadmission screening and resident review a mental health illness for one (#51) of one resident reviewed for the need of a level two screening. The director of nursing identified seven residents who had an active diagnosis of bipolar disorder. Findings: Resident #51 was admitted to the facility on [DATE] with an active diagnosis of bipolar disorder, a mental health illness. The admission base line care plan, dated 02/22/24, documented Resident #51 received an antidepressant medication to treat bipolar disorder. An admission assessment, dated 02/28/24, documented the resident had an active diagnosis of bipolar disorder. A level one preadmission screening and resident review, dated 02/27/24, documented the resident had a diagnosis of bipolar. The assessment question two under level was checked as no to indicate Resident #51 did not have a mental health illness. On 05/09/24 at 8:50 a.m., the assistant director of nursing stated Resident #51 did not have a mental health illness. They reviewed Resident #51 diagnosis and stated Resident #51 did have a diagnosis of bipolar which was a mental health illness. The assistant director of nursing then stated they would need to call due to the level one preadmission screening and resident review being filled out wrong.

Based on observation and interview, the facility failed to provide a clean and safe environment for two (#1 and #145) of 16 residents who resided on hall E in the facility. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 45 residents resided in the facility. Findings: A Cleaning and Disinfecting of Residents' Rooms policy, revision date August 2013, documented .The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms . Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . 1. Resident #1 had diagnoses which included dementia and anxiety disorder. A Care Plan, dated 04/19/18, documented the resident was at risk for incontinence. A Quarterly MDS Assessment, dated 01/07/23, documented the resident had severe cognitive impairment and required extensive assistance with toileting. The assessment documented the resident was always incontinent. 2. Resident #145 had diagnoses dementia and anxiety disorder. A Care Plan, dated 03/11/23, documented the resident was at risk for incontinence. An Admission MDS Assessment, dated 03/18/23, documented the resident had severe cognitive impairment and required supervision with toileting. The assessment documented the resident was occasionally incontinent of bladder and frequently incontinent of bowel. On 03/27/23 at 12:35 p.m., resident #1 and #145's shared restroom in room E4 was observed to have a brown/ black substance on the wall and rubber base. The resident's room was observed with a hole where a television cable was coming out of the wall and there was not a secure faceplate covering. On 03/28/23 at 11:13 a.m., the maintenance director observed the brown/black substance on the resident's restroom wall. She obtained cleaner to try to get the substance off the wall and some of the substance came off the wall with the cleaner. She stated housekeeping staff should have scrubbed/cleaned the wall and applied some paint to the wall. The maintenance director stated all cables should have a faceplate covering. She stated she was not aware of any unsecured faceplates in the resident's room E4. She observed the unsecured faceplate in room E4 and stated the faceplate must have just come loose from the wall and she indicated she would get some screws and secure the faceplate. On 03/28/23 at 11:17 a.m., the housekeeping supervisor stated resident rooms were cleaned daily. She stated if a brown/black substance was on the wall, housekeeping staff should have cleaned the substance off the wall. She stated room E4 was down for a deep clean at the beginning of each month on the 7th. She stated all plugs and cords should have faceplates. She stated she was unaware of any unsecured faceplates in the resident's room E4. On 03/28/23 at 12:13 p.m., two housekeeping staff members were observed to take cleaning supplies to room E4 and scrubbed the walls and rubber bases. The substance was removed from the walls and the rubber bases. On 03/28/23 at 4:15 p.m., the DON stated housekeeping had a schedule to clean the rooms and deep clean the rooms. She stated if a resident was able to independently use the restroom, the housekeeping staff should be checking the cleanliness of the restroom and the walls daily. She stated she would expect a faceplate to be on all cords or open areas. On 03/30/23 at 10:36 a.m., the Administrator stated she would expect the resident restrooms to be cleaned daily, and if there was a brown substance on the wall she would expect it to be cleaned off the wall. She stated she would expect all outlets and cords coming out of the wall to have face plates.

Based on record review, observation, and interview, the facility failed to obtain and follow the physician's order for Tubigrip stockings for one (#29) of one sampled resident reviewed for Tubigrip stockings. The Resident Census and Conditions of Residents report, dated 03/27/23, identified 45 residents who resided in the facility. Findings: A policy, Telephone Orders, dated February 2014, read in parts, .Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc.) .The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information . A Quarterly MDS Assessment, dated 02/10/23, documented the resident was cognitively intact and required extensive two person assist with bed mobility, transfers, and dressing. A Plan of Care, dated 02/11/23, read in parts, .Infection: I have an infection of the bone Osteomyelitis (left knee), I will remain free from discomfort, complications, or s/s related to my infection through the review date, administer medications and/or treatments per orders, monitor for adverse side effects and notify Dr as needed, encourage me to consume fluids, monitor for c/o pain, monitor for s/sx of adverse reaction to medication . A Physician Progress Note, dated 03/17/23, documented chronic joint infection and the resident would benefit from PT/OT. A Nurse Progress Note, dated 03/17/23, documented the resident returned from [name deleted-clinic] with recommendations for PT/OT. WBAT for L leg. Continue with Tubigrip on BLE. On 03/27/23 at 3:13 p.m., resident #29 was observed without stockings on BLE. The resident stated, I was supposed to be wearing stockings because I have a history of knee surgery. On 03/28/23 at 9:17 a.m., resident #29 was observed without stockings to the BLE. A Physician Order, dated 03/29/23, (on the day of survey), read in parts, .Tubigrip on at all times except for bath time. May take off at bedtime if resident request . On 03/29/23 at 12:35 p.m., LPN #2 was asked about resident #29's stockings. The LPN stated the resident had their stockings on today. LPN #2 stated they were not here on Monday (03/27/23) and when they realized the resident was not wearing the stockings on Tuesday (03/28/23) they put them on. On 03/29/23 at 12:38 p.m., resident #29 was observed in the dining room with Tubigrip stockings to BLE. The resident stated, The stockings really help my legs feel better. On 03/29/23 at 12:57 p.m., LPN #2 reported they ordered resident #29's Tubigrip stockings on Friday, 03/17/23, and the stockings arrived by Tuesday, 03/21/23. On 03/29/23 at 1:22 p.m., the DON was asked about resident #29's stockings. The DON reported LPN #2 forgot to put the order in the computer. The DON stated the resident was asking the LPN about the stockings, the LPN contacted the physician to get the order, and the communication was documented in the nurse progress note dated 03/17/23.

Based on record review, observation, and interview, the facility failed to provide a privacy curtain for one (#145) of 12 sampled residents who required a privacy curtain. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 45 residents resided in the facility. Findings: Resident #145 had diagnoses of dementia and anxiety disorder. A Care Plan, dated 03/11/23, documented the resident was at risk for incontinence. An Admission MDS Assessment, dated 03/18/23, documented the resident had severe cognitive impairment and required supervision with toileting. On 03/27/23 at 1:05 p.m., resident #145's room was observed to have only one privacy curtain for two residents who resided in the room. On 03/28/23 at 10:55 a.m., CNA #1 reported two curtains were to be hung in a room with two residents to provide privacy. The CNA observed resident #145's room and stated there should have been two privacy curtains in the room. The CNA stated she had not noticed the missing curtain and had not reported it to maintenance. On 03/28/23 at 11:02 a.m., LPN #1 reported there should be two curtains hung in a room with two residents to provide privacy. The LPN stated she had not noticed a missing privacy curtain in resident #145's room and had not reported the missing curtain. On 03/28/23 at 11:08 a.m., the maintenance director stated the missing privacy curtain in resident #145's room had not been reported to her. She stated the curtains were used to provide privacy and there should be two curtains hung in each room where two residents resided. She stated she would get housekeeping to hang the privacy curtain. On 03/28/23 at 4:11 p.m., the DON reported if there were two residents who resided in the room there should be two privacy curtains. The DON indicated the curtains were to help create privacy for the residents during care or visitation. On 03/30/23 at 10:34 a.m., the Administrator reported two privacy curtains should be hung in a room with two residents who reside in the same room. The Administrator was made aware of the observations during the survey and reported the facility did not have a policy related to privacy curtains.

Based on record review, observation, and interview, the facility failed to maintain the kitchen with professional standards to ensure a clean, sanitary environment. The Resident Census and Conditions of Residents report, dated 03/27/23, identified 44 residents who received nutrition from the facility's kitchen and one resident received enteral nutrition. Findings: A Cooks Cleaning List, dated 3/20/23 through 03/26/23, documented cleaning was to be performed on Monday, Tuesday, Wednesday, and Thursday. This list did not include cleaning for air conditioning vents or the dishwasher area. On 03/28/23 at 11:13 a.m., a kitchen tour was conducted. A six-foot area of wet towels was observed on the floor along the wall behind the dishwashing machine. Dietary aide #1 was asked about the towels underneath the dishwasher. The aide removed several wet towels with black spots on them that were on the floor tucked in behind the dishwasher. The area behind the dish machine was approximately a six- foot area along the back of the wall with a black scum-like substance extending up the wall tiles behind the dish machine. The dietary supervisor was asked about the towels. She stated, There was a leak in the pipes and they had an issue with the garbage disposal. She stated, There should not be a leak now, it was fixed. The dietary supervisor reported the maintenance director fixed the leak about two weeks previous and the garbage disposal was repaired as well. The dietary supervisor was asked why the towels were behind the dishwasher and stated, I'm not sure why they keep throwing the towels behind there. The dietary supervisor got a cleaning bucket and began to clean the scum (black thick substance) off the wall tiles behind the dishwasher. On 03/28/23 at 11:30 a.m., air conditioning vents in the kitchen above the sink were observed to be covered with a brownish, greasy substance. The dietary supervisor was asked when the air conditioning vents were last cleaned and they reported they weren't sure when the maintenance director had cleaned them. They were asked to describe the substance on the air conditioning vents and described it as a greasy, brown-colored substance. They stated they mixed cool aid at the sink located beneath the vents and thought that might have splattered on the vents. On 03/28/23 at 11:48 a.m., the maintenance director was asked about the air conditioning vents. They stated they cleaned the air conditioning vents about six months ago. They were asked about a leak under the dishwasher and reported they had repaired it a couple of weeks ago. They reported the garbage disposal had an issue and they fixed that as well. On 03/28/23 at 12:41 p.m., the maintenance director submitted documentation the air conditioner filters were changed in the kitchen for January, February, and March 2023. An invoice, dated 03/17/23, indicated the garbage disposal had been repaired.

Based on observation and interview, it was determined the facility failed to ensure a table was not wedged into a memory care doorway to prevent residents from exiting the unit while the door was held open by a metal cabinet. The facility identified 17 residents living on the memory care unit. Findings: On 07/30/21 at 11:17 p.m., LPN #2, CNA #1, and CNA #2 [in training] were observed sitting at the nurses' station. LPN #2 reported there were three staff in the building and RN #1 was on the way to work. She identified the census at that time to be 61 residents. The door to the memory care unit was observed to be held open by a metal cabinet and a table was located inside the doorway. At 11:25 p.m., CNA #1 and CNA #2 removed the table, entered the memory care unit and once again place the table in the doorway. One resident was observed walking in the memory care day room. The two CNA's then departed the memory unit and replaced the table into the doorway. Inspection of the table found it was wedged tightly in the door frame. On 07/31/21 at 12:00 a.m., RN #1 entered the facility. At 12:10 a.m., the DON was observed in the building. At 12:20 a.m., LPN #2 was observed to remove the table to enter the memory unit. At 12:21 a.m., LPN #2 replaced the table in the memory care doorway after departing the unit. At 12:35 a.m., administrator #2 was observed in the building. At 12:45 a.m., administrator #2 was observed to remove the table in the memory care doorway to enter and then replace it when he departed. At 1:00 a.m., the DON removed the table in the memory care doorway to enter the unit then replaced in the doorway when he departed. At 1:00 a.m., RN #1 was asked why the table was kept in the doorway of the memory care unit. She stated it was so the staff could see into the unit while they worked in other parts of the facility. She stated they did not have enough staff to keep a person on the unit to watch the memory care residents. She stated she knew the door should have been closed and locked. She was asked how long had the table been used in that manner. She stated she had worked at the facility for four months and the table had been used to block the door during that period. She was asked if she felt it was a safe alternative to a locked door with staff member on the unit itself. She stated it was not. At 1:10 a.m., the DON was asked why the table was used to block the memory care doorway. He stated it was because of the short staffing related to COVID-19. He was asked if the table used in that manner was safe for the residents of the unit. He stated it was not an egress. He stated the table was to be put in the doorway when staff did their rounds and that a CNA was to go onto the unit when they were not rounding.

Based on interview and record review, it was determined the facility failed to ensure uncertified and untrained staff did not provide personal care to residents for one (#7) of six residents reviewed for ADL help. The DON identified 61 residents who received personal care at the facility. Findings: A staffing policy, revised date October 2017, documented, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .Licensed nurses and certified nursing assistants are available 24 hours a day to provided direct care services . Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/09/21, documented the resident's cognition was intact and required extensive assistance from staff for performance of activities of daily living including personal hygiene and bathing. Review of the daily staffing schedule, dated 07/03/21, documented housekeeper #1 under the section for CNA's for the night shift. Review of housekeeper #1's time detail, dated 07/03/21-07/04/21, documented the housekeeper worked on the night shift from 9:56 p.m. until 6:00 a.m. On 08/02/21 at 11:46 a.m., housekeeper #1 was asked what department she was assigned. She stated the housekeeping department. She was asked if she was a certified nurse aide. She stated she was not. She was asked if in the current year had she performed duties outside of the housekeeping department. She stated she had been asked by administrator #1 to assist with cleaning up the residents on 07/02/21. She stated she initially had refused but did end up performing incontinent care, changing he residents and their bed linen. Housekeeper #1 added that the resident had been wet and they had to be changed. She was asked if any other staff members had assisted with resident care that night. She stated laundry #1 had helped. She was asked if she had received any training in resident care prior to performing those tasks. She stated she had not. On 08/02/21 at 11:39 a.m., the business office manager was asked for the CNA certification and/or training for housekeeper #1. She state the housekeeper did not have a certification. She stated she would assist with delivering food trays/drinks and assisted with things the residents needed. On 08/02/21 at 12:40 p.m., laundry #1 was asked to what department she was assigned. She stated the laundry. She was asked if she was a certified nurse aide. She stated she was not. She was asked if in current year she had performed duties outside of the laundry. She stated she had worked as a cook in the kitchen and had performed resident personal care. She was asked why she had performed those duties. She stated there had not been enough staff on duty and it needed to be done. She was asked if anyone had asked her to performed those duties. She stated no one specifically told her to do those but she had informed administrator #1 that there was no staff she did not indicate what we should do. She was asked what type of care she had given to the residents. She stated they had performed incontinent care, fed them, and transferred them. She was asked if she had received training as a nurse aide prior to giving care. She state she had not. On 08/03/21 at 9:41 a.m., resident #7 was asked if anyone other than members of the nursing department had assisted her with personal care. She stated that laundry #1 had performed incontinent care for her around 07/04/21 but she was not sure of the exact date. She was asked if she knew why the nursing staff members had not helped her. She stated there were not any working that night except maybe one nurse. She stated she had been told by laundry #1 that there were not enough staff in the building that night. On 08/03/21 at 11:15 a.m., CNA #3 was asked if the facility had enough staff to take care of the residents' needs. She stated the day shift was short staffed. She was asked if residents had not received showers/baths due to not having enough staff. She stated yes. She stated last week the residents scheduled for showers on the day shift had not received them because they did not have enough staff. She stated on 08/02/21 the residents had also not received baths. She stated the priority was providing incontinent care to the residents when they were short staffed. She stated they tried to turn and reposition residents every two hours but that was difficult when there was not enough staff. At 11:41 a.m., CMA #1 was asked if the facility had enough staff to take care of the residents' needs. She stated, We are short staffed. She stated they needed more help on the day shift. She stated some residents had not received showers due to not having enough staff. At 11:57 a.m., LPN #3 was asked if the facility had enough staff to take care of the residents' needs. She stated no. She stated the evening shift had been staffed better lately but the day shift did not have enough. She was asked if non-nursing staff had performed CNA duties. She stated yes. She named housekeeper #1. At 12:12 p.m., LPN #4 was asked about the staffing in the facility. She stated they had major issues with staffing. She stated staff were hired but would not show up to work. She was asked if there were enough staff to take care of the residents' needs. She stated no. She stated the care provided was minimal because sometimes they only had two CNA's. She stated they were not able to provide showers when they were short staffed. At 1:15 p.m., administrator #2 was asked if the facility had enough staff to perform all care for residents each shift. He stated not always. He was asked if non-nursing staff had worked as CNA's. He stated he had heard of it happening but it had not occurred while he was on duty. He was asked if showers/baths had been provided as scheduled. He stated no. He stated if a resident had not received their shower on the scheduled day they received it the following day. At 3:19 p.m., RN #1 was asked if she had ever worked with unlicensed/uncertified staff as CNA's. She stated yes. She stated on 07/03/21 she was the only nursing staff on the over night shift. She was asked if she notified anyone that no one was in the facility to assist her. She stated former administrator #1 and the DON were made aware. She stated the administrator was in the facility and assisted her on that shift. She stated former administrator #1 had notified the corporate administrator of the staffing situation on that shift. She was asked what duties former administrator #1 had performed. She stated she did laundry, loaded the linen cart while she provided incontinent care, assisted to ensure residents did not fall off their beds while she performed incontinent care, and provided water. She was asked if residents had ever not received their medications due to staffing. She stated yes. She stated the weekend of 07/04/21 or the weekend after 07/04/21 there was not a CMA to pass medications. She stated she was on duty and assisted the CNA's on the floor. She stated there were other nurses in the facility but medications had not been administered. She was asked if on the night shift, beginning 07/03/21, was she was able to perform her nursing tasks. She stated no. She stated she was able to provide incontinent care to the residents. On 08/04/21 at 9:46 a.m., the DON was asked about the facility's staffing. He stated staffing was an on-going struggle due to turnover of staff. He stated they hired staff but they quit. He stated they used to have contracts with two nursing agency companies but there had been issues with the time they had turned in so they no longer contracted with them. He stated they offered incentives to the facility staff to work extra shifts, and had an internal corporate float pool. He was asked if there had been enough staff to take care of the residents' needs. He stated no. He was asked if there was enough staff on evenings, nights, and weekends. He stated evenings and nights were the most adequately staffed shifts. He stated weekend staffing was a chronic concern. He stated they now offered Baylor pay. He was asked if non-nursing staff had worked as CNA's. He stated yes. He stated housekeeper #1 and laundry staff member #1 had worked as CNA's. He stated he did not know to what extent they had provided care because he was not in the facility. He was asked if showers/baths had been provided as scheduled. He stated they did their best to follow the shower schedule. He stated if a resident refused a shower they would alternate their schedule. He was asked if residents had not received showers/baths due to insufficient staffing. He stated, I'm sure. He was asked what the protocol was if the facility did not have adequate staffing on a shift. He stated they were to notify the administrator and the staff coordinator. He was asked about the shifts in which the facility did not have adequate staff to meet state minimum staffing requirements. He stated it was hard to find someone to come to work when staff unexpectedly quit. He stated he was careful on how he utilized his hours. He was asked who was responsible to ensure there was adequate staff in the building to provide resident care. He stated the administrator was responsible for staffing. He stated corporate had measures in place to ensure the DON could focus on DON duties.

Based on interview and record review, it was determined the facility failed to ensure sufficient nursing staff was available to provide adequate nursing care to four (#3, #6, #7 and #12) of five residents reviewed for sufficient staffing. The DON identified 61 residents who received nursing care in the facility. Findings: A staffing policy, revised date October 2017, documented, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .Licensed nurses and certified nursing assistants are available 24 hours a day to provided direct care services . 1. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan focus, dated 04/06/21, documented the resident had a potential for impairment to his skin integrity related to fragile skin, incontinence, and impaired mobility. A care plan intervention, dated 04/06/21, documented, Administer medications, supplements, and/or treatments per orders, monitor for adverse side effects and notify Dr as needed. A care plan focus, dated 04/06/21, documented the resident had a self care deficit related to his acute and chronic illnesses. A care plan intervention, dated 04/06/21, documented the resident required staff assistance with personal hygiene and bathing. A progress note, dated 05/06/21 at 1:02 p.m., documented the resident had returned from a dermatology appointment with a progress note which stated the resident had numerous [CONDITION(S)] carcinomas on his legs, arms, and face. The note further documented the dermatology office would contact the facility when they know which type of medication would be used based on the resident's insurance. A medication order, start date 05/20/21, documented [MEDICATION(S)] Cream 5% to be applied to arms, legs, and face topically every Monday, Tuesday, Wednesday, Thursday, and Friday for integumentary system for six weeks. A treatment administration record, dated May 2021, lacked documentation to indicate if [MEDICATION(S)] cream 5% was administered on 05/21/21 and 05/27/21. The treatment administration record documented 8:00 p.m. as the time the cream was to have been applied. On 07/26/21 at 9:15 a.m., the resident was contacted via telephone. The resident was asked if he had received baths or showers while at the facility. He stated he had only had three or four showers during his time there. He was asked if he had been given a reason for not receiving his baths. He stated he was told there was not enough staff. He was asked if he could identify any staff that had said they could not offer care because of short staffing. He stated he recalled RN#1 did but he could not recall the names of the others. The resident was asked if he had received [MEDICATION(S)] cream as ordered by his physician. He stated he had not and believed he had gone one week without it. 2. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/11/21, documented the resident was cognitively intact for daily decision making, required physical help in part of bathing activity from one staff member. The ADL sheets, dated May 2021, documented the resident was to receive a shower on Tuesday, Thursday, and Saturday. Review of the May 2021 ADL sheets revealed the resident received five showers out of 12 opportunities. A care plan, updated 06/12/21, documented, .I have an ADL self care deficit related to acute and/or chronic illness resulting in deconditioning, muscle weakness, fatigue and [CONDITION(S)] .Goal .I will have my needs met with the assistance of staff through the next review .I require supervision to extensive assist with my ADL functioning . The ADL sheets, dated June 2021, documented the resident was to receive a shower on Tuesday, Thursday, and Saturday. Review of the June 2021 ADL sheets revealed the resident received six showers out of 13 opportunities. The ADL sheets, dated 07/01/21 through 07/27/21, documented the resident was to receive a shower on Tuesday, Thursday, and Saturday. Review of the July 2021 ADL sheets revealed the resident received six showers out of 12 opportunities. On 07/27/21 at 2:00 p.m., the resident was asked if she had received showers/baths as scheduled. She stated no. She stated the facility was short staffed sometimes and the showers were not offered/provided. 3. Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/09/21, documented the resident's cognition was intact and required extensive assistance from staff for performance of activities of daily living including personal hygiene and bathing. 4. Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 04/30/21, documented the resident was cognitively intact for daily decision making and was totally dependent on staff for bathing. A care plan, updated 05/01/21, documented, .I have an ADL self care deficit related to acute and/or chronic illness resulting in deconditioning, [CONDITION(S)], deformity of my hip .Goal .I will have my ADL needs met with the assistance of staff through the next review .Assist me with my ADL functioning as needed .Whirlpool bath Tuesday, Thursday, Saturday . The ADL sheets, dated June 2021, documented the resident had showers scheduled weekly on Monday, Wednesday, and Friday. Review of the June 2021 ADL sheets revealed the resident received six showers/baths out of 13 opportunities. On 07/27/21 at 9:28 a.m., the resident was asked if she received showers/baths as scheduled. She stated she had not received enough showers/baths. On 08/03/21 at 11:15 a.m., CNA #3 was asked showers were provided to the residents as scheduled. She stated no. She stated last week the residents scheduled for showers on the day shift had not received them because they did not have enough staff. She stated on 08/02/21 the residents had also not received showers/baths. At 11:41 a.m., CMA #1 was asked if residents received their showers as scheduled. She stated no. She stated at times showers were not provided due to a lack of staff. At 11:57 a.m., LPN #3 was asked if residents received their showers as scheduled. She stated no. She was asked if residents had missed showers due to a lack of staff. She stated yes. At 1:15 p.m., administrator #2 was asked if residents received showers as scheduled. He stated if the staff had not provided the resident a shower on their scheduled day they offered them a shower the next day. Review of the daily staffing schedule, dated 07/03/21, documented housekeeper #1 under the section for CNA's for the night shift. Review of housekeeper #1's time detail, dated 07/03/21-07/04/21, documented the housekeeper worked on the night shift from 9:56 p.m. until 6:00 a.m. On 08/02/21 at 11:46 a.m., housekeeper #1 was asked what department she was assigned. She stated the housekeeping department. She was asked if she was a certified nurse aide. She stated she was not. She was asked if in the current year had she performed duties outside of the housekeeping department. She stated she had been asked by administrator #1 to assist with cleaning up the residents on 07/02/21. She stated she initially had refused but did end up performing incontinent care, changing he residents and their bed linen. Housekeeper #1 added that the resident had been wet and they had to be changed. She was asked if any other staff members had assisted with resident care that night. She stated laundry #1 had helped. She was asked if she had received any training in resident care prior to performing those tasks. She stated she had not. At 11:39 a.m., the business office manager was asked for the CNA certification and/or training for housekeeper #1. She state the housekeeper did not have a certification. She stated she would assist with delivering food trays/drinks and assisted with things the residents needed. At 12:40 p.m., laundry #1 was asked to what department she was assigned. She stated the laundry. She was asked if she was a certified nurse aide. She stated she was not. She was asked if in current year she had performed duties outside of the laundry. She stated she had worked as a cook in the kitchen and had performed resident personal care. She was asked why she had performed those duties. She stated there had not been enough staff on duty and it needed to be done. She was asked if anyone had asked her to performed those duties. She stated no one specifically told her to do those but she had informed administrator #1 that there was no staff she did not indicate what we should do. She was asked what type of care she had given to the residents. She stated they had performed incontinent care, fed them, and transferred them. She was asked if she had received training as a nurse aide prior to giving care. She state she had not. On 08/03/21 at 9:41 a.m., resident #7 was asked if anyone other than members of the nursing department had assisted her with personal care. She stated that laundry #1 had performed incontinent care for her around 07/04/21 but she was not sure of the exact date. She was asked if she knew why the nursing staff members had not helped her. She stated there were not any working that night except maybe one nurse. She stated she had been told by laundry #1 that there were not enough staff in the building that night. On 08/03/21 at 3:19 p.m., RN #1 was asked if any residents had missed medications due to insufficient staffing. She stated yes. She was asked what the circumstances were behind residents not receiving medications. She stated the weekend of 07/04/21 or the weekend after, there was not a CMA on duty. She stated the facility had one nurse aide and three nurses including herself. She stated she performed CNA duties for that shift. On 08/03/21 at 10:00 a.m., the DON was asked about the resident's medications not documented as administered. He stated he would look into it. He was asked if he was aware of any medication errors due to residents not receiving their scheduled medications. He stated no. On 08/04/21 at 9:46 a.m., the DON was asked if showers/baths had been provided as scheduled. He stated they did their best to follow the shower schedule. He stated if a resident refused a shower they would alternate their schedule. He was asked if residents had not received showers/baths due to insufficient staffing. He stated, I'm sure. He was asked if the facility had been able to provide all resident care to the residents on each shift. He stated no.

Based on interviews and record review, it was determined the facility failed to ensure residents received assistance with personal hygiene and bathing for three (#3, #6 and #12) of six residents reviewed for ADL assistance. The DON identified 61 resident who required ADL assistance. Findings: 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan focus, dated 04/06/21, documented the resident had a self care deficit related to his acute and chronic illnesses. A care plan intervention, dated 04/06/21, documented the resident required staff assistance with personal hygiene and bathing. A document, titled Documentation Survey Report, dated June 2021, documented under the subheading, Bathing and Nail Care, the resident did not receive such care on twenty-seven of the thirty days that month. An admission assessment, dated 04/12/21, documented the resident was cognitively intact, required extensive assistance with personal hygiene and bathing, and was always incontinent of bowel. On 07/26/21 at 9:15 a.m., the resident was contacted via telephone. The resident was asked if he had received baths or showers while at the facility. He stated he had only had three or four showers during his time there. He was asked if he had been given a reason for not receiving his baths. He stated he was told there was not enough staff. 2. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/11/21, documented the resident was cognitively intact for daily decision making, required physical help in part of bathing activity from one staff member. The ADL sheets, dated May 2021, documented the resident was to receive a shower on Tuesday, Thursday, and Saturday. Review of the May 2021 ADL sheets revealed the resident received five showers out of 12 opportunities. A care plan, updated 06/12/21, documented, .I have an ADL self care deficit related to acute and/or chronic illness resulting in deconditioning, muscle weakness, fatigue and [CONDITION(S)] .Goal .I will have my needs met with the assistance of staff through the next review .I require supervision to extensive assist with my ADL functioning . The ADL sheets, dated June 2021, documented the resident was to receive a shower on Tuesday, Thursday, and Saturday. Review of the June 2021 ADL sheets revealed the resident received six showers out of 13 opportunities. The ADL sheets, dated 07/01/21 through 07/27/21, documented the resident was to receive a shower on Tuesday, Thursday, and Saturday. Review of the July 2021 ADL sheets revealed the resident received six showers out of 12 opportunities. On 07/27/21 at 2:00 p.m., the resident was asked if she had received showers/baths as scheduled. She stated no. She stated the facility was short staffed sometimes and the showers were not offered/provided. 3. Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 04/30/21, documented the resident was cognitively intact for daily decision making and was totally dependent on staff for bathing. A care plan, updated 05/01/21, documented, .I have an ADL self care deficit related to acute and/or chronic illness resulting in deconditioning, [CONDITION(S)], deformity of my hip .Goal .I will have my ADL needs met with the assistance of staff through the next review .Assist me with my ADL functioning as needed .Whirlpool bath Tuesday, Thursday, Saturday . The ADL sheets, dated June 2021, documented the resident had showers scheduled weekly on Monday, Wednesday, and Friday. Review of the June 2021 ADL sheets revealed the resident received six showers/baths out of 13 opportunities. On 07/27/21 at 9:28 a.m., the resident was asked if she received showers/baths as scheduled. She stated she had not received enough showers/baths. On 08/03/21 at 11:15 a.m., CNA #3 was asked showers were provided to the residents as scheduled. She stated no. She stated last week the residents scheduled for showers on the day shift had not received them because they did not have enough staff. She stated on 08/02/21 the residents had also not received showers/baths. At 11:41 a.m., CMA #1 was asked if residents received their showers as scheduled. She stated no. She stated at times showers were not provided due to a lack of staff. At 11:57 a.m., LPN #3 was asked if residents received their showers as scheduled. She stated no. She was asked if residents had missed showers due to a lack of staff. She stated yes. At 1:15 p.m., administrator #2 was asked if residents received showers as scheduled. He stated if the staff had not provided the resident a shower on their scheduled day they offered them a shower the next day. On 08/04/21 at 9:46 a.m., the DON was asked if showers/baths had been provided as scheduled. He stated they did their best to follow the shower schedule. He stated if a resident refused a shower they would alternate their schedule. He was asked if residents had not received showers/baths due to insufficient staffing. He stated, I'm sure.

Based on interview and record review, it was determined the facility failed to ensure staffing met the state minimum requirements for 41 of 65 shifts reviewed. The facility identified 61 residents who resided in the facility. Findings: The nursing staff time detail for 06/28/21 through 07/19/21 was reviewed. Review of the time detail revealed the following dates and shifts lacked sufficient staff according to state minimum staffing ratios: ~ The census on 06/28/21 was 59. The day shift had six nursing staff who worked the entire shift. One CNA worked from 7:50 a.m. until 2:00 p.m., one RN worked from 6:00 a.m. until 7:00 a.m., one CNA-IT worked from 6:55 a.m. until 2:00 p.m., and one CNA worked from 6:00 a.m. until 6:30 a.m. According to state minimum staffing ratios, there should have been a minimum of 9.8 staff members for the day shift. The evening shift had four nursing staff who worked the entire shift. One LPN worked from 2:00 p.m. until 3:05 p.m., one RN worked from 4:00 p.m. until 5:14 p.m., one CNA worked from 2:00 p.m. until 2:41 p.m., one LPN worked from 2:00 p.m. until 3:40 p.m., one CNA-IT worked from 4:20 p.m. until 10:00 p.m., one CNA-IT worked from 2:00 p.m. until 2:58 p.m., one CMA worked from 2:00 p.m. until 8:37 p.m., and one CNA worked from 2:00 p.m. until 2:40 p.m. and from 4:44 p.m. until 8:22 p.m. According to state minimum staffing ratios, there should have been a minimum of 7.3 staff members for the evening shift. ~ The census on 06/29/21 was 60. The day shift had five nursing staff who worked the entire shift. One LPN worked from 9:00 a.m. until 2:00 p.m., one LPN worked from 6:00 a.m. until 7:23 a.m., one CNA worked from 6:00 a.m. until 6:33 a.m., one CMA worked from 8:18 a.m. until 2:00 p.m., and one CNA worked from 6:50 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of ten staff members for the day shift. The night shift had three nursing staff who worked the entire shift. One LPN worked from 10:00 p.m. until 12:41 a.m. and one CNA worked from 10:00 p.m. until 10:25 p.m. According to state minimum staffing ratios, there should have been a minimum of four staff members for the night shift. ~ The census on 06/30/21 was 61. The day shift had five nursing staff who worked the entire shift. One LPN worked from 11:23 a.m. until 2:00 p.m., one LPN worked from 6:00 a.m. until 9:33 a.m., one LPN worked from 7:00 a.m. until 8:00 a.m. and from 1:00 p.m. until 2:00 p.m., one LPN worked from 10:55 a.m. until 2:00 p.m., two CAN's worked from 6:00 a.m. until 6:32 a.m., and one CMA worked from 6:48 a.m. until 1:39 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.1 staff members for the day shift. The evening shift had five nursing staff who worked the entire shift. One LPN worked from 2:00 p.m. until 5:00 p.m., one RN worked from 3:00 p.m. until 4:22 p.m., one LPN worked from 2:00 p.m. until 3:30 p.m., one CNA-IT worked from 2:00 p.m. until 3:01 p.m., one CMA worked from 2:00 p.m. until 3:01 p.m., and one CMA worked from 2:00 p.m. until 3:36 p.m. According to state minimum staffing ratios, there should have been a minimum of 7.6 staff members for the evening shift. ~ The census on 07/01/21 was 61. The day shift had four nursing staff who worked the entire shift. One LPN worked from 6:00 a.m. until 8:40 a.m., one CNA worked from 6:00 a.m. until 6:24 a.m., two CNA's worked from 6:00 a.m. until 6:23 a.m., one CNA-IT worked from 7:16 a.m. until 2:00 p.m., one CMA worked from 7:05 a.m. until 2:00 p.m., and one CMA worked from 7:04 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.1 staff members for the day shift. ~ The census on 07/02/21 was 61. The day shift had five nursing staff who worked the entire shift. One LPN worked from 6:00 a.m. until 8:00 a.m., one CNA worked from 6:00 a.m. until 6:59 a.m., one CNA worked from 6:00 a.m. until 6:57 a.m., one CNA worked from 6:00 a.m. until 6:58 a.m., one CMA worked from 7:20 a.m. until 2:00 p.m., and one CNA worked from 9:00 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.1 staff members for the day shift. The evening shift had five nursing staff who worked the entire shift. One CNA worked from 2:00 p.m. until 2:38 p.m., one CNA-IT worked from 2:00 p.m. until 2:22 p.m., and one CNA worked from 2:00 p.m. until 7:09 p.m. According to state minimum staff ratios, there should have been a minimum of 7.6 staff members for the evening shift. ~ The census on 07/03/21 was 60. The day shift had two nursing staff who worked the entire shift. One LPN worked from 1:00 p.m. until 2:00 p.m., one RN worked from 6:00 a.m. until 10:49 a.m., one CNA worked from 6:00 a.m. until 6:30 a.m., and two CNA's worked from 6:00 a.m. until 6:20 a.m. According to state minimum staffing ratios, there should have been a minimum of ten staff members for the day shift. The evening shift had three nursing staff who worked the entire shift. One LPN worked from 2:00 p.m. until 6:43 p.m. and one RN worked from 5:18 p.m. until 10:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 7.5 staff members for the evening shift. The night shift had one nursing staff member who worked the entire shift. One LPN worked from 10:00 p.m. until 2:16 a.m., and one CNA-IT worked from 10:00 p.m. until 10:15 p.m. According to state minimum staffing ratios, there should have been a minimum of four staff members for the night shift. ~ The census on 07/04/21 was 60. The day shift had two nursing staff who worked the entire shift. One LPN worked from 9:05 a.m. until 2 p.m. According to state minimum staffing ratios, there should have been a minimum of ten staff members for the day shift. The evening shift had one nursing staff member who worked the entire shift. One LPN worked from 2:00 p.m. until 2:23 p.m., and one RN worked from 2:00 p.m. until 4:35 p.m. and from 7:17 p.m. until 10:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 7.5 staff members for the evening shift. ~ The census on 07/05/21 was 59. The day shift had five nursing staff who worked the entire shift. One LPN worked from 9:52 a.m. until 2:00 p.m., one RN worked from 6:00 a.m. until 11:17 a.m., one CNA worked from 6:00 a.m. until 6:34 a.m., two CNA's worked from 6:00 a.m. until 6:33 a.m., and one CNA worked from 7:09 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been 9.8 staff members for the day shift. The evening shift had five nursing staff who worked the entire shift. One RN worked from 5:49 p.m. until 10:00 p.m., one CNA worked from 2:00 p.m. until 2:30 p.m., and one CNA worked from 2:00 p.m. until 3:02 p.m. According to state minimum staffing ratios, there should have been a minimum of 7.3 staff members for the evening shift. ~ The census on 07/06/21 was 60. The day shift had seven nursing staff who worked the entire shift. One LPN worked from 9:02 a.m. until 2:00 p.m., one LPN worked from 6:00 a.m. until 7:59 a.m., two CNA's worked from 6:00 a.m. until 6:25 a.m., one CNA worked from 6:00 a.m. until 6:24 a.m., and one CNA-IT worked from 7:11 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of ten staff members for the day shift. The evening shift had six nursing staff who worked the entire shift. One LPN worked from 2:00 p.m. until 5:33 p.m., one CNA worked from 2:00 p.m. until 2:16 p.m., one CNA worked from 2:00 p.m. until 2:30 p.m., one CNA-IT worked from 2:00 p.m. until 2:19 p.m., one CMA worked from 2:00 p.m. until 2:15 p.m., and one CNA worked from 2:00 p.m. until 6:50 p.m. According to state minimum staffing ratios, there should have been a minimum of 7.5 staff members for the evening shift. The night shift had three nursing staff who worked the entire shift. One LPN worked from 10:00 p.m. until 10:33 p.m., one CNA worked from 10:00 p.m. until 10:23 p.m., one CNA worked from 10:00 p.m. until 10:15 p.m., and one CMA worked from 10:00 p.m. until 10:47 p.m. According to state minimum staffing ratios, there should have been a minimum of four staff members for the night shift. ~ The census on 07/07/21 was 61. The day shift had six nursing staff who worked the entire shift. One LPN worked from 12:40 p.m. until 2:00 p.m., one LPN worked from 6:00 a.m. until 9:57 a.m., one CNA worked from 6:00 a.m. until 6:48 a.m., one CNA worked from 6:00 a.m. until 6:25 a.m., and one CNA-IT worked from 8:25 a.m. until 1:26 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.1 staff members for the day shift. ~ The census on 07/08/21 was 62. The day shift had five nursing staff who worked the entire shift. One LPN worked from 7:13 a.m. until 2:00 p.m., one LPN worked from 6:00 a.m. until 9:59 a.m., one CNA worked from 6:00 a.m. until 6:48 a.m., two CAN's worked from 6:00 a.m. until 6:51 a.m., and one CNA-IT worked from 7:18 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.2 staff members for the day shift. ~ The census on 07/09/21 was 62. The day shift had seven nursing staff who worked the entire shift. One LPN worked from 7:11 a.m. until 2:00 p.m., one LPN worked from 6:00 a.m. until 8:38 a.m., one LPN worked from 9:53 a.m. until 2:00 p.m., one CNA worked from 6:00 a.m. until 6:42 a.m., one CNA worked from 6:00 a.m. until 6:43 a.m., and one CMA worked from 7:14 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.3 staff members for the day shift. The evening shift had five nursing staff who worked the entire shift. One LPN worked from 2:00 p.m. until 4:00 p.m., one LPN worked from 9:40 p.m. until 10:00 p.m., one CNA worked from 2:00 p.m. until 2:19 p.m., one CNA worked from 2:00 p.m. until 2:30 p.m., one CNA-IT worked from 2:00 p.m. until 4:45 p.m. and from 6:33 p.m. until 10:00 p.m., one CNA worked from 2:00 p.m. until 2:18 p.m., and one CNA worked from 2:00 p.m. until 7:09 p.m. According to state minimum staffing ratios, there should have been a minimum of 7.7 staff members for the evening shift. ~ The census on 07/10/21 was 62. The day shift had four nursing staff who worked the entire shift. Three CNA's who had worked the previous night shift worked from 6:00 a.m. until 6:16 a.m., and one CNA worked from 10:17 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.3 staff for the day shift. ~ The census on 07/11/21 was 62. The day shift had four nursing staff who worked the entire shift. One CNA-IT worked from 12:31 p.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.3 staff for the day shift. ~ The census on 07/12/21 was 63. The day shift had nine nursing staff who worked the entire shift. One LPN worked from 6:00 a.m. until 6:44 a.m., one LPN worked from 9:00 a.m. until 12:00 p.m., one RN worked from 6:00 a.m. until 8:00 a.m., two CNA's worked from 6:00 a.m. until 6:26 a.m., and one CNA worked from 6:00 a.m. until 6:27 a.m. According to state minimum staffing ratios, there should have been 10.5 staff members for the day shift. The evening shift had four nursing staff who worked the entire shift. One LPN worked from 2:00 p.m. until 6:29 p.m., one LPN worked from 5:57 p.m. until 10:00 p.m., one CNA worked from 5:58 p.m. until 10:00 p.m., one CNA worked from 2:00 p.m. until 6:27 p.m., and one CNA worked from 5:32 p.m. until 6:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 7.8 staff for the evening shift. ~ The census on 07/13/21 was 64. The day shift had seven nursing staff who worked the entire shift. Two CNA's worked from 6:00 a.m. until 6:45 a.m., one LPN worked from 7:00 a.m. until 2:00 p.m., one LPN worked from 6:00 a.m. until 6:24 a.m., and one CNA-IT worked from 7:00 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.6 staff for the day shift. The evening shift had four nursing staff who worked the entire shift. One LPN worked from 2:00 p.m. until 6:02 p.m., one LPN worked from 2:00 p.m. until 6:45 p.m., one CNA worked from 2:00 p.m. until 2:50 p.m., one CNA-IT worked from 5:17 p.m. until 10:00 p.m., one CNA-IT worked from 3:02 p.m. until 10:00 p.m., one CNA-IT worked from 2:00 p.m. until 2:50 p.m., and one CNA worked from 2:00 p.m. until 6:50 p.m. According to state minimum staffing ratios, there should have been a minimum of eight staff members for the evening shift. ~ The census on 07/14/21 was 63. The day shift had seven nursing staff who worked the entire shift. One LPN worked from 6:00 a.m. until 7:36 a.m., one LPN worked from 6:00 a.m. until 6:32 a.m., one CNA worked from 6:00 a.m. until 6:38 a.m., one CNA worked from 6:00 a.m. until 6:40 a.m., one CNA worked from 6:00 a.m. until 6:45 a.m., one CNA-IT worked from 8:24 a.m. until 2:00 p.m., one CMA worked from 10:06 a.m. until 2:00 p.m., and one LPN worked from 12:00 p.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.5 staff for the day shift. The evening shift had five staff who worked the entire shift. One LPN worked from 6:16 p.m. until 10:00 p.m., one LPN worked from 2:00 p.m. until 5:20 p.m., one LPN worked from 2:00 p.m. until 5:00 p.m., one CNA worked from 2:00 p.m. until 2:52 p.m., one CNA-IT worked from 2:00 p.m. until 3:00 p.m., one CMA worked from 2:00 p.m. until 3:35 p.m., one LPN worked from 2:00 p.m. until 3:16 p.m., and one CNA worked from 2:00 p.m. until 6:26 p.m. According to state minimum staffing ratios, there should have been 7.8 staff for the evening shift. ~ The census on 07/15/21 was 64. The day shift had seven nursing staff who worked the entire shift. One CNA worked from 6:00 a.m. until 6:51 a.m., one LPN worked from 11:30 a.m. until 2:00 p.m., and one LPN worked from 6:00 a.m. until 6:35 a.m. According to state minimum staffing ratios, there should have been a minimum of 10.6 staff for the day shift. The evening shift had four nursing staff who worked the entire shift. One LPN worked from 5:51 p.m. until 10:00 p.m., one LPN worked from 2:00 p.m. until 6:18 p.m., one LPN worked from 2:00 p.m. until 6:37 p.m., one LPN worked from 2:00 p.m. until 8:25 p.m., one LPN worked from 5:48 p.m. until 10:00 p.m., one CNA worked from 2:00 p.m. until 2:58 p.m., one CNA worked from 2:00 p.m. until 4:24 p.m., one CMA worked from 2:00 p.m. until 5:22 p.m., and one CNA from 2:00 p.m. until 6:32 p.m. According to state minimum staffing ratios, there should have been a minimum of eight staff for the evening shift. The night shift had two nursing staff who worked the entire shift. One LPN worked from 10:30 p.m. until 11:15 p.m. and one CMA worked from 10:00 p.m. until 10:15 p.m. According to state minimum staffing ratios, there should have been a minimum of 4.2 staff who worked the night shift. ~ The census on 07/16/21 was 64. The day shift had seven nursing staff who worked the entire shift. One LPN worked from 6:00 a.m. until 6:53 a.m. According to state minimum staffing ratios, there should have been a minimum of 10.6 staff for the day shift. ~ The census on 07/17/21 was 65. The day shift had four nursing staff who worked the entire shift. One LPN worked from 10:15 a.m. until 2:00 p.m., one RN worked from 6:00 a.m. until 12:07 p.m., one CNA worked from 6:00 a.m. until 6:30 a.m., and one CNA-IT worked from 8:05 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.8 staff for the day shift. The evening shift had five nursing staff who worked the entire shift. One LPN worked from 2:00 p.m. until 3:45 p.m. and one RN worked from 4:59 p.m. until 10:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 8.1 staff for the evening shift. ~ The census on 07/18/21 was 63. The day shift had four nursing staff who worked the entire shift. One LPN worked from 10:17 a.m. until 2:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 10.5 staff who worked the day shift. The evening shift had four nursing staff who worked the entire shift. One LPN worked from 2:50 p.m. until 10:00 p.m. According to state minimum staffing ratios, there should have been a minimum of 7.8 staff who worked the evening shift. ~ The census on 07/19/21 was 63. The day shift had seven nursing staff who worked the entire shift. One LPN worked from 10:40 a.m. until 2:00 p.m., one RN worked from 6:00 a.m. until 7:31 a.m., and one CNA worked from 6:00 a.m. until 6:39 a.m. According to state minimum staffing ratios, there should have been a minimum of 10.5 staff members for the day shift. Review of the daily staffing schedule, dated 07/03/21, documented housekeeper #1 under the section for CNA's for the night shift. Review of housekeeper #1's time detail, dated 07/03/21-07/04/21, documented the housekeeper worked on the night shift from 9:56 p.m. until 6:00 a.m. On 08/02/21 at 11:39 a.m., the business office manager was asked for the CNA certification and/or training for housekeeper #1. She state the housekeeper did not have a certification. She stated she would assist with delivering food trays/drinks and assisted with things the residents needed. At 11:46 a.m., housekeeper #1 was asked if she performed any other duties other than housekeeping. She stated if the residents needed something she would try to assist them such as refilling their water. She was asked if she was a CNA. She stated no. She was asked if she worked any night shifts. She stated she had worked over night once, on 07/03/21, because the facility was short staffed and they needed another person in the building. On 08/03/21 at 11:15 a.m., CNA #3 was asked if the facility had enough staff to take care of the residents' needs. She stated the day shift was short staffed. She was asked if residents had not received showers/baths due to not having enough staff. She stated yes. She stated last week the residents scheduled for showers on the day shift had not received them because they did not have enough staff. She stated on 08/02/21 the residents had also not received baths. She stated the priority was providing incontinent care to the residents when they were short staffed. She stated they tried to turn and reposition residents every two hours but that was difficult when there was not enough staff. At 11:41 a.m., CMA #1 was asked if the facility had enough staff to take care of the residents' needs. She stated, We are short staffed. She stated they needed more help on the day shift. She stated some residents had not received showers due to not having enough staff. At 11:57 a.m., LPN #3 was asked if the facility had enough staff to take care of the residents' needs. She stated no. She stated the evening shift had been staffed better lately but the day shift did not have enough. She was asked if non-nursing staff had performed CNA duties. She stated yes. She named housekeeper #1. At 12:12 p.m., LPN #4 was asked about the staffing in the facility. She stated they had major issues with staffing. She stated staff were hired but would not show up to work. She was asked if there were enough staff to take care of the residents' needs. She stated no. She stated the care provided was minimal because sometimes they only had two CNA's. She stated they were not able to provide showers when they were short staffed. At 1:15 p.m., administrator #2 was asked if the facility had enough staff to perform all care for residents each shift. He stated not always. He was asked if non-nursing staff had worked as CNAs. He stated he had heard of it happening but it had not occurred while he was on duty. He was asked if showers/baths had been provided as scheduled. He stated no. He stated if a resident had not received their shower on the scheduled day they received it the following day. At 3:19 p.m., RN #1 was asked if she had ever worked with unlicensed/uncertified staff as CNA's. She stated yes. She stated on 07/03/21 she was the only nursing staff on the over night shift. She was asked if she notified anyone that no one was in the facility to assist her. She stated former administrator #1 and the DON were made aware. She stated the administrator was in the facility and assisted her on that shift. She stated former administrator #1 had notified the corporate administrator of the staffing situation on that shift. She was asked what duties former administrator #1 had performed. She stated she did laundry, loaded the linen cart while she provided incontinent care, assisted to ensure residents did not fall off their beds while she performed incontinent care, and provided water. She was asked if residents had ever not received their medications due to staffing. She stated yes. She stated the weekend of 07/04/21 or the weekend after 07/04/21 there was not a CMA to pass medications. She stated she was on duty and assisted the CNA's on the floor. She stated there were other nurses in the facility but medications had not been administered. She was asked if on the night shift, beginning 07/03/21, was she was able to perform her nursing tasks. She stated no. She stated she was able to provide incontinent care to the residents. On 08/04/21 at 9:46 a.m., the DON was asked about the facility's staffing. He stated staffing was an on-going struggle due to turnover of staff. He stated they hired staff but they quit. He stated they used to have contracts with two nursing agency companies but there had been issues with the time they had turned in so they no longer contracted with them. He stated they offered incentives to the facility staff to work extra shifts, and had an internal corporate float pool. He was asked if there had been enough staff to take care of the residents' needs. He stated no. He was asked if there was enough staff on evenings, nights, and weekends. He stated evenings and nights were the most adequately staffed shifts. He stated weekend staffing was a chronic concern. He stated they now offered Baylor pay. He was asked if non-nursing staff had worked as CNA's. He stated yes. He stated housekeeper #1 and laundry staff member #1 had worked as CNA's. He stated he did not know to what extent they had provided care because he was not in the facility. He was asked if showers/baths had been provided as scheduled. He stated they did their best to follow the shower schedule. He stated if a resident refused a shower they would alternate their schedule. He was asked if residents had not received showers/baths due to insufficient staffing. He stated, I'm sure. He was asked what the protocol was if the facility did not have adequate staffing on a shift. He stated they were to notify the administrator and the staff coordinator. He was asked about the shifts in which the facility did not have adequate staff to meet state minimum staffing requirements. He stated it was hard to find someone to come to work when staff unexpectedly quit. He stated he was careful on how he utilized his hours. He was asked who was responsible to ensure there was adequate staff in the building to provide resident care. He stated the administrator was responsible for staffing. He stated corporate had measures in place to ensure the DON could focus on DON duties.

Based on observation, interview, and record review, it was determined the facility failed to ensure untrained support staff did not prepare and serve meals to the facility residents. The DON identified 61 residents who received their meals from the facility kitchen. Findings: A staffing policy, revised date October 2017, documented, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .Other support services (e.g., dietary .) are also staffed to ensure that resident needs are met . On 07/25/21 at 10:16 a.m., two staff members were observed working in the kitchen. Cook #1 and dietary aide #1 were asked what areas of the facility were they assigned. Each stated they were assigned only to the dietary department. They were asked if they had recieved training prior to working in the facility. Each stated they had. Each were asked if they had current food handler's permits each stated they had. On 07/25/21 at 1:15 p.m., the maintenance supervisor was asked if he had worked in any other departments of the facility outside the maintenance department. He stated he had helped in the kitchen as a cook. He added he had previously owned and worked as a cook in his own restaurant in another county. He was asked when he had cooked in the facility. He stated it was in July of 2021. He was asked for what duration had he cooked. He stated for about one and a half to two weeks he had cooked breakfast and lunch at the facility. He was asked why he had begun cooking for the facility. He stated it was his understanding that the cook had suddenly walked out. He was asked if he had received any training in the tasks he performed prior to working as a cook in the kitchen. He stated he had not. He was asked if he had a food handlers permit during the time he cooked. He stated he did not. On 07/26/21 at 11:00 a.m., the employee records for cook #1 and dietary aide #1 were reveiwed. Each record indicated each had recieved training prior to working in the dietary department and each had a food handlers permit. On 08/02/21 at 11:46 a.m., housekeeper #1 was asked what department she was assigned. She stated the housekeeping department. She was asked if she had ever worked in the kitchen. She stated on the morning of 07/04/21 she and laundry #1 had found that no kitchen staff had showed up for work. She was asked if administrator #1 had been aware of the missing kitchen staff. She stated the administrator was also unaware the kitchen staff was not at work. She was asked what she had done in the kitchen that morning. She stated she had cooked eggs, sausages, bacon, and oatmeal. She was asked if anyone else had assisted in the kitchen that day. She stated laundry #1. She was asked who had prepared the specialty meals such as puree's that day. She stated laundry #1 had experience with that so she did it. She was asked if she had received any training to work in the kitchen prior to performing those tasks. She stated she had not. She was asked if she had a food handler's permit during the time she worked in the kitchen. She stated she did not. At 12:40 p.m., laundry #1 was asked to what department she was assigned. She stated the laundry. She was asked if in the current year she had performed duties outside of the laundry. She stated she had worked as a cook in the kitchen. She was asked why she had performed those duties. She stated there had not been enough staff on duty and it needed to be done. She was asked if anyone had asked her to performed those duties. She stated no one specifically told her to do those but she had informed administrator #1 that there was no staff she did not indicate what we should do. Laundry #1 was asked what tasks she had performed in the kitchen. She stated she cooked, served, and cleaned. She added that she had been a cook at the facility 13-[AGE] years ago. She was asked if she had received any training in the kitchen prior to performing those duties. She stated she had not. She was asked if anyone from other departments had assisted with the resident care of work in the kitchen. She stated housekeeper #1 had helped in both areas. She was asked if she had a food handler's permit during the time she worked in the kitchen. She stated she did not. On 08/03/21 at 1:15 p.m., administrator #2 was asked if the facility had any recent problems in the dietary department. He stated he was aware of some changes in dietary. He stated a dietary worker had not shown up for work on a Monday and Tuesday and he had worked in the kitchen. He was asked if the meals had been served on time. He stated there had been some problems in that area caused by staffing issues. He was asked if he was aware of non kitchen staff working in the kitchen. He stated he was aware of that having occurred. He was asked if those individual had food handlers permits. He stated he knew they did not. He was asked if the facility trained staff before they worked in dietary. He stated they usually have new staff shadow others and some have previous dietary experience.

Based on interview and record review, it was determined the facility failed to ensure residents were free of significant medication errors for one (#6) of three sampled residents who were reviewed for medication administration. The facility identified 61 residents who received medications. Findings: A facility policy, titled Adverse Consequences and Medication Errors, revised date April 2014, documented a medication error was defined as the preparation or administration of drugs or biological which is not in accordance with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Omission - a drug is ordered but not administered . Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/11/21, documented the resident was cognitively intact for daily decision making and required extensive assistance of staff for transfers, dressing, and bathing. A care plan, updated 06/12/21, documented, .I have [CONDITION(S)] .with potential for complications, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] .Give all cardiac meds as ordered by the physician .I have Hypertension with potential for acute changes in my blood pressure .Administer medications and/or treatments per orders .I am on anticoagulant therapy with potential for complications, [CONDITION(S)] .Administer anti-coagulation medication as ordered . Review of the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] ~ [MEDICATION(S)] 2.5mg for [CONDITION(S)]; ~ [MEDICATION(S)] 40mg for [CONDITION(S)]; and ~ [MEDICATION(S)] 25mg for hypertension. An order summary report, dated 08/03/21, documented the following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ~ [MEDICATION(S)] 2.5mg by mouth two times a day for [CONDITION(S)]; ~ [MEDICATION(S)] 40mg by mouth two times a day for [CONDITION(S)]; and ~ [MEDICATION(S)] 25mg by mouth two times a day for hypertension. On 08/02/21 at 9:53 a.m., resident #6 was asked if she received medications as ordered by the physician. She stated one or two times she had not received her bedtime medications. She was asked why she had not received her medications. She stated she had been told there was not anyone available to administer the medications to her. On 08/03/21 at 3:19 p.m., RN #1 was asked if any residents had missed medications due to insufficient staffing. She stated yes. She was asked what the circumstances were behind residents not receiving medications. She stated the weekend of 07/04/21 or the weekend after, there was not a CMA on duty. She stated the facility had one nurse aide and three nurses including herself. She stated she performed CNA duties for that shift. On 08/03/21 at 10:00 a.m., the DON was asked about the resident's medications not documented as administered. He stated he would look into it. He was asked if he was aware of any medication errors due to residents not receiving their scheduled medications. He stated no.

Based on interview and record review, it was determined the facility failed to ensure: a. residents were administered their prescribed medications for four (#1, #3, #6, and #7) of four residents reviewed for medications. The DON identified 61 resident who had medications administered to them by staff; and b. narcotic medications were routinely reconciled for three (E hall, A-B-F hall, and C-D hall) of three medication cart narcotic logs reviewed. The facility identified 39 residents who received narcotic medications. Findings: A controlled substances policy, revised date December 2012, documented the facility would comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. It documented, .Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services . A facility policy, titled Adverse Consequences and Medication Errors, revised date April 2014, documented a medication error was defined as the preparation or administration of drugs or biological which is not in accordance with a physician's order. It documented an example of an error include, .Omission - a drug is ordered but not administered . 1. Resident #1 had diagnoses which included [CONDITION(S)], chronic [CONDITION(S)], and muscle weakness. A quarterly assessment, dated 05/23/21, documented the resident's cognition was intact and she required extensive assistance with activities of daily living. Review of a medication administration record, dated 07/01/21 through 07/31/21, found no documentation for the administration of the following prescribed medications on the dates and times indicated below: ~ [MEDICATION(S)] Suspension 50 mcg/act one spray each nostril one time a day for allergic rhinitis on 07/18/21. ~ [MEDICATION(S)] capsule 100mg give one capsule by mouth one time a day for prophylaxis on 07/18/21. ~ [MEDICATION(S)] packet 17GM give one packet by mouth one time a day for constipation on 07/18/21 at 8:00 a.m. ~ Multivitamin give one by mouth one time each day for supplement on 07/18/21. ~ Omeprazole capsule delayed release 20mg give one capsule by mouth one time a day for GERD on 07/18/21. ~ Regular health shake 4oz one time daily for weight support on 07/18/21 at 8:00 a.m. ~ Trazadone HCL tablet 50mg give 0.5 tablet by mouth one time a day for [CONDITION(S)] on 07/04/21 in the evening. ~ [MEDICATION(S)] tablet 2.5mg give one tablet by mouth two times a day for anticoagulation therapy on 07/04/21 at 8:00 p.m., 07/10/21 at 8:00 p.m., and 07/18/21 at 8:00 a.m. ~ Calcium [MEDICATION(S)] - vitamin D tablet 200 - 250mg - unit give one tablet by mouth two times a day for supplement on 07/04/21 at 8:00 p.m., 07/10/21 at 8:00 p.m., and 07/18/21 at 8:00 a.m. ~ Megastrol acetate suspension 40mg/ml give 10ml by mouth two times a day for appetite stimulant on 07/04/21 at 8:00 p.m., 07/10/21 at 8:00 p.m., and 07/18/21 at 8:00 a.m. ~ [MEDICATION(S)] tablet 32.4mg give one tablet by mouth two times a day for [CONDITION(S)] on 07/04/21 at 8:00 p.m., 07/10/21 at 8:00 p.m., and 07/18/21 at 8:00 a.m. ~ [MEDICATION(S)] HCL tablet 10mg give one tablet by mouth before meals for [CONDITION(S)] on 07/04/21 at 4:00 p.m., and 07/18/21 at 7:00 a.m., and 11:00 a.m. ~ [MEDICATION(S)] HCL tablet 50mg give one tablet by mouth three times a day for pain on 07/04/21 at 8:00 p.m, 07/10/21 at 8:00 p.m., and 07/18/21 at 8:00 a.m. ~ Refresh plus solution 0.5% instill one drop in both eyes four time a day for redness with dry eyes on 07/04/21 at 4:00 p.m. and 8:00 pm, 07/10/21 at 8:00 p.m., and 07/18/21 at 8:00 a.m. and 12:00 p.m. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] and adult failure to thrive. A care plan focus, dated 04/06/21, documented the resident had a potential for impairment to his skin integrity related to fragile skin, incontinence, and impaired mobility. A care plan intervention, dated 04/06/21, documented, Administer medications, supplements, and/or treatments per orders, monitor for adverse side effects and notify Dr as needed. A progress note, dated 05/06/21 at 1:02 p.m., documented the resident had returned from a dermatology appointment with a progress note which stated the resident had numerous [CONDITION(S)] carcinomas on his legs, arms, and face. The note further documented the dermatology office would contact the facility when they know which type of medication would be used based on the resident's insurance. A medication order, start date 05/20/21, documented [MEDICATION(S)] Cream 5% to be applied to arms, legs, and face topically every Monday, Tuesday, Wednesday, Thursday, and Friday for integumentary system for six weeks. A treatment administration record, dated May 2021, lacked documentation to indicate if [MEDICATION(S)] cream 5% was administered on 05/21/21 and 05/27/21. The treatment administration record documented 8:00 p.m. as the time the cream was to have been applied. On 07/26/21 at 9:15 a.m., resident #3 was contacted via telephone call. The resident was asked if he had received [MEDICATION(S)] cream as ordered by his physician. He stated he had not and believed he had gone one week without it. 3. Resident #6 had diagnoses which included [CONDITION(S)], coronary artery disease, hypertension, and [CONDITION(S)]. A quarterly assessment, dated 03/11/21, documented the resident was cognitively intact for daily decision making and required extensive assistance of staff for transfers, dressing, and bathing. A care plan, updated 06/12/21, documented, .I have gerd r/t hyperacidity, medication use, and/or poor diet .Give anti-ulcer medication as ordered .I have Coronary Artery Disease .with potential for complications, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] .Give all cardiac meds as ordered by the physician .I have altered respiratory status/Difficulty Breathing r/t [CONDITION(S)] .Administer medication/puffers as ordered .I have constipation r/t decreased mobility .Administer medications and/or treatments per orders .I have an alteration in hematological status r/t Vitamin/Mineral deficiency .Administer medications and/or treatments per orders .I am at risk for alterations in fluid balance due to use of diuretic medication .Administer medications as ordered .I am on hypnotic/sedative therapy r/t [CONDITION(S)] .Administer medications and/or treatments per orders .I have Hypertension with potential for acute changes in my blood pressure .Administer medications and/or treatments per orders .I am on anticoagulant therapy with potential for complications, [CONDITION(S)] .Administer anti-coagulation medication as ordered . Review of the medication administration record, dated July 2021, revealed blanks on 07/04/21 and 07/17/21 for the 8:00 p.m. dosages of the following medications: ~ Lantanoprost Emulsion 0.005% one drop both eyes for [CONDITION(S)]; ~ [MEDICATION(S)] 10mg capsule for [CONDITION(S)]; ~ [MEDICATION(S)] 2.5mg tablet for [CONDITION(S)]; ~ Budesonide-[MEDICATION(S)] Aerosol 80-4.5 mcg/act two puffs for [CONDITION(S)]; ~ Calcium-Vitamin D 500-200mg tablet for supplement; ~ [MEDICATION(S)] 40mg tablet for [CONDITION(S)]; ~ Guiafenesin ER 600mg tablet, give two tablets, for seasonal allergies; ~ [MEDICATION(S)] solution 30mls for constipation; ~ [MEDICATION(S)] 25mg tablet for hypertension; ~ [MEDICATION(S)] 40mg tablet for GERD; and ~ [MEDICATION(S)] Aerosol solution 108mcg/act two puffs for shortness of breath. An order summary report, dated 08/03/21, documented the following physician orders: ~ Lantanoprost Emulsion 0.005% one drop both eyes at bedtime for [CONDITION(S)]-start date 01/25/21; ~ [MEDICATION(S)] 10mg capsule by mouth at bedtime for [CONDITION(S)]-start date 09/16/20; ~ [MEDICATION(S)] 2.5mg tablet by mouth twice daily for [CONDITION(S)]-start date 09/16/20; ~ Budesonide-[MEDICATION(S)] Aerosol 80-4.5 mcg/act two puffs orally two times a day for [CONDITION(S)]-start date 09/16/20; ~ Calcium-Vitamin D 500-200mg tablet by mouth two times a day for supplement-start date 09/16/20; ~ [MEDICATION(S)] 40mg tablet by mouth two times a day for [CONDITION(S)]-start date 09/16/20; ~ Guiafenesin ER 600mg tablet give two tablets two times a day for seasonal allergies-start date 09/16/20; ~ [MEDICATION(S)] solution 10gm/15mls give 30mls by mouth two times a day for constipation-start date 09/16/20; ~ [MEDICATION(S)] 25mg tablet by mouth two times a day for hypertension-start date 09/16/20; ~ [MEDICATION(S)] 40mg tablet by mouth two times a day for GERD-start date 09/16/20; and ~ [MEDICATION(S)] Aerosol solution 108mcg/act two puffs inhale orally three times a day for shortness of breath-start date 04/16/21. 4. Resident #7 had diagnoses which included chronic kidney disease and type 2 diabetes millitus. A quarterly assessment, dated 05/09/21, documented the resident was cognitively intact and required extensive assistance with activities of daily living. Review of a medication administration record, dated 07/01/21 through 07/31/21, found no documentation for the administration of the following prescribed medications on the dates and times indicated below: ~ [MEDICATION(S)] 10mg give two tablets at bedtime related to chronic pain on 07/04/21 at 8:00 p.m. and 07/17/21 at 8:00 p.m. ~ Donepazil HCL 10mg give one tablet at bedtime related to cerebral infarction on 07/04/21 at 8:00 p.m. and 07/17/21 at 8:00 p.m. ~ [MEDICATION(S)] sulfate 325mg give one tablet one time daily on 07/10/21 at 8:00 a.m. ~ [MEDICATION(S)] 80mg give one tablet at bedtime related to [CONDITION(S)] on 07/04/21 at 8:00 p.m. and 07/17/21 at 8:00 p.m. ~ Loratadine 10mg give one tablet one time daily for seasonal allergies on 07/10/21 at 8:00 a.m. ~ [MEDICATION(S)] 5mg give one tablet at bedtime related to [CONDITION(S)] on 07/04/21 at 8:00 p.m. and 07/17/21 at 8:00 p.m. ~ [MEDICATION(S)] HCL 15mg give one tablet one time a day related to type 2 diabetes mellitus on 07/10/21 at 8:00 a.m. ~ [MEDICATION(S)] HCL 50mg give one tablet at bedtime related to chronic pain on 07/04/21 at 8:00 p.m. ~ [MEDICATION(S)] suspension 50 mcg/act 2 sprays each nostril two time daily for seasonal allergies on 07/04/21 at 8:00 p.m., 07/10/21 at 8:00 a.m., and 07/17/21 at 8:00 p.m. ~ [MEDICATION(S)] 500mg give one tablet two times a day related to seizures on 07/04/21 at 7:00 p.m., 07/10/21 at 7:00 a.m., and 07/17/21 at 7:00 p.m. On 08/03/21 at 3:19 p.m., RN #1 was asked if any residents had missed medications due to insufficient staffing. She stated yes. She was asked what the circumstances were behind residents not receiving medications. She stated the weekend of 07/04/21 or the weekend after, there was not a CMA on duty. She stated the facility had one nurse aide and three nurses including herself. She stated she performed CNA duties for that shift. On 08/03/21 at 10:00 a.m., the DON was asked about the residents' medications not documented as administered. He stated he was not aware any residents had missed their medications and would look into it. 5. Review of the E hall narcotic medication shift count sheet, dated 06/23/21 through 08/03/21, revealed the following: ~ The on-coming nurse had not signed the narcotic shift count sheet on 06/27/21 at 10:00 p.m., 06/28/21 at 10:00 p.m., 07/01/21 at 2:00 p.m., 07/02/21 at 6:00 a.m., 07/04/21 at 2:00 p.m., 07/09/21 at 6:00 a.m., 07/10/21 at 6:00 a.m., 07/12/21 at 6:00 a.m., 07/14/21 at 6:00 a.m., 07/16/21 at 6:00 a.m., 07/23/21 at 2:00 p.m., 07/24/21 at 10:00 p.m., 07/25/21 at 10:00 p.m., or 07/31/21 at 10:00 p.m.; ~ The off-going nurse had not signed the narcotic shift count sheet on 06/23/21 at 2:00 p.m., 06/29/21 at 2:00 p.m., 07/02/21 at 10:00 p.m., 07/05/21 at 2:00 p.m., 07/09/21 at 6:00 a.m., 07/11/21 at 6:00 a.m., 07/19/21 at 6:00 a.m., 07/24/21 at 6:00 a.m., 07/25/21 at 6:00 a.m., 07/26/21 at 10:00 p.m., 07/30/21 at 10:00 p.m., or 08/01/21 at 6:00 a.m.; ~ Neither the on-coming nurse nor the off-going nurse had signed the narcotic shift count sheet on 06/27/21 at 10:00 p.m., 07/02/21 at 2:00 p.m., 07/04/21 at 10:00 p.m., 07/12/21 at 6:00 p.m., 07/16/21 at 2:00 p.m., or 07/23/21 at 10:00 p.m.; and~ There were no dated entries for 07/17/21 through 07/18/21. Review of the A, B, and F hall narcotic medication shift count sheet, dated 06/21/21 through 08/03/21, revealed the following: ~ The on-coming nurse had not signed the narcotic shift count sheet on 06/27/21 at 10:00 p.m., 06/28/21 at 2:00 p.m., 07/02/21 at 10:00 p.m., 07/03/21 at 2:00 p.m., 07/08/21 at 2:00 p.m., 07/10/21 at 6:00 a.m., 07/10/21 at 10:00 p.m., 07/27/21 at 2:00 p.m., 07/28/21 at 10:00 p.m., or 07/29/21 at 10:00 p.m.; ~ The off-going nurse had not signed the narcotic shift count sheet on 06/21/21 at 10:00 p.m., 06/28/21 at 6:00 a.m., 06/28/21 at 10:00 p.m., 07/01/21 at 2:00 p.m., 07/03/21 at 6:00 a.m., 07/03/21 at 10:00 p.m., 07/09/21 at 2:00 p.m., 07/10/21 at 4:00 p.m., 07/11/21 at 6:00 a.m., 07/21/21 at 10:00 p.m., 07/27/21 at 10:00 p.m., 07/29/21 at 6:00 a.m., or 07/31/21 at 6:00 a.m.; and ~ Neither the on-coming nor the off-going nurse had signed the narcotic shift count sheet on 07/30/21 at 6:00 a.m., 2:00 p.m., or 10:00 p.m. Review of the C and D hall narcotic medication shift count sheet, dated 06/26/21 through 08/01/21, revealed the following: ~ The on-coming nurse had not signed the narcotic shift count sheet on 07/02/21 at 10:00 p.m., 07/10/21 at 6:00 a.m., 07/11/21 at 2:00 p.m., 07/21/21 at 6:00 a.m., 07/22/21 at 6:00 a.m., 07/28/21 at 2:00 p.m., 07/29/21 at 10:00 p.m., 07/30/21 at 2:00 p.m., or 08/01/21 at 6:00 a.m.; ~ The off-going nurse had not signed the narcotic shift count sheet on 07/03/21 at 10:00 p.m., 07/10/21 at 4:00 p.m., 07/11/21 at 10:00 p.m., 07/18/21 at 2:00 p.m., 07/21/21 at 2:00 p.m., 07/29/21 at 6:00 a.m., 07/30/21 at 6:00 a.m., or 07/31/21 at 10:00 p.m.; and ~ Neither the on-coming nurse nor the off-going nurse had signed the narcotic shift count sheet on 07/03/21 at 6:00 a.m., 07/03/21 at 2:00 p.m., 07/22/21 at 2:00 p.m., 07/28/21 at 10:00 p.m., 07/30/21 at 10:00 p.m., 07/31/21 at 6:00 a.m., or 07/31/21 at 10:00 p.m. On 08/04/21 at 9:04 a.m., CMA #2 was asked how often narcotics were reconciled. She stated at the beginning and end of each shift. She was asked where they documented the reconciliation. She stated on the narcotic shift count sheets for each medication cart. She was asked why there was not documentation for each narcotic count/reconciliation. She stated the staff members may have forgotten to sign due to being short staffed. At 9:46 a.m., the DON was asked how often CMA's and/or nurses were to reconcile narcotic medications. He stated at the beginning and end of each shift. He was asked who was responsible to monitor to ensure reconciliation of narcotics routinely occurred. He stated he was responsible. He was asked why narcotic reconciliation had not been documented as routinely completed. He stated they needed to train the staff to correct the issue.

Based on observation and interview, it was determined the facility failed to ensure staff appropriately wore face masks for six staff members who were observed to not utilize the bottom strap of their face mask. The facility identified 72 residents who resided in the facility. Findings: The Centers for Disease Control guidance titled, Using Personal Protective Equipment, documented: .Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap) .Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie) . On 11/23/20 at 9:46 a.m., maintenance worker #1 was observed on C hall. He stated he was checking the hand sanitizer dispensers. The bottom strap of his N95 mask was observed to hang below his chin. At 10:30 a.m., maintenance worker #1 was observed to walk through the front lobby area of the facility. The bottom strap of his N95 mask was observed to hang below his chin. At 10:31 a.m., hospice aide #1 was observed to enter the facility. She was observed to walk through the facility to the memory care unit. She entered the unit and talked to a staff member in the medication room. The bottom strap of her N95 face mask was observed to hang below her chin. At 11:19 a.m., CNA #1 was observed to work on the B hall. Her N95 mask was observed to be missing the bottom strap. She was asked where the bottom strap of her N95 face mask was. She stated the strap had snapped off. She was asked what the status of the residents on B hall was. She stated they had tested negative for COVID-19 but they were isolated because they were symptomatic. She was asked when the bottom strap had snapped off. She stated an hour ago. She was asked how she would obtain a replacement face mask. She stated there were more at the front of the facility where the screening took place. She was asked if she had requested another N95 mask. She stated she had not requested one and would call for a replacement mask. At 11:23 a.m., she donned PPE, utilized the same N95 with the missing bottom strap, and entered a resident's room. She exited the room at 11:31 a.m. She was asked what care she had provided for the resident. She stated she had provided incontinent care, changed the resident's gown, and transferred her from her bed to her chair. At 11:36 a.m., maintenance worker #1 delivered supplies to the back door of the B hall. The bottom strap of the N95 mask was observed to be below his chin. At 11:37 a.m., the administrator was observed to deliver N95 masks to the back door of the B hall. At 11:57 a.m., the dietary manager was observed to deliver the noon meal cart to the memory care unit door. The bottom strap of her N95 face mask was observed to be below her chin. At 12:09 p.m., CNA #3 was observed on the memory care unit. Her N95 mask was observed to be worn upside down. She was asked why her N95 was upside down. She stated she must have put it on upside down after her break. At 12:11 p.m., maintenance worker #1 was observed delivering a food cart with styrofoam container to the back door of the A hall. The bottom strap of the N95 mask was observed to be below his chin. At 4:33 p.m., the infection preventionist was asked how staff were monitored to ensure their face masks were properly worn. She stated they conducted monitoring rounds throughout the day. At 4:39 p.m., laundry worker #1 was observed to walk from the E hall to the D hall. The bottom strap of her N95 was not observed to be placed around her head. She was asked where the bottom strap of the N95 face mask was. She pulled it from inside the N95 face mask and stated she had tucked it in when she was doing laundry. At 4:40 p.m., the DON was asked how staff were monitored to ensure face masks were properly worn. He stated they conducted rounds. He stated when a staff member was screened to enter the building, they were provided an N95 mask. He stated before the staff member entered they were monitored to ensure they had properly placed the face mask. He was informed of the above observations and acknowledged the findings.

On 12/11/19 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent a repeated significant medication error from occurring for a resident who received subcutaneous injections of an anticoagulation medication. The physician's orders [REDACTED]. Resident #2 received 5 to 15 times the correct dosage of [MEDICATION NAME] ([MEDICATION NAME]) subcutaneous injectable every 12 hours from the evening of 11/01/19 through the morning of 11/08/19. The resident was admitted to the hospital's intensive care unit on 11/08/19 with new onset subdural hemorrhages of the brain. The IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 4:40 p.m., the director of nursing (DON), Administrator, and corporate consultants were notified of the IJ situation and were asked to provide a plan of removal. At 6:30 p.m., the corporate consultant provided an acceptable plan of removal. The facility's plan of removal documented: .Plan of Removal - Significant Medication Error (Related to Anticoagulant Therapy) 12-11-19 The named resident receiving anticoagulant therapy was discharged from the facility on 11-8-19 at 1440 (2:40 p.m.). The facility will review residents with orders for anticoagulants to ensure the appropriate dose is ordered per the physician. The current orders will be reviewed and approved by the physician as of 12-11-19 at 1720 (5:20 p.m.). Inservice will be provided to nurses/CMAs (certified medication aides) regarding anticoagulants/blood thinners and the risks and adverse side effects. The inservice will also include the proper procedure of transcribing medication orders and the 5 rights of medication administration (right route, right dose, right time, right resident, right medication). This will be completed on 12-11-19 at 1813 (6:13 p.m.) Two nurses will verify admission orders [REDACTED]. This process will begin 12-11-19 at 6:30 p.m. Audits will be conducted by DON twice weekly to ensure residents who have received new or changed anticoagulant orders are receiving the correct dose per the physician beginning on 12-11-19 at 1814 (6:14 p.m.). QA will review audits weekly to ensure substantial compliance is achieved beginning 12-11-19 at 18:30 (6:30 p.m.) . The IJ was removed on 12/11/19 at 6:30 p.m. after all components of the plan of removal had been completed. The deficient practice remained at a pattern level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to administer an anticoagulant medication as ordered on the hospital transfer orders for two (#2, #8) of three residents whose anticoagulation therapy orders were reviewed. Resident #2 received 5 to 15 times the correct dosage of [MEDICATION NAME] ([MEDICATION NAME]) subcutaneous injectable every 12 hours from the evening of 11/01/19 through the morning of 11/08/19. The resident was admitted to the hospital's intensive care unit on 11/08/19 with new onset subdural hemorrhages of the brain. The facility identified nine residents who received anticoagulation therapy in the last 60 days. 1. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The computerized tomography scan (CT) of the resident's head without contrast, dated 10/24/19, documented the resident had a small right frontotemporal subdural hemorrhage (of the brain) with a trace amount of subarachnoid and intraventricular blood. The CT scan of the resident's head without contrast, dated 10/25/19, documented, .no interval acute intracranial abnormality. Essentially resolved subdural and subarachnoid hemorrhage (of the brain). Stable dependent small volume intraventricular hemorrhage . The report documented the scan had been compared with the previous scan dated 10/24/19. The hospital discharge instructions, dated 11/01/19, documented the resident was to receive [MEDICATION NAME] ([MEDICATION NAME]) 30 milligrams (mg)subcutaneous (sq) injectable every 12 hours. The electronic medical record, dated 11/01/19, documented the resident was to receive [MEDICATION NAME] ([MEDICATION NAME]) 300 milligrams per three milliliters subcutaneous every 12 hours. (The concentration of the medication was ordered at 100 mg/ml). The pharmacy packing slip, dated 11/01/19, documented the facility received four [MEDICATION NAME] injectable vials at a concentration of 150 mg/ml. The Medication Administration Record, [REDACTED]. A physician's progress note, dated 11/08/19, documented, .Send to ER - ileus . A physician's orders [REDACTED]. An ER note, dated 11/08/19, documented, .pt to ed (emergency department) with C/O (complaint of) increased confusion and lethargy for past several days .Impression and Plan .Urinary tract infection .Subdural hematoma . A CT scan, dated 11/08/19, documented, .Small right frontal and right occipital subdural hemorrhages, new since (MONTH) 25, 2019 . A hospital history and physical, dated 11/08/19, documented the resident had an [MEDICAL CONDITION], [MEDICAL CONDITIONS], and his blood was over anticoagulated. On 12/11/19 at 3:15 p.m., the hospital transfer orders and facility admission records were reviewed. On 12/11/19 at 3:20 p.m., the ADON was asked what was the procedure for receiving a new resident from the hospital. She stated she received faxed transfer orders from the hospital and entered the orders into the resident's electronic medical record for the facility. She stated the hospital transfer orders received when the resident arrived at the facility was reviewed against the orders already in the electronic medical record and confirmed by the admitting nurse. She was shown the hospital discharge orders and asked where she had received the order for [MEDICATION NAME] 300 mg every 12 hours. She reviewed the hospital transfer orders which documented the resident was to receive 30 mg [MEDICATION NAME] every 12 hours and the facility Medication Administration Record [REDACTED]. She stated she had incorrectly transcribed the medication as [MEDICATION NAME] 300 mg every 12 hours instead of the ordered 30 mg every 12 hours. The ADON turned to her computer and instructed the surveyor to observe her enter an order for [REDACTED].>The ADON entered the medication name and a pull down menu provided options for dosage. The 300 mg per three milliliter dosage was just above the 30 mg per milliliter dosage for [MEDICATION NAME]. The ADON stated she thought she had scrolled the cursor down and selected the 30 mg dosage but must have inadvertently selected the 300 mg dosage which resided immediately above 30 mg dosage. She was asked who checked the orders to confirm their accuracy. She stated the admitting nurse would have confirmed the orders. The DON was present and stated he received a phone call from the pharmacy stating they did not have pre-filled syringes and would have to send vials of [MEDICATION NAME]. He stated the pharmacy had said nothing about the dosage of the [MEDICATION NAME] and only asked for when the medication was to be discontinued. The DON stated he was to have called the pharmacy back at a later date regarding when the medication was to be discontinued. On 12/11/19 at 4:20 p.m., LPN #2 was asked how she administered the [MEDICATION NAME] injection for resident #2. She stated she had never given that much [MEDICATION NAME] so only administered one milliliter. She paused, and then stated she had misread the order and had administered the wrong dose. On 12/11/19 at 5:15 p.m., LPN #1 was asked how she administered the [MEDICATION NAME] injection for resident #2. She stated she did not recall but would review the medication administration record. She printed the record and stated she remembered she had seen the medication required a dose of three milliliters so when she administered the medication, she did so in a single injection with a three milliliter syringe. On 12/11/19 at 5:17 p.m., LPN #3 was asked how she administered the [MEDICATION NAME] injection for resident #2. She stated she had administered his [MEDICATION NAME]. She stated she was told the insulin syringes held one milliliter of medication so she administered the dose with three insulin syringes full of [MEDICATION NAME]. The LPN was asked if that meant the resident was injected three separate times with insulin syringes for each administered dose of [MEDICATION NAME]. She stated yes. She was asked if she was the admitting nurse for the resident. She stated yes. She was asked if she reviewed the admission paperwork she received before she confirmed the orders already in the electronic medical record. She stated she confirmed the orders in the electronic medical record but did not recall if she had reviewed the admission paperwork. 2. Resident #8 was admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. The hospital transfer orders, dated 10/18/19, documented to administer [MEDICATION NAME] 40mg/0.4ml injection under the skin every day for seven days. On 10/22/19 the resident was re admitted to the hospital. The hospital transfer orders, dated 11/04/19, included a refrigerator list of medications the resident routinely received and a list of discontinued medications which documented [MEDICATION NAME] 40mg/0.4ml injection was to be discontinued. A facility written admission order, dated 11/04/19, documented to start [MEDICATION NAME] sodium solution 40 mg/0.4ml inject 0.4 ml subcutaneous in the morning for circulation for 30 days. The nurse practitioner's progress note, dated 11/05/19, documented no changes to current treatment and medication plans for listed DX's. A review of the clinical record documented the resident received 40mg of [MEDICATION NAME] subcutaneous daily from 11/05/19 through 12/04/19. On 12/12/19 at 11:00 a.m., LPN #4 was asked why the [MEDICATION NAME] was restarted. She stated the nurse practitioner visited the resident on 11/05/19 and wrote for no changes. She was asked who entered the order. She stated LPN #2 entered the order. On 12/12/19 at 11:10 a.m., LPN #2 was asked where she obtained the order for [MEDICATION NAME]. She stated she used the refrigerator list in the hospital transfer paperwork received with the resident. She was asked if the order for [MEDICATION NAME] listed on the refrigerator list was compared to the hospital transfer orders received. She stated no. On 12/12/19 at 1:00 p.m., the DON provided a copy of the order for [MEDICATION NAME] 40 mg/0.4ml injection signed by the nurse practitioner. The order was not dated. He was asked if there was any documentation for the rationale for continuing the [MEDICATION NAME] after the hospital transfer orders documented to discontinue the medication or if the physician was aware the order was discontinued at the hospital. He stated no documentation was found for the rationale to continue the [MEDICATION NAME]. He was asked for the number for the nurse practitioner who signed the order for [MEDICATION NAME]. He provided the number and stated she was currently out of state on leave. On 12/12/19 at 1:14 p.m., the resident's primary care physician was asked if he was aware that the order for [MEDICATION NAME] had been discontinued at the hospital. He stated no. He was asked if he was aware the [MEDICATION NAME] 40 mg/0.4ml injection was ordered to be administered at the facility for 30 days. He stated no. He stated he would not have written the order for that length of time. He was informed the facility's nurse practitioner had signed the order. He stated she was not part of his practice and he was not aware she had signed the order.

Based on observation, interview, and record review, it was determined the facility failed to ensure nursing staff was competent and possessed the necessary skills to care for residents who received anticoagulation therapy for two (#2, #8) of three residents who received anticoagulation therapy. Resident #2 received 5 to 15 times the correct dosage of [MEDICATION NAME] ([MEDICATION NAME]) subcutaneous injectable every 12 hours from the evening of 11/01/19 through the morning of 11/08/19. The resident was admitted to the hospital's intensive care unit on 11/08/19 with new onset subdural hemorrhages of the brain. The facility identified nine residents who received anticoagulation therapy in the last 60 days. 1. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The computerized tomography scan (CT) of the resident's head without contrast, dated 10/24/19, documented the resident had a small right frontotemporal subdural hemorrhage (of the brain) with a trace amount of subarachnoid and intraventricular blood. The CT scan of the resident's head without contrast, dated 10/25/19, documented, .no interval acute intracranial abnormality. Essentially resolved subdural and subarachnoid hemorrhage (of the brain). Stable dependent small volume intraventricular hemorrhage . The report documented the scan had been compared with the previous scan dated 10/24/19. The hospital discharge instructions, dated 11/01/19, documented the resident was to receive [MEDICATION NAME] ([MEDICATION NAME]) 30 milligrams (mg)subcutaneous (sq) injectable every 12 hours. The electronic medical record, dated 11/01/19, documented the resident was to receive [MEDICATION NAME] ([MEDICATION NAME]) 300 milligrams per three milliliters subcutaneous every 12 hours. (The concentration of the medication was ordered at 100 mg/ml). The pharmacy packing slip, dated 11/01/19, documented the facility received four [MEDICATION NAME] injectable vials at a concentration of 150 mg/ml. The Medication Administration Record, [REDACTED]. A physician's orders [REDACTED]. An ER note, dated 11/08/19, documented, .pt to ed (emergency department) with C/O (complaint of) increased confusion and lethargy for past several days .Impression and Plan .Urinary tract infection .Subdural hematoma . A CT scan, dated 11/08/19, documented, .Small right frontal and right occipital subdural hemorrhages, new since (MONTH) 25, 2019 . A hospital history and physical, dated 11/08/19, documented the resident had an [MEDICAL CONDITION] and his blood was over anticoagulated. On 12/11/19 at 3:20 p.m., the ADON was asked what was the procedure for receiving a new resident from the hospital. She stated she received faxed transfer orders from the hospital and entered the orders into the resident's electronic medical record for the facility. She stated the hospital transfer orders received when the resident arrived at the facility was reviewed against the orders already in the electronic medical record and confirmed by the admitting nurse. She was shown the hospital discharge orders and asked where she had received the order for [MEDICATION NAME] 300 mg every 12 hours. She reviewed the hospital transfer orders which documented the resident was to receive 30 mg [MEDICATION NAME] every 12 hours and the facility Medication Administration Record [REDACTED]. She stated she had incorrectly transcribed the medication as [MEDICATION NAME] 300 mg every 12 hours instead of the ordered 30 mg every 12 hours. The ADON turned to her computer and instructed the surveyor to observe her enter an order for [REDACTED].>The ADON entered the medication name and a pull down menu provided options for dosage. The 300 mg per three milliliter dosage was just above the 30 mg per milliliter dosage for [MEDICATION NAME]. The ADON stated she thought she had scrolled the cursor down and selected the 30 mg dosage but must have inadvertently selected the 300 mg dosage which resided immediately above 30 mg dosage. She was asked who checked the orders to confirm their accuracy. She stated the admitting nurse would have confirmed the orders. The DON was present and stated he received a phone call from the pharmacy stating they did not have pre-filled syringes and would have to send vials of [MEDICATION NAME]. He stated the pharmacy had said nothing about the dosage of the [MEDICATION NAME] and only asked for when the medication was to be discontinued. The DON stated he was to have called the pharmacy back at a later date regarding when the medication was to be discontinued. On 12/11/19 at 4:20 p.m., LPN #2 was asked how she administered the [MEDICATION NAME] injection for resident #2. She stated she had never given that much [MEDICATION NAME] so only administered one milliliter. She paused, and then stated she had misread the order and had administered the wrong dose. She was asked if she was unsure of the accuracy of a medication, what would she do. She stated she would look it up on Google or YouTube. She also stated she would ask the other nurses or contact the pharmacy. On 12/11/19 at 5:15 p.m., LPN #1 was asked how she administered the [MEDICATION NAME] injection for resident #2. She stated she did not recall but would review the medication administration record. She printed the record and stated she remembered she had seen the medication required a dose of three milliliters so when she administered the medication, she did so in a single injection with a three milliliter syringe. She was asked if she was unsure of the accuracy of a medication, what would she do. She stated she would look it up on Google or YouTube. She also stated she would ask the other nurses, the ADON or DON, or contact the pharmacy or physician. On 12/11/19 at 5:17 p.m., LPN #3 was asked how she administered the [MEDICATION NAME] injection for resident #2. She stated she had administered his [MEDICATION NAME]. She stated she was told the insulin syringes held one milliliter of medication so she administered the dose with three insulin syringes full of [MEDICATION NAME]. The LPN was asked if that meant the resident was injected three separate times with insulin syringes for each administered dose of [MEDICATION NAME]. She stated yes. She was asked if she was the admitting nurse for the resident. She stated yes. She was asked if she reviewed the admission paperwork she received before she confirmed the orders already in the electronic medical record. She stated she confirmed the orders in the electronic medical record but did not recall if she had reviewed the admission paperwork. She was asked if she was unsure of the accuracy of a medication, what would she do. She stated she would look it up on Google or YouTube. She also stated she would ask the other nurses or contact the physician or pharmacy. On 12/12/19 at 1:14 p.m., the resident's primary care physician was asked if he was aware of the resident's significant medication error. He stated yes. He asked why did the nurses not stop when they saw the order and call someone for clarification. 2. Resident #8 was admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. The hospital transfer orders, dated 10/18/19, documented to administer [MEDICATION NAME] 40mg/0.4ml injection under the skin every day for seven days. On 10/22/19 the resident was re admitted to the hospital. The hospital transfer orders, dated 11/04/19, included a refrigerator list of medications the resident routinely received and a list of discontinued medications which documented [MEDICATION NAME] 40mg/0.4ml injection was to be discontinued. A facility written admission order, dated 11/04/19, documented to start [MEDICATION NAME] sodium solution 40 mg/0.4ml inject 0.4 ml subcutaneous in the morning for circulation for 30 days. The nurse practitioner's progress note, dated 11/05/19, documented no changes to current treatment and medication plans for listed DX's. A review of the clinical record documented the resident received 40mg of [MEDICATION NAME] subcutaneous daily from 11/05/19 through 12/04/19. On 12/12/19 at 11:00 a.m., LPN #4 was asked why the [MEDICATION NAME] was restarted. She stated the nurse practitioner visited the resident on 11/05/19 and wrote for no changes. She was asked who entered the order. She stated LPN #2 entered the order. On 12/12/19 at 11:10 a.m., LPN #2 was asked where she obtained the order for [MEDICATION NAME]. She stated she used the refrigerator list in the hospital transfer paperwork received with the resident. She was asked if the order for [MEDICATION NAME] listed on the refrigerator list was compared to the hospital transfer orders received. She stated no. On 12/12/19 at 1:00 p.m., the DON was asked if there was any documentation for the rationale for continuing the [MEDICATION NAME] after the hospital transfer orders documented to discontinue the medication or if the physician was aware the order was discontinued at the hospital. He stated no documentation was found for the rationale to continue the [MEDICATION NAME]. He was asked for the number for the nurse practitioner who signed the order for [MEDICATION NAME]. He provided the number and stated she was currently out of state on leave. On 12/12/19 at 1:14 p.m., the resident's primary care physician was asked if he was aware that the order for [MEDICATION NAME] had been discontinued at the hospital. He stated no. He was asked if he was aware the [MEDICATION NAME] 40 mg/0.4ml injection was ordered to be administered at the facility for 30 days. He stated no. He stated he would not have written the order for that length of time. He was informed the facility's nurse practitioner had signed the order. He stated she was not part of his practice and he was not aware she had signed the order.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received care and services to prevent the development of a stage three pressure ulcer and/or to promote healing of an existing pressure ulcer for two (#79 and #84) of three sampled residents who were reviewed for pressure ulcers. The facility identifed five residents who had pressure ulcers. Findings: A pressure ulcer policy, revised 07/2017, documented, .A pressure ulcer will present as an open ulcer .Prevention Moisture .Keep the skin clean and free of exposure to urine and fecal matter .Mobility/Repositioning. Choose a frequency for repositioning based on the resident's mobility .At least every hour, reposition residents who are chair-bound, or bed-bound with the head of the bed elevated 30 degrees or more .At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort . 1. Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admit screener form, dated 02/26/19, documented the resident had no pressure ulcers. An admission assessment, dated 03/11/19, documented the resident was moderately impaired with cognitive skills. The assessment documented the resident required extensive assistance and two plus person physical assist with bed mobility/transfers, had limited range of motion in one upper and one lower extremity, was always incontinent of bladder/bowel, was at risk for the development of pressure ulcers, and had no pressure ulcer. A care plan, dated 03/11/19, documented, .Focus: I have potential for pressure ulcer development r/t (related to) immobility. Interventions: Causes of skin breakdown; including transfer/positioning requirements .frequent repositioning .I need assistance to turn/reposition at least every two hours, more often as needed or requested .If I refused treatment, confer with me, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. A Braden scale assessment for predicting pressure sore risk, dated 03/12/19, documented the resident's skin was kept constantly moist by perspiration/urine, dampness was detected each time the resident was moved/turned, and the resident required moderate to maximum assistance in moving. The assessment documented the resident had a Braden score of 14, which indicated the resident was at moderate risk for the development of a pressure ulcer. A weekly wound sheet, dated 03/13/19, documented the resident acquired a stage three pressure ulcer to her coccyx which measured 2.0 centimeters in length, X (times) .6 centimeters in width, X .1 centimeters in depth. A nurse's note, dated 03/13/19, documented, Healogics wound nurse in evaluated resident. Stage 3 wound noted to coccyx. Minimal exudate present. 100% granulation noted. New orders received Silver Alginate, cover with dry drsg twice daily. Supplements in place. [MEDICATION NAME] ordered for 3-14-2019. Cushion placed in wheel chair. Son's notified. A physician's orders [REDACTED].Cleanse stage 3 Coccyx wound with normal saline, pat dry, Apply Silver Alginate, cover with dry drsg (dressing) every day and evening shift for stage 3 coccyx wound until resolved . A care plan, updated 03/13/19, documented, .Focus: .I have a stage III pressure ulcer to my coccyx. Goal: My stage III pressure ulcer will show signs of healing and remain free from infection .Interventions: Assess/record/monitor wound healing. Measure length, width, and depth where possible .Administer treatments as ordered and monitor for effectiveness .Assess and document status of wound perimeter, wound bed, and healing progress .Report improvements and declines to the MD (medical doctor) .Gel cushion to my wheelchair .Healogics to follow and assist with my wound care . An ADL (activities of daily living) sheet, dated (MONTH) 2019 documented 24 blanks where no documentation was completed regarding turning/repositioning and 24 blanks where no documentation was completed regarding bladder and bowel continence from 03/01/19 through 03/13/19. A 14-day assessment, dated 03/18/19, documented the resident was cognitively intact. The assessment documented the resident required extensive assistance and two plus person physical assist with bed mobility/transfers, had limited range of motion in one upper and one lower extremity, was always incontinent of bladder/bowel, was at risk for the development of pressure ulcers, and had one stage three pressure ulcer. On 03/28/19 at 3:05 p.m., licensed practical nurse (LPN) #3 was observed to perform wound care on the resident. She stated the resident was incontinent when she went to check on her and she had called the CNAs (certified nurse aides) to provide care. The LPN and the surveyor waited outside the room as the CNAs finished providing care. During the wound care observation, the resident was assisted to her right side by CNA #3. There was no dressing observed on the resident's coccyx pressure ulcer wound. Wound care was provided to the open wound on the resident's coccyx by the LPN and a dressing was put in place. After the wound care observation, the LPN was asked why there was not a dressing on the resident's coccyx wound. She stated, I don't know, it may have came off during incontinent care. She was asked if anyone had informed her the dressing was not there. She stated no. On 04/01/19 at 2:47 p.m., the LPN/care plan coordinator was asked about the blanks in the ADL care sheets. He stated the sheets should be completed and the blanks indicated the care was not done. He was asked why it was not done. He stated he did not know. He was asked if anyone monitored to ensure the resident was being turned/repositioned and incontinent care was completed as needed. He stated the charge nurses were supposed to look at the tasks in the ehr (electronic health record) and monitor if care was being completed and documented by the CNAs. He was asked if anyone monitored the nurses to ensure they monitored care and care was being provided as needed. He stated they talked about residents and care/interventions in the IDT meetings. The LPN/care plan coordinator was asked if he was aware if anyone had addressed the blanks in the documentation or if care had been provided as needed. He stated he did not know. He was asked if he knew why the resident developed the pressure ulcer. He stated he was not sure how well the interventions on the care plan had been done. He stated they should have been implemented and documented regarding turning, repositioning, and incontinent care being done every two hours and as needed. He stated the resident was a larger lady and did not like to move. He stated she had a history of [REDACTED]. He was asked if the pressure ulcer was a stage three when discovered. After he reviewed the ehr, he stated the first assessment that mentioned the pressure ulcer was the one on 03/13/19 that documented it as a stage three. At 3:43 p.m., the resident was asked about her care at the facility and the pressure ulcer. She stated, I think it (the pressure ulcer) happened when I was lying there in bed, wet. I was wet and waiting to be changed by staff. She stated she had been incontinent since her stroke in (MONTH) 2019. She stated, You wait to be changed. I'm not changed every two or three hours like I'm supposed to be. She was asked if she had to wait a long period to be changed recently. She stated yes. She stated she had issues being changed on all three shifts. She stated on 6 to 2 shift, it could be 10:30 a.m. before staff came down to her room, on 2 to 10 shift, it could be 2:30 p.m. to 6:30 p.m. before staff would come and check on her, and on 10 to 6 shift it could be four to five hours before staff would come in. She stated she usually always woke up wet in the early morning. She stated it was still happening and had happened last night and again early this am. The resident was asked if she needed assistance to turn and reposition. She stated yes. She stated she could move her upper body a little but could not shift her hips. She was asked if staff came in every two hours or more often if needed to turn and reposition her. She stated, No, I have to call them. On 04/02/19 at 9:30 a.m., the resident was asked if she had been incontinent this am. She stated she was dry at this time. She stated staff had been in at six a.m. to provide incontinent care and turn her, but had not come back since. She was asked if she refused care at times. She stated she usually needed care when they came in and did not refuse because sometimes it would be four or five hours before they came in again. At 9:40 a.m., CNA #2 was asked when she had been to the resident's room to provide care. She stated she had went down to her room after shift change at six a.m., and provided care and had not been back since then. She was asked about the blanks in the ADL documentation. She stated that meant it was not done. At 9:50 a.m. , LPN #1 was asked about the pressure ulcer. She stated the resident was alert/interviewable and could communicate her needs. The LPN stated she was not aware the resident refused care and was not sure why the resident had developed a pressure ulcer. At 2:15 p.m., the LPN/care plan coordinator was asked why the care plan interventions were not consistently implemented regarding turning/repositioning and incontinent care. He stated he did not have an answer. At 2:40 p.m., the wound care nurse was asked about the resident's pressure ulcer. She stated a CNA had told her the resident had a sore. She stated she went and assessed the wound and it was a stage three pressure ulcer. She stated she was not sure how long the pressure ulcer had been there before she was made aware of it. 2. Resident #84 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. An admit/readmit screener form, dated 03/08/19 at 9:52 p.m., documented the resident had a stage two sheer to the left buttock. The form documented calazyme ointment was in place to the left buttock. There was no documentation of a physician's orders [REDACTED]. A physician's orders [REDACTED]. The admission assessment, dated 03/15/19, documented the resident was cognitively intact; required extensive assistance with bed mobility, transfers, and personal hygiene; was at risk for pressure ulcers; and had one stage two pressure ulcer. The resident's 03/2019 treatment administration record had four undocumented blank spaces for the [MEDICATION NAME] cream. The cream was discontinued on 03/26/19. On 04/02/19 at 2:14 p.m., the wound nurse stated there was no order upon admission for the use of the [MEDICATION NAME] cream. She stated it was house stock and was used as a preventative wound treatment. She did not have a reason why the treatment had not been done those four shifts.