Every finding on record at San Juan Nursing Home, Inc.

Based on interview and record review, the facility failed to ensure that care and services were provided by qualified persons in accordance with the written plan of care for 1 or 3 residents (Resident #1) reviewed for qualified persons.The facility failed to provide direct supervision to a student nurse while the student nurse administered a gastrostomy tube bolus feeding. This failure could place residents with a G-tube at risk of abdominal discomfort, aspiration, and decreased quality of life.Findings included: Record review of Resident #1's admission record dated 06/17/26 revealed an original admission date of 02/01/22 and admission date of 04/08/24. The diagnoses included: dysphagia (trouble swallowing), anorexia (loss or lack of appetite), Encounter for attention to gastronomy (routine care, maintenance, changing, or fixing a clogged or dislodged G-tube (a flexible feeding tube surgically placed through the abdomen directly into the stomach)), and gastro-esophageal reflux disease (when stomach acid flows back up into the esophagus and causes heartburn). Record review of Resident #1's Care Plan dated 02/02/22 revealed Resident #1 required the use of a feeding tube.Record review of Resident #1's MDS assessment dated [DATE] revealed an additional diagnosis of gastroparesis (a condition in which the muscles in the stomach did not move food).Record review of Resident #1's Order Summary Report dated 06/18/26, revealed an order, dated 04/10/24, enteral feed order, every day shift and night shift The order indicated to check residual (use a 60 mL syringe to aspirate (pulling back on the plunger) and measure the remaining liquid in a person's stomach): The order indicated if there was more than 100 mL of stomach content, return gastric contents to the stomach, withhold medication and notify the physician. This Order Summary Report also revealed an order dated 04/08/24, enteral feed order four times a day, bolus feedings (a method of delivering liquid nutrition or formula directly into the stomach through a feeding tube using a syringe): Jevity 1.2 (nutrient-packed liquid meal replacement) bolus (a method of delivering liquid nutrition directly into the stomach through a feeding tube using a syringe), 4 times a day.Resident #1 was not interviewed because resident had expired.During an interview on 06/16/26 at 9:29 AM, Resident #1's family member stated they observed Resident #1 received a bolus feeding from a student nurse. Resident #1's family member stated the student nurse, name unknown, entered Resident #1's room with feeding supplies in hand. Resident #1's family member stated the student nurse was waiting for the instructor to enter the room to proceed with the bolus feeding. Resident #1's family member stated the student nurse proceeded to administer the bolus feeding without the instructor or a nurse present. Resident #1's family member stated the student nurse did not check for residuals prior to administering the feeding. Resident #1 family member stated that by the time the student nurse was finishing with the feeding, the instructor showed up and assisted the student nurse with the last portion of the formula and water input. Resident #1's family member stated that it was her understanding that all student nurses had to be supervised by the Clinical Instructor or a facility nurse. Resident #1's family member stated that at no time during the feeding was Resident #1 in any distress. During an interview on 6/16/26 at 5:05 PM, LVN A stated it was important to check for residuals prior to a G-tube feeding because it ensured the stomach was emptied properly and it prevented the risk for aspiration. LVN A stated she was aware nursing students participated in the administration of bolus feedings to residents. LVN A stated that from her understanding, nursing students were allowed to administer bolus feeding without the supervision of the clinical instructor or a nurse present once they were checked off on the bolus feeding skill (successfully demonstrated clinical competency in safely caring for and managing a feeding tube). LVN A stated she would hand off the feeding supplies to students so they could administer the bolus feedings. LVN A stated the clinical instructor would inform the facility nurses on which nursing students were checked off on the bolus feeding skill. During an interview on 6/16/26 at 6:35 PM, LVN B stated nursing students were allowed to administer bolus feeding alone when they were checked off by the clinical instructor. LVN B stated once the student was checked off, neither the clinical instructor nor a facility nurse had to be present during the administration of the feeding. LVN B stated she remembered nursing students approached her on several occasions to do the bolus feeding for Resident #1. LVN B stated she knew which nursing students were checked off because the instructor informed her. LVN B stated that when the nursing students were done administering the feeding, the student would inform her of the completed task. LVN B stated she would then go into the resident's room and check on the resident to ensure they tolerated the feeding well. LVN B stated she did not remember Resident #1 having issues with a bolus feeding provided by a nursing student. LVN B stated it was important to check for residuals prior to a G-tube feeding to prevent aspiration or abdominal discomfort. During an interview on 6/17/26 at 9:19am the Clinical Instructor stated that if the nursing students administered bolus feedings on their own, they were first checked off in a skills lab at school and then again at the nursing facility with a resident. She stated she was the one that checked off students on their skills. The Clinical Instructor stated that all students were aware of checking residuals before each bolus feeding. She stated that checking residuals was done to prevent aspiration. The Clinical Instructor stated that all the nursing students that were at the facility doing clinical work, had all been checked off to administer bolus feedings. The Clinical Instructor stated all the nursing students were competent to perform the skill without supervision. The Clinical Instructor stated she did not remember an incident where she arrived at the end of a bolus feeding for Resident #1. The Clinical Instructor stated that if a nursing student had made an error, they would follow the facility's policies to resolve the issue. The Clinical Instructor stated she could not provide student's personal information for interviews unless she had prior approval from [Nursing School]. During an interview on 6/18/26 at 11:22am the DON stated students were allowed to administer bolus feedings without supervision to residents once they were checked off by the Clinical Instructor. The DON stated he was not aware that there was an issue with a nursing student doing a bolus feeding on Resident #1. He stated that the Clinical Instructor did not allow the nursing students to perform the task alone unless they were checked off. The DON stated there was not an orientation on behalf of the facility when the students first started their clinicals at the facility, but they were provided with a tour. The DON stated that going forward, there would be a collaborative effort with the nursing school, and he would complete a facility competency check-off as well. The DON stated the facility did not have a policy regarding student nurses and performing tasks independently. During an interview on 6/18/26 at 11:52am the Administrator stated the facility did not have a protocol in place in relation to student nurses. She stated she would talk to the DON to get something in place. The Administrator stated that at the end of the day, the nursing students were just students. She stated if the nursing students were not licensed to do a procedure, then they should not have been doing things independently.There were no observations done of a student nurse providing a G-tube feeding because nursing students were on a school break. Record review of the facility's policies dated 06/18/26 revealed there was not a facility policy in place regarding student nurses providing care to residents.Record review of the facility's Resident Rights policy revised October 2009 revealed 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Record review of [Nursing school's] Affiliation Agreement with the facility, revised January 2025 revealed, Responsibilities of PartiesBoth parties will cooperate to provide students with optimal clinical education opportunities to learn assigned tasks.Responsibilities of [Nursing School][Nursing School] will provide qualified instructors for clinical oversight and instruction.Instructors and students of [Nursing School] will comply with the policies of the Clinical Facility in carrying out clinical assignments and responsibilities.Responsibilities of the Clinical FacilityThe Clinical Facility may choose to assist in the clinical experience program by providing, through its supervisory personnel, regular evaluations of the students. 4.The Clinical Facility will appoint an appropriate member of the Facility to provide orientation to [Nursing School] faculty regarding Clinical Facility policies and rules. 6. The Clinical Facility will provide opportunities for practical and/or observational experience to supplement the instruction given by [Nursing School] but will retain full responsibility for patient care delivered at the facility.

Based on interview and record review the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 3 of 5 residents (Resident #12, #4, and #2) reviewed for assessments.1. The facility failed to complete a Significant Change in Status MDS Assessment after Resident #12 admitted to hospice services on [DATE].2. The facility failed to complete a Significant Change in Status MDS Assessment after Resident #2 had four new diagnoses changes: Klebsiella Pneumoniae ([DATE]), Urinary Tract Infection (UTI [DATE]), Do Not Resuscitate (DNR [DATE]), and Pleural Effusion ([DATE]).3. The facility failed to complete a Significant Change in Status MDS Assessment after Resident #4 had increasing symptoms of cough, congestion, and shortness of breath which began [DATE] and was still progressing through the last day of survey [DATE].These failures could place residents at risk of having inaccurate assessments, not having individual needs met, and decreased quality of life.Findings included:1. Record review of Resident #12's face sheet, dated [DATE], revealed Resident #12 was a [AGE] year-old male admitted to the facility on [DATE]. Pertinent diagnoses included Congestive Heart Failure (CHF - a chronic condition where the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup and other various symptoms), Atrial fibrillation (AFib - an irregular heart rhythm which originates in the heart's upper chambers (the atria) and could lead to symptoms such as fatigue, heart palpitations, shortness of breath, and dizziness), and Encounter for Palliative Care (Palliative Care - a medical specialty which focuses on relieving the symptoms and stresses of a serious illness in order to maximize the quality of life, according to the patient's and family's goals and aspirations).Record review of Resident #12's physician orders, dated [DATE], revealed Resident #12 had an order to be admitted to hospice with a diagnosis of CHF. Record review of Resident #12's care plan, dated [DATE], revealed Resident #12 had a care plan for Hospice. Interventions included correlating care with hospice to ensure all needs were met on a daily basis; keep Resident #12 comfortable, repositioned, clean, and dry; monitor Resident #12 for changes in condition.Record review of Resident #12's EHR did not indicate a Significant Change in Status MDS Assessment was completed after Resident #12 was admitted to hospice services on [DATE]. There were no Significant Change in Status MDS Assessments in Resident #12's EHR for the entirety of their admission in the facility.2. Record review of Resident #4's face sheet, dated [DATE], revealed Resident #4 was a [AGE] year-old female initially admitted to the facility on [DATE], with a readmission on [DATE]. Pertinent diagnoses included Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), Do Not Resuscitate, Klebsiella Pneumoniae (a bacterium which could cause serious infections, particularly in hospital settings, and was known for its antibiotic resistance), and Urinary Tract Infection (UTI - an infection in any part of the urinary system).Record review of Resident #4's progress note, dated [DATE], revealed chest x-ray impression revealed small faint infiltrate on the right lung (Infiltrated Lungs referred to the presence of abnormal substances, such as fluid or cells, within the lung tissue, often detected through imaging techniques). Progress note dated [DATE] revealed Resident #4 was started on Amoxicillin for UTI. Progress note dated [DATE] revealed Resident #4 had a care plan conference with the RP and family, and it was determined code status would be changed from full code to DNR. Progress note dated [DATE] revealed Resident #4 had a small pleural effusion, but no thoracentesis was needed (Thoracentesis - a medical procedure used to remove excess fluid from the pleural space around the lungs, helping to relieve symptoms and diagnose underlying conditions). Record review of Resident #4's care plan, dated [DATE], revealed Resident #4 had a care plan for Do Not Resuscitate. Interventions included if Resident #4 was found without respirations or heartbeat, do not begin CPR. Keep Resident as comfortable as possible. A care plan initiated [DATE], and revised [DATE], revealed Resident #4 was at risk for shortness of breath related to a respiratory infection. Interventions included monitoring and documenting breathing patterns, and reporting abnormalities to the doctor. A care plan initiated [DATE], and revised [DATE], revealed Resident #4 was incontinent of bowel and bladder. Interventions included monitoring for signs and symptoms of infection, and report changes to the doctor. Record review of Resident #4's electronic health record did not indicate a Significant Change in Status MDS Assessment was completed after Resident #4 was diagnosed with Klebsiella Pneumoniae ([DATE]), Urinary Tract Infection (UTI [DATE]), Do Not Resuscitate (DNR [DATE]), and Pleural Effusion ([DATE]). There were no Significant Change in Status MDS Assessments in Resident #4's EHR for the entirety of their admission in the facility.3. Record review of Resident #2's face sheet, dated [DATE], revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE]. Pertinent diagnoses included Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), and Dysphagia (difficulty in swallowing, which could occur at any stage of the swallowing process).Record review of Resident #2's physician orders dated [DATE] revealed an order for oxygen at 2 Liters via nasal cannula as needed for low oxygen. A physician order dated [DATE] revealed give Resident #2 oxygen at 2 Liters via nasal cannula as needed for low oxygen saturations. An order dated [DATE] revealed Resident #2 had an order for Guaifenesin (an ingredient in cough and cold medicine which was used to help clear mucus or phlegm from the chest when there was a cold or flu), every 4 hours as needed for cough. Resident #2 had an order dated [DATE] which revealed Resident #2 needed Albuterol Nebulization, 1 vial every 8 hours as needed for cough and/or congestion. Record review of Resident #2's progress note, dated [DATE], revealed Resident #2 had coughing and received prescribed cough medication. A progress note dated [DATE] revealed Resident #2 had coughing and received prescribed cough medication. A progress note dated [DATE] revealed Resident #2 had coughing and received prescribed cough medication. A progress note dated [DATE] revealed Resident #2 had coughing and received prescribed cough medication. A progress note dated [DATE] revealed Resident #2 had coughing and received prescribed cough medication. A progress note dated [DATE] revealed Resident #2 had coughing and received prescribed cough medication. A progress note dated [DATE] revealed Resident #2 had coughing and received prescribed cough medication. A progress note dated [DATE] revealed Resident #2 had coughing and congestion and unable to excrete phlegm (unable to cough up mucous) so chest percussion therapy (involved rhythmic clapping or thumping on the chest and back to loosen mucus in the lungs) with deep suctioning was performed with no success. Progress note dated [DATE] revealed Resident #2 had congestion and shortness of breath. Oxygen saturation was 84%, so Resident #2 was placed on 3 Liters of oxygen, and saturation came up to 89%. Progress note dated [DATE] revealed Resident #2 had audible crackles. Progress note dated [DATE] revealed Resident #2 continued with cough and congestion. Oxygen was still being utilized to keep saturations above 90%. Progress note dated [DATE] revealed Resident #2 received an order for a STAT chest x-rays, lab work, and continue with Albuterol treatments three times per day for 7 days for congestion.Record review of Resident #2's care plan, dated [DATE], and revised [DATE], revealed a care plan for altered respiratory status related to cough and/or congestion. Interventions included administer medications as ordered and monitor for effectiveness and side effects. A care plan dated [DATE] revealed Resident #2 had a care plan for oxygen therapy as needed for low oxygen saturations. Interventions included monitor for signs and symptoms of respiratory distress and report to the doctor; oxygen at 2 Liters via nasal cannula as needed for low oxygen saturations; check oxygen saturations as indicated or needed. Record review of Resident #2's electronic health record did not indicate a Significant Change in Status MDS Assessment was completed after Resident #2 progressively worsened with cough, congestion and shortness of breath which began [DATE]. Resident #2's Annual MDS Assessment, dated [DATE] and completed [DATE], did not reveal any oxygen therapy or treatments, or any suctioning therapy or treatments. There were no Significant Change in Status MDS Assessments in Resident #2's EHR for the entirety of their admission in the facility.In an interview on [DATE] at 9:36 am, MDS-C stated he made sure the MDS assessments were completed and filled out, then submitted. He also said there were 3 MDS nurses who worked on MDS assessments, but he was not the coordinator. MDS-C stated no one was tracking anything regarding the MDS assessments, then subsequently stated significant change MDS assessments were getting done in the facility because he was the one who did them. He stated a significant change was a change in the residents' diagnoses or care which was projected to last long term, longer than 14 days, and affected 2 or more care areas, such as residents being placed on hospice. MDS-C stated he found out about residents with changes in the morning meetings which were held twice per week, or when he ran the 24-hour report in the morning. He could not recall any residents in the facility in the past 3-6 months who he had performed a Significant Change MDS Assessment on.In an interview on [DATE] at 10:30 AM, the DON stated Resident #2 recently had a significant change in which he had to continuously be placed on Oxygen due to low Oxygen saturation levels. The DON stated a significant change was something which deviated from the baseline which required treatment or monitoring, such as a change in the residents' care, and the fact Resident #2 had not consistently used Oxygen previously, but it was currently being utilized continuously, would be considered a significant change. The DON stated if there was a change in condition, the floor nurses assessed the situation and put it in a progress note, but they did not do an actual assessment of the residents such as a focused assessment or SBAR assessment for a change in condition, but he saw how it would be needed, and the nurses should have been doing focused assessments, SBARs, or significant change assessments, which should trigger the MDS to do the Significant Change in Condition MDS assessments, but they were not being done. He stated the progress notes or changes got relayed back to MDS-C in the morning meetings or in their group communication text/chat. The DON stated MDS-C had not been doing significant change assessments, except when there was a big change, such as new hospice orders.In an interview on [DATE] at 1:30 PM the Administrator stated the MDS coordinator did MDS assessments in conjunction with the other MDS staff and the speech therapist. She stated since the facility was a non-profit, they did not get help from people such as regional nurses or regional MDS. She stated it was up to them to figure out what needed to be done. She stated staff had been trained in MDS assessments, so they should have known when and how to complete significant change assessments, but she was not sure if they had been doing it. In an interview on [DATE] at 2:15 pm, MDS-B (the MDS Coordinator) stated she used to be the DON for this facility, but she moved over to the MDS coordinator position. She stated she had been trained on how to complete MDS assessments and forms, and the MDS was the actual comprehensive assessment to meet all the needs of the residents and establish a plan of care. MDS-B stated MDS-C was the one who did the actual MDS assessment, and she just signed off on them once they were completed. She stated she had not actually checked for accuracy or to make sure the proper assessments were completed. She stated it was just her job to sign off the MDS had been completed. MDS-B stated in-house acquired pressure ulcers could be considered significant changes if it affected two or more care areas or lasted longer than 14 days, as well as progressive cough and congestion and use of Oxygen could be considered a significant change if it affected 2 or more care areas or lasted longer than 14 days, but she was not sure who in the facility had actually had recent significant changes warranting assessments to be completed. Record review of the facility's Change in a Resident's Condition or Status policy, revised [DATE], revealed A significant change of condition is a decline or improvement in the resident's status which: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. Impacts more than one area of the resident's health status; c. required interdisciplinary review and/or revision to the care plan; d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii).Record review of the facility's Assessment Schedule for the RAI, revised [DATE], revealed Page 2-7, a significant change in status assessment is not required in a case where the resident's condition is expected to return to baseline within a short period of time, such as one to two weeks. If the condition does not return to baseline, the assessment should be completed as soon as needed to provide appropriate care to the residents, but in no case later than 14 days after the determination was made which a significant change occurred. The amount of time which would be appropriate for a facility to monitor a resident depends on the clinical situation and severity of symptoms experienced by the resident. Generally, if the condition has not resolved within approximately 2 weeks, staff would begin a comprehensive RAI assessment.

Based on interviews and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 5 of 16 residents reviewed for PASRR. (Residents #2, 7, 8, 9, and 11) 1. The facility failed to refer Resident #2 for PASRR Level II assessment when the facility incorrectly coded his PASRR Level I assessment. 2. The facility failed to refer Resident #7 for PASRR Level II assessment when the facility incorrectly coded her PASRR Level I assessment. 3. The facility failed to refer Resident #8 for PASRR review following new mental illness diagnosis. After admission, he was diagnosed with mood disorder due to known physiological condition, delusional disorders, and insomnia. 4. The facility failed to refer Resident #9 for PASRR review following new mental illness diagnosis. After admission, she was diagnosed with major depressive disorder, recurrent, severe with psychotic symptoms. 5. The facility failed to refer Resident #11 for PASRR Level II assessment when the facility incorrectly coded her PASRR Level I assessment. Further, and after admission, her diagnoses included anxiety disorder, major depressive disorder, recurrent, severe without psychotic features, mood disorder due to known physiological condition, vascular dementia, depression, bipolar disorder, and delusional disorders. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings include: 1. Record review of face sheet dated 11/05/24 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses (all dated 11/05/24) included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Mood disorder due to known physiological condition with mixed features, and anxiety disorder due to known physiological condition with mixed features, and cognitive communication deficit. Resident #2's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated his Brief Interview for Mental Status (BIMS) score was 12 out of 15 showing moderate cognitive impairment. He was coded as having depression, required staff dependence for all ADL's, and was always incontinent of bowel. He had a urinary catheter and a feeding tube. His active diagnoses included progressive neurological conditions, Diabetes, stroke, anxiety disorder, and bipolar disorder. He was taking psychotropic medications. Record review of Resident #2's PL1 dated 11/05/24 was negative for MI, ID, or DD. There were no other PASRR screenings. 2. Record review of Resident #7's electronic face sheet dated 04/12/24 reflected the resident was an [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses included Parkinson's (a brain disorder that slows down movement, causes tremors, stiffness, and balance problems, making everyday tasks difficult. It is a progressive disease where brain cells die, affecting control over the body, worsening over time) (04/12/24) , Psychotic disorder with hallucinations due to known physiological condition (12/11/23), unspecified dementia (11/30/23), depression, and functional quadriplegia (the complete inability to move the arms and legs due to severe frailty or debility without actual physical damage or injury to the brain or spinal cord). Record review of Resident #7's quarterly MDS assessment dated [DATE], revealed a BIMS score of 00, indicating severely impaired cognition. She had no functional abilities and was dependent on staff for all ADL's and was always incontinent of bowel. She had a urinary catheter and a feeding tube. Her active diagnoses included depression, Parkinson's, and psychotic disorder. She was taking antidepressant and antipsychotic medications, and was on continuous oxygen therapy. Record review of Resident #7's PL1 dated 11/30/23 was negative for MI, ID, or DD. There were no other PASRR screenings. 3. Record review of face sheet dated 06/19/24 indicated Resident #8 was a [AGE] year-old male admitted on [DATE]. His diagnoses dated 06/19/24 included unspecified dementia; unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, depression, Parkinson's, and lack of coordination. On 08/14/24, he was diagnosed with mood disorder due to known physiological condition, delusional disorders, and insomnia. Record review of Resident #8's quarterly MDS assessment dated [DATE], revealed a BIMS score of 02, indicating severely impaired cognition. He had physical behavioral and/or verbal symptoms (hitting, kicking, pushing, scratching, grabbing, abusing others sexually and/or threatening others, screaming and/or cursing at others) directed towards others occurring 1-3 days a week. He was dependent on staff for all ADL's and was always incontinent of bladder and bowel. His active diagnoses included non-Alzheimer's dementia, mood disorder, progressive neurological conditions, stroke, Parkinson's, anxiety, depression, psychotic disorder and heart failure. He was taking antidepressant and antipsychotic medications. He was receiving oxygen therapy. Record review of Resident #8's PL1 dated 06/18/24 was negative for MI, ID, or DD. There were no other PASRR screenings. 4. Record review of face sheet dated 06/19/24 indicated Resident #9 was an [AGE] year-old female admitted on [DATE] with an original admission date of 03/15/24. Her diagnoses dated 03/15/24 included unspecified dementia; unspecified severity, with other behavioral disturbance, anxiety disorder, major depressive disorder, recurrent, and insomnia. On 03/22/24, she was diagnosed with major depressive disorder, recurrent, severe with psychotic symptoms. She was also dependent on dialysis, had heart failure, chronic respiratory failure and was dependent on oxygen. Record review of Resident #9's annual MDS assessment dated [DATE], revealed a BIMS score of 15, indicating no impaired cognition. She utilized a manual wheelchair and could self-propel. She was independent of staff for all ADL's except set-up and verbal or touching cues. She was occasionally incontinent of bladder and always continent of bowel. Her active diagnoses included non-Alzheimer's dementia, progressive neurological conditions, anxiety, depression, respiratory failure, end stage renal disease, and heart failure. She was taking antidepressant medications. She was receiving oxygen therapy. She was on dialysis. Record review of Resident #9's PL1 dated 03/15/24 was negative for MI, ID, or DD. There were no other PASRR screenings. 5. Record review of face sheet dated 03/14/18 indicated Resident #11 was a [AGE] year-old female admitted on [DATE]. Her diagnoses dated 03/14/18 included anxiety disorder, diabetes, arthritis, heart failure, and anemia. On 11/17/20, she was diagnosed with major depressive disorder, recurrent, severe without psychotic features. On 01/27/22 she was diagnosed with mood disorder due to known physiological condition. On 10/01/22 she was diagnosed with vascular dementia. On 01/10/23 she was diagnosed with depression, bipolar disorder, and delusional disorders. Record review of Resident #11's quarterly MDS assessment dated [DATE], revealed a BIMS score of 00, indicating severely impaired cognition. She was dependent on staff for all ADL's and was always incontinent of bladder and bowel. Her active diagnoses included anemia, heart failure, progressive neurological conditions, diabetes, non-Alzheimer's dementia, anxiety disorder, bipolar disorder, psychotic disorder and asthma. She was taking antianxiety medications. She was receiving oxygen therapy and under hospice care. Record review of Resident #11's PL1 dated 03/13/18 was negative for MI, ID, or DD. There was a form 1012 signed by the physician dated 11/24/2020 but was never filed. There were no other PASRR screenings. In an interview with MDS C on 12/11/25 at 9:36 am, he said MDS B documented the care plans and diagnoses. He said his job was to make sure the MDS's were filled out and signed and he submitted them to an electronic portal. He said the PL1's got updated when there was a new diagnosis. He said he for sure did not have any other PASRR documents for Resident #2, 7, 8, 9, or 11. He said he would send the 1012 form to the MDS people in a nearby town, but after Covid, meetings were by phone-it was one of those things. He said Resident #11 went on hospice and he did not know why. He said the facility had three MDS coordinators, and he was not one of them, but since he had worked there for 15 years, he received the brunt of it. He said MDS B worked on the diagnoses and care plans. He said no one was tracking anything. He said MDS B was the coordinator and she was responsible for PASRR. He said right now the facility was changing titles and cutting staff. For example, he would remain as MDS for LTC (long term care). He said MDS F would be doing therapy and MDS B was taking over the care plan's. He said he had not followed up with any PASRR since Covid. He said administration, DON's and everyone had been changing a lot over the last several years. He said he never had training on PASRR, none of them (MDS) did. He said he never suggested getting training because there's no money in it for him. Requested MDS F and B for interviews. In an interview with the DON on 12/11/25 at 10:15 am, he said the process for identifying residents with new qualifying diagnoses after admission was a form that was supposed to be filled out and sent to the state. He said MDS #C was responsible for making the referral to the appropriate state-designated authority when a resident was identified as having newly evident qualifying diagnoses for MD, ID, or related conditions. He said if there was a resident identified, he did not know why there was not a referral made or forms signed. He said the residents could decline because they were not getting services they otherwise could have benefitted from. Requested MDS F and B for interviews. In an interview with the ADM on 12/11/25 at 1:30 pm she said MDS B was the MDS coordinator. She said the facility was currently going through some training for MDS. She said MDS F was the coordinator for care plans and LTC (Long Term Care), and also managed therapy schedules. She said the admin team met and decided to change the MDS nurses' rolls but could not explain them. She said the Admissions coordinator was also assisting with the MDS nurses because it was collaborative. She said the speech therapist was doing the BIMS scores within their scope. She said the social worker, activities director, and the dietary manager were part of the collaboration. She said MDS B opened the MDS's and checked to make sure they were complete. She said MDS C checked for accuracy. She said the MDS staff had training on MDS, but could not say when or produce any documentation for the MDS training. She said there had not been any PASRR training for years. She said PASRR was resident's cognitive level. She did not know what the process was for PASRR or what a form 1012 was or when it needed to be used. She said none of her staff had been trained for PASRR. Requested MDS F and B for interviews. In an interview with MDS B on 12/11/25 at 2:15 pm she said she had started work at the facility in January 2025 but was DON for 8 years. She said she took the MDS course 3 times and took some association courses on her own. She said MDS was the actual comprehensive assessment to meet all the needs of the residents and establish a plan of care. She said MDS C was responsible for scheduling the quarterly MDS dates and all other MDS due dates, including changes. She said the administrative staff reviewed the 24-hour reports to determine significant changes. She said MDS C was the only person who did MDS. She said the ICP took care of the nutrition rooms. She said staff were trained by the DON, ADON, ICP, and the fire dept. She said MDS F did care plans and she (MDS B) assisted clinical management, was the CNA coordinator, care plans, and signed off the MDS's. She said she did not make sure the MDS's she signed were accurate. She said the Admissions nurse did the PASRR's. Requested MDS F and the Admissions nurse for interviews. MDS F nor the Admissions nurse provided interviews. Record review of facility policy titled Resident Assessment-Coordination with PASRR Program with an implemented date February 12, 2027 reflected: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. 3. A record of the pre-screening shall be maintained in the resident's medical record. 5a. a.The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 nutrition rooms for storage, preparation, and sanitation. The facility failed to discard damaged pans and utensils. The facility failed to keep food products in the refrigerators and freezers sealed properly. The facility failed to follow a cleaning schedule. These failures could place residents at risk for food contamination and foodborne illness. Findings include: Initial tour and observation of the kitchen on 12/09/24, beginning at 8:15 am revealed 4 of 7 non-stick type coated frying pans were flaking. Three of the pans were completely bare, except for the sides. There were 2 large spatulas with chunks of plastic missing around the edges in the use bin. The underside of the shelf directly over the food on the steam table had chunks of removable red, brown, and black substances. There was a removable fuzzy black substance on and around the gaskets and on the doors of the 2-compartment bread refrigerator. There were tomatoes with fuzzy black spots on them, and they were leaking juices in the walk-in refrigerator. There were 7 large limp carrots with fuzzy black spots on them. The carrots were inside a large box touching more large carrots. There was an unsealed zip-type bag of cut cabbage that was open to air in the walk-in refrigerator. There was a large open plastic bag labeled sausage slices in the walk-in freezer. The sausage slices had ice on them. In an interview with DA G on 12/09/25 at 8:20 am, she said she did not know the pans were damaged, and she could not throw them out because the DM had to do that. She said the cooks and the DM were in charge of the refrigerators and freezers. In an interview with DA H on 12/09/25 at 8:40 am, she said she was unaware of the flaking non-stick coating on the pans. She said the bits of the coating could get into the food and make residents sick. In an interview with the [NAME] on 12/09/25 at 8:50 am, she said the non-stick coating from the pans were like that because they used metal utensils in them. She said they did not use the pans. She said the pans were hanging on the clean rack. She said the DM was the only one allowed to discard damaged utensils. She said the damaged spatulas were used in the puree machine. She said she guessed the broken-off pieces were in the food. She said the residents could ingest the particles of the spatulas, pans, and whatever was on the underside of the steam table shelf. She said whoever unloaded the truck deliveries was responsible for storing the items properly. She said she did not know who stacked the boxes to the ceiling in the walk-in freezer. She said the DA's and the cooks were responsible for properly storing leftover food in the refrigerators and freezers. She said she did not know who had left food open. She said that when kitchen staff came across bad food, such as the tomatoes and carrots, they threw them out as soon as they saw them. She said leaving the tomatoes and carrots in the state they were in could cause cross-contamination and make residents sick. She said the DM did not come in until 8 or 9 am. His presence was requested at this time. During a return visit to the kitchen and an interview with the DM on 12/10/25 at 2:00 pm, he said he did not come to work until 8 or 9 am in the morning. He said he was at the facility yesterday and knew the state was in the building. He shrugged his shoulders when asked why he did not speak with this state surveyor yesterday. He said he was responsible for everything in the kitchen. He said there was a cleaning schedule, but the kitchen had not been cleaned properly for over nine months. He said there had been staffing shortages, so he had to cut some things out. He said not cleaning the kitchen properly could compromise the cleanliness of the kitchen and make residents sick. He said there was mold around both of the bread refrigerator doors and gaskets. He said the damaged non-stick pans were not being used and did not know why they were hanging on the clean rack. He said he was in charge of discarding damaged utensils, so he knew when to replace them. When asked at what point non-stick pans were considered damaged, he said when the coating started coming off. He said the coating was toxic, and the pieces probably got into the food and could make the residents sick, but he had not heard about anyone getting sick. He said the particles on the underside of the shelf above the steam table probably got into the food. He said all food in the refrigerators and freezers should be tightly sealed, labeled, and dated. He said the cooks and DA's were responsible for storing food. He said the rotten tomatoes and carrots should not be in the same box as the good ones because whatever was on the bad ones could cross-contaminate the good ones and make residents sick. He said the personal items on the carts in the kitchen should not be there because of cross-contamination. He said the kitchen staff had a place to store their personal items. He said the carts were not a designated area for staff belongings. He said kitchen staff were not responsible for the nutrition refrigerators, and he did not know who was. He said staff should know not to stack boxes in the walk-in refrigerators to the ceiling. He said it could impede the sprinklers if there was a fire. He said the ice accumulation on the condenser hose was always like that. He said that was why he did not report it to anyone. In an interview with the DON on 12/11/25 at 12:13 pm he said nurses were responsible for cleaning, labeling, and dating resident belongings in the designated resident refrigerator. He said labeling and dating food and beverages were required to prevent cross-contamination and potential illness from expired products. He said all staff were responsible for cleaning, labeling, and dating personal belongings in the designated employee refrigerator. He said he did not check the refrigerators because he assumed staff were. In an interview with MDS B on 12/11/25 at 2:15 pm she said the ICP took care of the nutrition rooms. In an interview with the ADM on 12/11/25 at 2:30 pm, she said she was unaware there was anything going on with the kitchen. She said she had been there before but was not sure what to look for. Record review of the facility's 4-page cleaning schedules for 2025 revealed: Page 1, Mondays and Tuesdays, weeks 1-5. Mondays covered freezers, walk-in cooler, pantry, bathroom, walk-in curtain, juice machine & tubes, coffee station, hand washer, bread refrigerator, small refrigerator, wipe ice machine, toaster/can opener. Tuesdays covered can opener, garbage cans, dust pans, veggie sink, dish machine, wash room, wipe ice machine, bathroom, hand washer, dish room curtain, coffee station. Page 2, Wednesdays covered juice machine & tubes, plate cart, cabinets, walls, windows, coffee station, hand washer, toaster/can opener, wipe ice machine, bathroom, walk-in curtain. Thursdays covered all heated carts, serving carts, plate cart, stove hood, clean utensil rack, wipe ice machine, bathroom, dishroom curtain, can opener, hand washer, coffee station. Page 3, Friday and Saturday. Fridays covered juice machine & tubes, garbage cans, cabinets, hand washer, coffee station, mop closet, toaster/can opener, wipe ice machine, bathroom, walk-in curtain, and blue carts. Saturday covered ovens, dishmachine, doors, walls, toaster/can opener, wipe ice machine, bathroom, dishroom curtain, hand washer, coffee station, ice machine-1st Saturday of the month clean ice machine/empty ice/wash the scoop. Page 4, Sundays covered plate cart, all parts of stove, floor mats, bathroom, wipe ice machine, walk-in curtain, cabinets, can opener, hand washer and kitchen floor. There were no check-offs for any days in December 2025. November 2025, only Page 3, Saturday, week 2 was checked off. October 2025, page 3, Saturday week 3 and page 4, Sunday week 3 were checked off. No days in September 2025. August page 1, Tuesday, week 4, Wednesday page 2, week 3 and 4 were checked off. July page 2 Wednesday week 1 and Thursday week 1 were checked off. June 2025 page 1 Monday week 2, Tuesday week1 Wednesday weeks 1 and 2, and Thursday week 4 were checked off. Record review of the facility policy revised on 04/06/25, titled, Sanitation Inspection revealed under Policy: It is the policy of this facility ,as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers .b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. Record review of the facility policy revised 04/06/25, titled, Food Safety Requirements revealed under Policy: .Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. 1. Food safety practices shall be followed throughout the facility's entire food handling process. 1 b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. 1 e. Equipment used in the handling of food, including dishes, utensils, and other equipment that comes in contact with food. 3 c. Refrigerated storage .Practices to maintain safe refrigerated storage include: iv. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so its use-by date, or frozen/discarded v. Keeping foods covered or in tight containers. 8. Additional strategies to prevent foodborne illness include, but are not limited to: a. Preventing cross-contamination of foods. References: FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (E) EMPLOYEES are visibly observing FOODS as they are received to determine that they are from APPROVED sources, delivered at the required temperatures, protected from contamination, UNADULTERED, and accurately presented, by routinely monitoring the EMPLOYEES' observations and periodically evaluating FOODS upon their receipt 2-4 Hygienic Practices 2-401 Food Contamination Prevention 2-401.11 Eating, Drinking, (A) Except as specified in (B) of this section, an EMPLOYEE shall eat, drink, only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection cannot result. (B) A FOOD EMPLOYEE may drink from a closed BEVERAGE container if the container is handled to prevent contamination of: (1) The EMPLOYEE'S hands; (2) The container; and (3) Exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Ch. 3-305 Preventing contamination from the premises 3-305.11 Food Storage FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A)Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. (C) Except as specified in (D) of this section, if used with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned throughout the day at least every 4 hours.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 6 medication carts (Nurse Med-Cart, [NAME] Wing, Long Hall) reviewed for labeling and storage. The facility failed to ensure the Nurse Medication Cart for the long hall in Wing 1 was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications which were not prescribed to them.Findings included:Observation on 12/09/2025 at 9:42 AM revealed an unlocked med-cart parked down from the nurse's station in the long hall on Wing 1 with no nurses or other staff around it. The keys for the medication cart were hanging from the lock of the medication cart. There were residents noted to be walking and passing by. The med-cart lock was popped out, and all drawers were able to be opened and accessed. The med-cart was full of medications, including narcotics.In an interview on 12/09/2025 at 9:45 AM, LVN-D stated it was her med-cart, and she had forgotten to lock it and pull the keys out of it before she walked away. She stated the med-cart should always be locked when not in use because if left unlocked, anyone, including residents, could get into it and get medications out which did not belong to them, and this could cause harm. She stated the keys left in the med-cart contained the regular med-cart key, the narcotic box key, a key to the medication room, a key to the lock box in the medication room, as well as many other keys which she was not sure what they went to because she had never had to use them, but she thought they may have belonged to the other medication carts. LVN-D stated it was the responsibility of the nurse who was working the med-cart this shift to keep up with the keys for this med-cart and to ensure the med-cart remained locked when not in use. In an interview on 12/11/2025 at 10:30 AM, the DON stated he was not aware any of the nurses had left their medication cart unlocked. He stated it was the nurse of the med-carts responsibility to keep up with the keys for their med-cart, as well as be sure the med-cart was locked every time they stepped away from it. He stated if the med-carts were not kept locked, residents or anyone else could have gained access to the cart and taken medication which did not belong to them. He stated he was not sure exactly what keys were on LVN-D's key ring, but for sure there was the med-cart key, the narcotic box key, and the key to the medication room. He stated he was starting an in-service today with the nurses and medication aides regarding their med-cart keys and locking the med-carts. In an interview on 12/11/2025 at 1:30 PM, the Administrator stated it was the nurse's responsibility to keep her medication cart locked and keep up with the keys which went to her medication cart. She stated if medication carts were left unlocked, anyone could have gotten into the cart and taken medication, and it could have harmed them. She stated the nurses and medication aides knew this because it was discussed in their annual training, and they had been in-serviced regarding this as well. Record review of the facility's Storage of Medication Policy, revised April 2007, revealed 2. The nursing staff shall be responsible for maintaining medication storage and preparation area in a clean, safe, and sanitary manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on interview and record review the facility failed to develop a QAPI plan that described the process for conducting quality assessment and assurance activities, including the process on how the committee would identify and correct quality deficiencies for 3 of 16 residents. The facility did not have a QAPI plan process for conducting change in condition assessments. This failure could place residents at risk of not receiving quality care and services. The findings include: In an interview on 12/11/25 at 10:08 AM, the ADM stated a significant change was a change in the resident's condition and was something that deviates from the resident's baseline that would require treatment or monitoring. The ADM stated if an injury or accident occurred; nurses would document a progress note but not complete an actual assessment. The ADM stated the floor nurses should be doing an assessment with any changes the resident has had, such as a focused assessment or an SBAR but was unsure if the nurses were completing any assessments. The ADM stated since significant changes were not being made, the facility was not able to track and trend resident changes, and it was not a part of QAPI. In an interview on 12/11/2025 at 10:30 AM, the DON stated if there was a change in condition with a resident, the floor nurses assessed the situation and put it in a progress note, but they did not do an actual assessment of the residents such as a focused assessment or SBAR assessment for a change in condition, but he saw how it would be needed. The DON stated the nurses should have been doing focused assessments, SBARs, or significant change assessments, which would trigger the MDS to do the Significant Change in Condition MDS assessments, but they were not being done. The DON stated significant changes in residents were not being tracked and trended. Record review of QAPI confirmed significant changes were not being tracked. In an interview on 12/11/2025 at 2:15 pm, MDS B (the MDS Coordinator) stated she used to be the DON for this facility, but she moved over to the MDS coordinator position. She stated she had been trained on how to complete MDS assessments and forms, and the MDS was the actual comprehensive assessment to meet all the needs of the residents and establish a plan of care. MDS B stated MDS C was the one who did the actual MDS assessment, and she just signed off on them once they were completed. She stated she had not actually checked for accuracy or to make sure the proper assessments were completed. She stated it was just her job to sign off the MDS had been completed. MDS B stated administration meets twice a week, Mondays and Wednesdays to discuss anything going on in the facility and with residents, but they were not tracking and trending significant changes or monitoring them. Record review of the facility's Quality Assurance Performance Improvement policy dated 02/12/25 reflected: Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care quality of life and addresses all the care and unique services the facility provides. Policy Explanation and Compliance Guidelines: 3. The QAPI plan will address the following elements: c. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies, Key components of the process include, but are not limited to, the following: i. Tracking and measuring performance. ii. Establishing goals and thresholds for performance improvements. Iii. Identifying and prioritizing quality deficiencies. V. Developing and implementing corrective action or performance improvement activities. Program Development Guidelines: 1. Program Design and Scope - b. At a minimum, the QAPI program will: i. Address all systems of care and management practices. 3. Program Feedback, Data Systems, and Monitoring - c. Data is collected from all departments and is used to develop and monitor performance indicators. i. Facility staff are responsible for following department procedures for data collection. ii. Department heads are responsible for ensuring data is collected appropriately and performance metrics are monitored in accordance with facility policy.

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one of six Residents (Resident #5) that were reviewed for infection control and transmission-based precautions policies and practices. 1) The facility failed to ensure LVN performed hand hygiene after removing gloves prior to and after setting up Resident #5's wound care supplies. 2) The facility failed to ensure LVN used a sterile, individually wrapped applicator to apply medication to Resident #5's wound. 3) The facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella bacteria can grow and spread. These failures could place residents at risk of infection through cross contamination of pathogens and infectious diseases. Findings include: Record review of Resident #5's face sheet dated 12/11/25 reflected an [AGE] year-old-female with an original admission date of 08/01/25. Diagnoses included hypertension (high blood pressure), type 2 diabetes (insufficient insulin production in the body), end stage kidney disease (kidneys can no longer maintain the body's balance of fluids, electrolytes, and waste products), and cerebral infarction (blood flow to part of the brain is obstructed, leading to the death in brain cells). Record review of Resident #5's physician orders dated 11/11/25 reflected: Stage IV Pressure Ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone): Cleanse with Vashe (wound cleanser), pat dry with 4x4 gauze, apply collagen powder (promotes new tissue growth), apply Silvadene (topical antibiotic cream), cover with dry 4x4 gauze, cover with ABD pad, and secure with tape, every day and night shift. Record review of Resident #5's quarterly MDS dated [DATE] a BIMS of 00 (severe cognitive impairment). During an observation on 12/10/25 at 1:16 PM, LVN A sanitized the wound care tray, removed gloves and put on new gloves without sanitizing or washing hands. During an observation on 12/10/25 at 1:19 PM, LVN A removed a wooden applicator from a shared cup containing multiple applicators located on the medication cart and placed it on the tray. The applicators were stored together in an open container, were not individually wrapped, and were not sterile. During an observation on 12/10/25 at 1:25 PM, LVN A removed gloves after prepping Resident #5's wound care supplies and put on new gloves without sanitizing or washing hands. In an interview on 12/10/25 at 1:47PM, LVN A stated it was important to wash or sanitize hands after every glove removal to prevent cross-contamination. LVN A stated Resident #5's wound could get infected and get worse if introduced to bacteria. LVN A stated he was nervous and forgot some of the steps. LVN A stated that the orders did not state what to use when applying the medication and just thought he could use one of the wooden applicators located on the medication cart. LVN A stated he probably should have used an individual sealed applicator since it would be sterile. LVN A stated since he used a non-sterile wooden applicator, Resident #5's wound could possibly not heal or become infected. In an interview on 12/11/25 at 2:03 PM, the IP stated hand sanitizer could be used after glove removal and hand washing should take place when hands are visibly soiled. The IP stated it was important to ensure hands were cleaned before staff moved on to the next resident to prevent cross contamination. The IP stated by using a non-sterile applicator, Resident #5's wound could obtain an organism and could become septic since the resident's immune system was low. The IP stated that hand hygiene skills were done continuously throughout the year. In an interview on 12/11/25 at 2:56 PM, the ADON stated she frequently would do spot checks on wound care, but she had no process for tracking and trending wounds. The ADON stated it was important to ensure hands were sanitized or washed after every glove removal to prevent cross contamination. In an interview on 12/11/25 at 3:07 PM, the DON stated all staff should be washing their hands after every glove removal to prevent infection and the spread of germs. The DON stated the ADON would do spot checks on wound care but did not have a process to track and trend competency. The DON stated LVN A should have used a sterile, individualized wrapped applicator to prevent the spread of infection. The DON stated Resident #5's wound could not heal or become worse. During an interview on 12/11/25 at 11:22 AM, the MD stated he was new to the Maintenance Director position and had not established any preventions to monitor and prevent Legionella. The MD stated he was unsure what the previous MD was doing and since he has become the MD, nothing had been done to the water system other than the replacement of 3 water heaters due to them not working. The MD stated it was important to monitor and try to prevent Legionella because the residents could become very sick if the water became contaminated. The MD stated he was going to start working on a prevention strategy immediately. In an interview on 12/11/25 at 12:39 PM, the IP stated she was aware of the organism Legionella but was not aware or trained on the prevention of it. The IP stated if the water became contaminated, the residents could experience pneumonia and possible rheumatic fever. In an interview on 12/11/25 at 12:47 PM, the DON stated it was important for the facility to monitor and have prevention strategies in place to prevent Legionella. The DON stated it could cause illness not only to the population but to guests as well. The DON stated the MD was working on a prevention strategy to implement immediately. Record review of the facility's Handwashing/Hand Hygiene policy dated April 2010 reflected: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Polic Interpretation and Implemantation 5. Employees must wash their hands for at least fifteen (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: k. Before and after changing a dressing; u. After removing gloves or aprons; and v. After completing duty. 7. Hand hygiene is always the final step after removing and disposing of personal protective equipment. Record review of the facility's Wound Care policy dated October 2010 reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following equipment and supplies will be necessary when performing this procedure. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. Record review of the facility's Legionella Surveillance policy dated 02/12/25 reflected: Policy: It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections. Policy Explanation and Compliance Guidelines: 1. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. c. Physical controls: i. Cooling towers and potable water systems shall be routinely maintained. ii. Non-potable water systems shall be routinely cleaned and disinfected. d. Temperature controls: i. Cold water shall be stored and distributed below 68 F. ii. Hot water shall be stored above 140 F and circulated at a minimum return temperature of 124 F.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 7 of 12 boxes of medical supplies (200 hallway) reviewed for medication storage and labeling. The facility failed to ensure7 boxes of medical supplies in the medication storage room, on the 200 hallway, had current usage dates and expired supplies were stored along with current medications/supplies. This failure could place residents at risk of receiving expired medical supplies, wound dressings that past expiration date would not have the intended therapeutic level or effect on a resident's wound. The findings include: Observation on 09/05/24 at 10:16 AM of the medication storage room, on the 200 hallway, revealed 2 boxes of 10 count [NAME] Collagen Dressings 1 x 1 with an expiration date of 11/2023; 3 boxes of 10 count [NAME] Silicone super-absorbent Dressings 3.5 x 4 with an expiration date of 10/19/2023; 1 box 10 count Allevyn Adhesive 3 x 3 dressing; 1 box 10 count Allevyn Adhesive 4 x 4 with an expiration date of 01/01/24. Interview with LVN E, the floor nurse, on 09/05/24 11:15 AM, he stated there was a box in the medication room where they put and then discarded expired medications. Then the ADON, the DON and the pharmacist disposed of expired medications, but not sure how often. Everyone as a group was responsible for reviewing expiration dates in the medication room and carts and kept things organized and dated, the ADON and DON did random checks of medication rooms and carts, but sure how often. Interview with the ADON on 09/05/24 at 11:50 AM, she that she was the ADON for both wings, and everyone was responsible for checking expiration dates in the medication room. She stated she did random checks but there was no set time to check, just random checks every 2-3 months. She looked and signaled to wound dressing boxes and stated yeah, probably overlooked those and she set them aside from current medications and supplies. Interview with the DON on 09/05/24 at 03:15 PM, the DON stated dressings and supplies, as long as they were not pharmaceutical, could be tossed. The DON stated that everyone who had access to the medication room is responsible for ensuring expired medications and supplies are discarded and should keep the medication room tidy, and medication carts as well. Dressings should be discarded if expired and replaced if needed. Expired dressings would not be effective as manufacturer intended. Interview with the DON on 09/06/24 at 05:12 PM, the DON stated the facility did not have any policy specifically on expired medication/supplies. Record review of the facility policy, titled Record review of the facility's Discarding and Destroying Medication policy, revised April 2007, reflected Medications that cannot be returned to the dispensing pharmacy (e.g., non-unit-dose medications, medications refused by the resident, and /or medication left by residents upon discharge ) shall be destroyed.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #71) reviewed for care plans: The facility failed to ensure Resident #71's care plan reflected her diagnosis of Dementia. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The findings included: Record review of Resident #71's face sheet, dated 9/6/2024, reflected a [AGE] year-old female with an initial admitted [DATE]. Resident #71 had diagnoses which included the following: Unspecified Dementia (a neurological condition affecting the brain that worsens over time which causes the loss of the ability to think, remember, and reason to levels that affect daily life and activities), and depression (a mood disorder that involves a persistent low mood or loss of interest in activities that affects how a person feels, thins, and functions). Record review of Resident #71's quarterly MDS, dated [DATE], reflected the resident was rarely/never understood and rarely/never understood and cognitive skills for daily decision making were severely impaired. Resident #71 was dependent on staff for ADLs and mobility. Resident #71 had Non-Alzheimer's Dementia. Record review of Resident #71's most recent care plan, dated 8/21/24, did not reflect Resident #71 had a diagnosis of Dementia and did not have a focus, goals, or interventions/tasks care planned for her diagnosis of Dementia. Observation on 09/03/24 at 11:58 AM revealed Resident #71 is not interviewable. The resident's eyes were open, but she did not respond to any questions. In an interview on 9/6/24 at 1:40 PM with MDS A, he said he focused on updating information on the MDS, but it was a collaborative effort among staff to ensure care planning was completed. The State Surveyor asked who was responsible for updating Resident # 71's care plan for Dementia diagnosis, MDS B said that she was responsible. In an interview on 9/6/24 at 3:04 PM with MDS B. She said she was responsible for ensuring the care planning for Resident #71 was completed. She said they usually printed out the order summary, then addressed each diagnosis on the MDS. She said Dementia was mentioned in the ADLs portion of Resident #71's care plan. The care plan reflected Resident #71 had an ADL self-care performance related to dementia, fatigue, impaired balance, limited mobility, limited range of motion, muscle spasms, and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination. She also said when there was a treatment or medication for the condition, that would trigger them to care plan, but the resident did not have any. She said it just got overlooked. She said if Resident #71's dementia was not care planned, staff would be unable to anticipate the resident needs due to Resident #71 could not communicate. In an interview on 9/6/24 at 3:12 PM with the DON. He said Resident #71's dementia diagnosis should have been care planned. He said it was a collaborative effort for care planning. He said the initial care plan was done by the nurse doing admission. He said the more comprehensive care plans, such as dementia were completed by the MDS staff. He said if Resident #71's Dementia was not care planned, all the resident's needs would not be met appropriately. Record review of the facility's Care Plans - Comprehensive Policy, dated October 2010, reflected: Policy Statement An individualized comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Purpose of Care Plan 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; . e. Reflet treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aide in preventing or reducing declines in the resident's functional status and/or functional levels; . i. Reflect currently recognized standards of practice for problem areas and conditions . Care Plan Interventions 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying sources(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident.

Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 residents (Resident #12) reviewed for respiratory care. The facility failed to ensure Resident #12 received oxygen at the prescribed rate. This failure could place residents at risk for respiratory distress. The findings include: Record review of Resident #12's face sheet, dated 9/5/24 reflected the resident was a 90 -year-old female originally admitted to the facility on [DATE]. Resident #12 had diagnoses which included the following: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior which eventually grow severe enough to interfere with daily tasks), Parkinsonism (a neurodegenerative disease which causes slowed movements, stiffness, tremors, and unstable posture, leading to profound gait impairment), hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure that can cause heart failure when high blood pressure is unmanaged), and vascular dementia (brain damage caused by multiples strokes which causes memory loss in older adults). Record review of Resident #12's Comprehensive MDS assessment, dated 7/20/24, reflected the resident rarely/never understood and rarely/never understood and cognitive skills for daily decision making were severely impaired. Resident #12 was dependent on staff for ADLs and mobility. Record review of the most recent Care Plan for Resident #12, dated 8/1/24, reflected the resident had oxygen therapy as needed for Hypoxemia (low blood oxygen), to maintain O2 above 92 percent. Date Initiated: 06/17/2024. Revision on: 07/02/2024. Interventions/tasks reveal OXYGEN SETTINGS: O2 via nasal cannula at 2 lpm as needed for Hypoxemia to maintain o2 above 92 percent. Date Initiated: 06/17/2024. Revision on: 07/02/2024. Record review of the Doctor's Order Summary reflected Resident #12 was prescribed O2 via nasal cannula at 2 lpm as needed for Hypoxemia to maintain O2 above 92 percent. Active 06/17/2024. Record review of the MAR/TAR for September 2023 reflected the resident prescribed was O2 via nasal cannula at 2 lpm as needed for Hypoxemia to maintain O2 above 92 percent. -Order Date- 06/17/2024. Record reflected the resident was administered O2 on 9/4/24 O2 sat at 89 %, and on 9/5/24 O2 sats at 96%. Observation on 09/03/24 at 04:45 PM, revealed Resident #12 lying in bed with her eyes closed and the head of the bed was elevated. Resident #12 did not respond to the State Surveyor when knocked on door or asked questions. Resident was not interviewable. Resident was groomed and dressed appropriately. Resident receiving O2 at 3L via NC. Suctioning supplies located next bedside. Resident did not have symptoms of respiratory distress, such as shortness of breath/difficulty breathing, rapid breathing, bluish tint around mouth or fingertip, or cough. Interview on 9/6/24 at 1:40 PM, MDS A said since the oxygen was prescribed as needed and it was not used the whole month of July, it was not captured on the MDS for 7/20/24. He said they only did a 7-day look back. He said if the resident was using the oxygen anytime during the 7-day look back of the next quarterly MDS, it would trigger and be captured that month. Interview and observation on 9/4/24 at 4:34 PM, revealed LVN C checked the O2 flow rate. LVN C stated the flow rate was set at 3LPM. LVN C adjusted the flow rate to 2L, and she stated that's what was on the order. She said the floor nurse was responsible to ensure their residents received the correct oxygen rate. LVN C said she usually checked O2 rates every time they went into the resident's room to ensure the flow rate was accurate. LVN C said she checked Resident #12's flow rate and O2 saturation that morning and her saturation was at 96 %. Said she might have bumped the oxygen concentrator machine and it caused the flow rate to change, but she was not sure. She said if residents received more oxygen than prescribed by the doctor, dependency on the oxygen could occur and the residents could get nasal irritation. Interview on 9/4/24 at 4:43 PM with LVN D, she said to read the oxygen flow rate on an oxygen concentrator machine, the line next to the numbered liters should be located at the center of the ball. She said the floor nurses were responsible for ensuring the flow rates for their assigned residents were accurate. She said she checked oxygen flow rates first thing in the morning when she arrived on shift and throughout the day. She said if a resident received more oxygen than prescribed by the doctor, it could affect their saturation and could cause respiratory alkalosis (a condition that occurs when the body's blood becomes too alkaline which can be caused by hyperventilation, too high a supplemental oxygen setting, or give too large a volume in each breath) or respiratory distress for receiving too much oxygen. Interview on 9/4/24 at 4:57 PM with the DON, he said the floor nurses assigned to the residents on that floor were responsible for ensuring the oxygen flow rates on the oxygen concentrator were accurate. The DON said it should be checked twice a day on shift change at a minimum. The DON said the nurses were trained during their onboarding/initial training process. The DON said they also did spot checks especially withing the first 90 days of onboarding to ensure the staff were comfortable using all the equipment. The DON said the negative effect of a resident receiving more oxygen than prescribed by the doctor depended on a resident's diagnosis. He said if the resident had a diagnosis of Congestive Heart Failure (the heart's capacity to pump blood cannot keep up with the body's need, causing blood to back up, causing fluid to build up in the lungs) it could be problematic, but he said, at the end of the day following a doctor's order should be what we are doing. Record review of Licensed Nurse Competencies Checklist reflected the nursing staff trained were checked off on Respiratory: Oxygen Mask/Nasal Cannula, Oxygen Equipment Set Up, Oxygen Equipment Maintenance/Cleaning, Oxygen Equipment Storage, and Respiratory Training: Nebulizer treatment, respiratory exercised, and required documentation). Record review of the Oxygen Administration policy, dated October 2010, reflected: The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure . 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute . 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered . 11. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.

Based on record review and interviews, the facility failed to develop a base line care plan that included instructions needed to provide effective and person-centered care of the resident for 1 resident (Resident #117) of 17 residents reviewed for base line care plans. The facility did not develop a base line care plan for Resident #117 that addressed Resident #117's use of antipsychotic medication. This failure could place resident receiving antipsychotic medications of not receiving the necessary care required to maintain psychosocial well-being. The findings were: Record review of Resident #117's Physician's Orders dated 05/30/23 revealed Resident #117 was an [AGE] year-old female who was admitted to the facility on [DATE] with admitting diagnosis of Alzheimer's disease, Type 2 Diabetes Mellitus, and generalized anxiety disorder. Record review of Resident #117's Interim Care Plan (base line care plan) revealed the section for antipsychotics/psychotropics was blank. Record review of Resident #117's Physician's Orders dated 05/30/23 revealed an order for Olanzapine oral tablet 5 mg, give one tablet orally one time a day for anxiety. Record review of Resident#117's e-MAR revealed Resident #117 was administered Olanzapine tablet 5mg on 05/30/23, 05/31/23, and 06/01/23 at 6:30 PM. In an interview on 06/02/23 at 09:45 AM, Resident #117 said she did feel anxiety at times, but she felt well now. Resident said she took her medication. Resident said she only felt anxious when she had a problem and would feel nervous then. Resident said she has not seen her family member in years, and she hoped that her family member was alive. Resident said when she was thinking of her family member, she began to feel nervous. Resident said she did not know if she was taking the medication for anxiety. In an interview on 06/02/23 at 09:57 AM, LVN A said, Resident #117 received the Olanzapine in the evenings. Resident #117 had not had any signs of anxiety. In an Interview on 06/02/23 at 12:37 PM, MDS/LVN B said the Interim Care Plan had to be completed within 24 hours. The admitting nurse was responsible for completing the Interim Care Plan. The nurse would interview the resident or the family if they were available. The MDS/LVN B said the nurse must document all the medications on the Interim Care Plan and would call the physician to see if the resident would continue with the same medications from the hospital. The DON was responsible to review and sign it. In an interview on 06/02/23 at 01:01 PM, LVN C said she had been employed since February 2023. LVN C said when they admit a new resident, they must conduct a full body assessment, check for any injuries to the body, check if the resident had any devices on their body such as an ostomy or g-tube, ask the resident questions about their medical history, ROM, if they have pain, check their neuro status, if they had any diseases, such as cancer. The nurse would do an extensive history, if nothing then they would document that the resident did not have any diseases. The nurse would take their vitals. The nurse would then call the resident's MD and gave a full report and go over the medications and ask if the resident would continue with the same medications. The nurse would also call the RP if the resident had any behaviors and what their medications they are taking. LVN C said, Yes, Resident #117 was taking an antipsychotic, taken once at night. but was unable to remember the name. LVN C said she made a typing error, and the medication should have been checked on the Interim Care Plan. LVN C said if Resident #117 did not get her medication, she might have an episode of psychosis or anxiety and the nurse would have to do research to see what medications resident was taking and if she had been prescribed any antipsychotics and then call the doctor for a script and in the meantime the resident was going through an episode of psychosis or anxiety until they obtained the medication. In an interview on 06/02/23 at 2:30 PM, Assistant Administrator provided a copy of facility's policy for Interim Care Plan (base line care plan). Assistant Administrator said the base line care plan would be done by the admitting nurse. Record review of facility policy revised on 11/08/22 revealed: A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. 1. To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. 2. The Interdisciplinary Team will review the Attending Physician's order (e.g., dietary needs, medications, and routine, treatments, etc.), and implement a nursing care plan to meet the resident's immediate care needs. 3. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan.

Based on interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury, to other officials (including to the State Survey Agency) for 1 of 5 resident (Resident #3) reviewed for abuse, in that; 1. The facility failed to immediately report (within 2 hours) to the State Survey Agency (HHSC) an allegation of abuse made by Resident #3 The failure could affect residents who made allegations of abuse and result in undetected abuse and/or decline in feelings of safety and well-being. The findings were: 1. Record review of Resident #3's face sheet dated 07/06/2022 revealed a [AGE] year-old male with an initial admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's MDS dated [DATE] revealed a BIMs score of 15 which indicated resident is cognitively intact. Record review of Residents #3's health status note written by the DON stated Resident stated the students held him down with their body and a female held down both of his hands and swabbed him as he voiced he couldn't breathe like [NAME]. He states he repeatedly told them he couldn't breathe but the students would not release him and would laugh. He states he does not understand why they'd treat him like that and stated maybe they thought he was handicapped. During an interview on 06/30/2022 at 2:10 p.m. Resident #3 stated 2 students aggravatedly assaulted him. Resident #3 stated they violated my civil rights. And stated he had to get the police involved. When asked if he could give me more information regarding what happened Resident #3 would repeatedly say they aggravated assault me. Resident #3 stated he recalled the incident and felt comfortable telling me the details but stated you'll find out later. When asked if he could tell me anything about the alleged aggravated assault Resident #3 stated, no and stated he didn't want to talk about it. During an interview on 7/01/2022 at 12:53 p.m. Student C stated herself and Student D entered Resident #3's room to administer a COVID test, she stated she told Resident #3 what she would be doing but Resident #3 did not verbally respond and was just looking at her. Student C stated I was giving him a swab in one nostril and as I was going to go a little further he stated moving his head side to side making groans and moans and moving back and forth so it seemed he was getting aggravated and yelling, so I told my fell ow student that we should walk away. Student C stated nursing staff had let her and Student D know that Resident #3 can be a little combative and can get agitated easily. Student C stated that as a preventative measure her and Student D placed their hands in flat and kind of like hoovering over Resident #3's wrist incase he became combative. Student C stated that Resident #3 never stated he could not breathe. Student #1 also stated that her and Student D were never on him with a knee. During an interview on 07/01/2022 at 12:59 p.m. Student D stated he and Student C entered Resident #3's room to perform a COVID test. Student #2 stated he had his hands flat out in front of him, over Resident #3 but not touching Resident #3. Student D stated this was to guard himself from getting hit because staff had warned us about him Student D stated Resident #3 did not refuse the COVID test, and stated he was never on Resident #3 with his legs and Resident #3 never stated he couldn't breathe. During an interview on 7/01/2022 2:00 p.m. with LVN B she stated she heard Resident #3 yell and entered his room. LVN B stated both Student C and Student D were away from resident when she entered room. LVN B stated she tried to ask Resident #3 what happened but stated Resident #3 was too aggravated and just kept saying call the police. LVN B stated Resident #3 was lying vertical on bed with his feet off the bed and when she approached him to ask again what happened he swung and struck her arm. LVN B stated she did not notice any bruising, marks, discoloration or signs of trauma on Resident #3's wrist, hands, arms or chest. During an interview on 07/1/2022/2022 at 4:45 p.m., the DON stated abuse allegations should be reported within 2 hours. The DON stated he was responsible for reporting alleged abuse. The DON stated he was made aware of the incident on 6/22/2022 at 11:30 a.m. and reported it the following Monday on 6/27/2022. When asked why It was not reported within 2-hour time frame the DON stated, lots of moving pieces and multiple calls to police. And honestly its my first time I've had to deal with something like this. When asked how can not reporting alleged abuse impact residents, the DON stated, It could lead to a lack of safety and physical or emotional negative consequences and to a lack of trust between staff and residents. During an interview on 7/01/2022 at 5:55pm the Administrator stated the DON was responsible for reporting allegation of abuse. The Administrator stated allegations of abuse should be reported within 24 hours. The Administrator sated she was made aware of the incident on 6/22/22 and stated it wasn't reported until 06/27/2022. When asked why it wasn't reported within the appropriate time frame the Administrator stated, We had a lot of stuff going on. When asked how not reporting alleged abuse can impact residents she stated, If it's a true allegation of abuse then there's injury that can be caused to the patients. Record Review of TULIP (HHSC online incident reporting application) on 06/30/2022 at 3:30 p.m. revealed the facility had self-reported the allegation of abuse from Resident #3 on 06/27/2022. The DON and Administrator were both informed of the incident on 06/22/2022. Record review of a facility policy titled Abuse investigation dated 2001 and last revised April 2010 did not include any verbiage relating to the time frame an allegation of abuse should be reported.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of each resident, for one Resident (Resident#24) of four residents observed for medication administration. MA C did not withhold Resident #24 blood pressure medication, as ordered by Resident #24's Physician's orders. This failure could place residents who take blood pressure medications at risk for [CONDITION(S)] (low blood pressure), or [CONDITION(S)] (slow heart rate). The findings were: Record review of Resident #24's Admission Record dated 03/03/22, revealed Resident #24 was a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: Hypertension (high blood pressure), History of Falling, and Type 2 Diabetes Mellitus (body's ability to produce or respond to the hormone insulin is impaired) with Diabetic [CONDITION(S)] (damage to blood vessel clusters in your kidneys that filter waste from your blood). Record review of Resident #24's Quarterly MDS dated , 12/24/21 revealed Resident #24: -was able to make herself understood -was able to understand others -has had and active diagnoses of hypertension (high blood pressure) in the last 7 days. Record review of Resident #24's care plan revealed: Date initiated: 06/28/21, Revision on 06/28/21, Resident #24 has hypertension (high blood pressure). On a NAS (no added salt) to help manage hypertension. Interventions included: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic [CONDITION(S)] (blood pressure drops when standing, after you have been sitting or lying down) and increased heart rate and effectiveness. Follow parameters as ordered. Medication changes on 09/01/21. Observation on 03/03/22 at 8:52 a.m., MA C checked Resident #24's blood pressure and pulse with an automatic wrist blood pressure cuff. Blood pressure at 146-65 and pulse rate at 56. MA C administered Resident #24's medications, including [MEDICATION(S)] 5mg one tablet (medication that is used for high blood pressure), and administered them to Resident #24. MA C documentation revealed she documented Resident #24's pulse rate at 60. Record review of Resident #24's physician orders revealed: [MEDICATION(S)] 5mg give 1 tablet by mouth in the morning for hypertension. Notify MD is SBP(first number in blood pressure, which is the pressure caused by your heart contracting and pushing out blood) over 160 or DBP(second number in blood pressure, measures the pressure in your arteries when your heart rests between beats) over 100. Hold medication if SBP less than 100 or pulse below 60. In an interview with MA C on 03/03/22 at 11:20 a.m., MA C said in all honesty she did not check the pulse rate on the blood pressure cuff. MA C said she should have held the blood pressure medication and notified the nurse. MA C said she will have to notify the nurse. Reviewed the blood pressure readings on the blood pressure cuff, blood pressure at 146/65 and pulse rate at 56. In an interview with the DON on 03/03/22 at 11:29 a.m., he said there could be negative side effects if the blood pressure is given, and it is underneath the parameters. DON said the parameters are there for a reason. DON said when new nurses or medication aides first start working, a competency test is done by the ADON. DON said the nurses and medication aides are checked annually by the ADONs. DON said regarding the incident, they will have to do an incident report, and notify the doctor. Record review of facility policy titled Administering Medication, revised in April 2010, revealed: 3. Medications must be administered in accordance with the orders, including any required time frame. 4. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

Based on observation, record review and interview the facility failed to ensure the corridors were equipped with firmly secured handrails for one of six corridors. The handrail outside of room 124 was not secured on wall allowing for movement away from the wall. This failure could place residents who use handrails for mobility at risk of injuries or falls. The findings were: Observational round conducted on 03/03/22 at 10:14 a.m. revealed a handrail segment on the southern wall of the [NAME] wing directly outside of RM#124 was not secured to the wall. Upon placing light pressure on the rail the rail moved. Closer inspection of the wall bracket revealed the screw was not in the wall allowing for the rail to move freely about two inched from the wall. In an interview with the administrator on 03/03/22 at 10:34 a.m., she said the facility does rounds weekly and checking the rails was on the list to review. Administrator observed rail and indicated she would direct maintenance to look at it. In an interview with LVN D on 03/03/22 at 11:31 a.m., she said there were no resident in the hall that ambulate by walking unassisted and the majority who use the rail, use to assist in propelling themselves with the wheel chair. LVN D said there had been no incidents of falls in the hall due to the rail. Review of the facility maintenance log revealed the last inspection was 02/17/22 with no reported issues of the rail.

Based on observation, interview, and record review the failed to review the risks and benefits of bed rails with the resident or resident representative prior to installation for 1 of 3 residents (Resident #51) reviewed for bedrails. Resident #51 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Bed Rail Assessment for Resident #51 indicated the resident was not a candidate for the use of bed rails. This deficient practice could affect residents who utilized bed rails by placing them at risk for unintended entrapment of the head, neck or limb, restraints, and injuries. Findings include: Observation on 03/01/22 at 9:44 am revealed Resident #51 in his room, in bed, eyes closed, with [CONDITION(S)] and oxygen and tube feeding. Observation revealed ¼ bed rails up on both sides of Resident #51's bed. Resident #51 did not respond to surveyor greeting. Observation on 03/01/22 at 2:25 pm revealed Resident #51 in his room, his room, in bed, eyes closed, with [CONDITION(S)] and oxygen and tube feeding on. Observation revealed ¼ bed rails up on both sides of Resident #51's bed. Resident #51 did not respond to surveyor greeting. Record review of Resident #51's Admission Record revealed resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #51's quarterly MDS dated [DATE] documented resident; - cognitive status was severely impaired - was total dependent on two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. -had impairment on both sides on upper and lower extremities. -received [CONDITION(S)] care. Record review of Resident #51's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #51's care plan dated 03/01/22 revealed no documentation concerning his bed rails. Record review of Resident #51's medical records revealed no informed consent for use of bed rails. Record review of the Evaluation for Use of Bed Rails for Resident #51 dated 02/28/22 indicated the use of side bed rails created a risk for getting caught between the rails, impeding movement, have a negative psychosocial outcome for this resident such as feelings of isolation, increased anxiety, and resident does not benefit from side rails, is unable to callout for help, is dependent on staff for all ADLs. During an interview on 03/22/22 at 9:50 am with LVN A said Resident #51's bed had both size ¼ bed rails raised up. LVN A said Resident #51's bed should not have the bed rails up because he was not a candidate for bed rails. Resident #51 had been readmitted on [DATE] and had not returned to his original room and bed because he was placed in this current room. Resident #51's room had a bed that had ¼ bed rails built in and someone had raised the bed rails. Resident #51 would be placed in his original room with bed that had no bed rails. LVN A said she did not know who might have raised the bed rails and staff including herself did not see that they should not have been raised up. The raised bed rails might cause injury, and resident might get stuck in the rails. During an interview on 03/03/22 at 9:55 am with CNA B, she stated she came into work at 6:00 am and did her rounds. CNA B said she did not notice that the bed rails on Resident #51 were both raised up. CNA B said hospice staff sometimes came during the week to bath resident and they might have raised both bed rails to provide him with care. She said the bed rails for Resident #51 should not be raised because this might cause an injury, such as getting stuck between bed rails and bed or cause a skin tear on his arms. During an interview on 03/03/22 at 2:00 pm with the DON, he stated Resident #51 had come been readmitted from the hospital and had been placed in another hall and bedroom that had a bed that had bed rails built in. Someone might have raised the bed rails on his bed without knowing the bed rails should not have been raised. Resident #51 is not a candidate for bed rails as his bed rail assessment indicated. There was no order for bed rails or a consent from Resident #51's responsible party. The DON said the bed rails for Resident #51 placed him at risk for entrapment and he could not speak or yell out for help. Record review of facility provided policy titled, Proper Use of Side Rails dated October 2010 indicated an assessment will be made to determine the resident's symptoms or reason for using side rails. The use of side rails as an assistive device will be addressed in the resident care plan. Consent for side rail use will be obtained from the resident or legal representative after presenting potential benefits and risks.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 resident(Resident #51) of six residents reviewed for unnecessary medications: [REDACTED] The facility's Pharmacist Consultant recommended on 11/19/20 to consider a gradual reduction of Duloxetine ([MEDICATION NAME]), medication for depression for Resident #51 to 20 mg twice a day. Resident #51 received [MEDICATION NAME] 30 mg twice a day until 02/23/21. This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications. The findings were: Record review of Resident #51's Admission Record indicated Resident #51 was a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] for Resident #51 indicated; -cognitive status was severely impaired, -was dependent on two staff for bed mobility, transfers, dressing, toilet use, eating and personal hygiene, -had functional limitation in range of motion on both sides of upper and lower extremities and -received anti-depressant and opioid medications. Record review of Resident #51's Comprehensive Physician Orders dated active as of 02/26/21 indicated an order for [REDACTED].>- Duloxetine HCI Capsule Delayed Release Sprinkle 20 mg. Give 1 capsule by mouth two times a day for chronic pain/depression, start date; 02/23/21. Record review of Resident #51's care plans revised 02/16/21 indicated R#51: uses antidepressant medication for pain/Chronic depression. Interventions included; - Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q day and night SHIFT, revised on 01/26/21. -Evaluate use of medication at least once every 90 days for any possibility of gradual dose reduction. GDR done to reduce dosage on antidepressant for chronic pain with end goal of discontinuation. Record review of MARs for Resident #51 dated 02/01/21 -02/28/21 indicated R#51 was administered Duloxetine Capsule Delayed Release Particles 30 mg twice a day from 02/01/21-02/23/21 at 8:00 a.m. and 4:00 p.m. Record review of MARs for Resident #51 dated 02/01/21-02/28/21 indicated R#51 was administered one tablet [MEDICATION NAME] 15 mg at bedtime for appetite stimulant/depression from 02/01/21/-02/28/21. Record review of Pharmacist's Consultations revealed a recommendation letter titled Consultation Report dated 01/28/21 for Resident #51. The letter was addressed to Resident #51's physician: Repeated Recommendation from 11/19/20; Please respond promptly to assure facility compliance with Federal regulations. Receives multiple antidepressants for depression concomitantly without documentation in the medical record of an inadequate response to monotherapy; [MEDICATION NAME] 15 mg QHS and Duloxetine HCL 30 mg BID. Recommendation; Please reduce Duloxetine to 20 mg BID with the end goal of discontinuation, while monitoring for reemergence of depressive and withdrawal symptoms and optimizing therapy with [MEDICATION NAME]. Rationale for Recommendation; Evidence for the effectiveness and safety of combined antidepressant medications is limited and should only be used in certain situations. (e.g., treatment failure, dose optimization limited by side effects). The risk for drug interactions, adverse events, noncompliance, and medication errors are increased. The Consultation Report for Resident #51 indicated the Physician's Response with a checked off box: I accept the recommendations above, please implement as written. The Consultation Report indicated a signature by LVN A and dated 02/23/21. On 02/25/21 at 10:51 a.m. Resident #51 was observed in her wheelchair in the dining room by nurse's station. Resident #51 was alert and due to her cognitive impairment was unable to respond to surveyor interview. Interview on 02/25/21 at 1:34 p.m. with LVN A revealed she received pharmacist recommendations from the facility DON. The DON would receive the recommendations from the Pharmacist Consultant and then he would print reports and make copies of recommendations. The DON would provide her with the pharmacist recommendation. She was responsible to carry out pharmacist recommendations for the residents in her wing. LVN A said she did not receive the pharmacist recommendation for Resident #51 dated 11/19/20 until around 02/17/21. LVN A said she looked for the recommendation dated 11/29/20 as indicated on the recommendation dated 01/28/21. She said she was unable to find the recommendation dated 11/19/21 and asked the DON on or about 02/17/21. The DON told her he would look for the recommendation dated 11/19/20 because he had not received the recommendation. She then called Resident #51's physician on 02/23/21 and received orders from Resident #51's physician that he accepted the recommendation to GDR the medication Duloxetine to 20 mg twice a day. Interview with the DON on 02/25/21 at 1:53 p.m. revealed he had never received the November 2020 monthly Pharmacist Consultant's recommendations from the Pharmacist Consultant via email. He said the Pharmacist Consultant would email the pharmacist recommendations, then he would print the recommendations and distribute to the corresponding charge nurses for follow up with resident physicians. The DON said he had been on leave from work intermittently and had not questioned the Pharmacist Consultant about the November pharmacy recommendations. The December 2020 and January 2021 recommendations both had been received via email. December 2020 recommendations were received via email on 12/22/20 and were distributed. January 2021 recommendations were received via email on 01/28/21 and distributed to charge nurses. Any repeated recommendations would show up after 30 days. The recommendation made on 11/19/20 for Resident #51 would not show up until January 2021. The DON said he expected his staff to get a response from resident's physician within 7 days after receiving copy of recommendation. He had not made the Pharmacist Consultant's emails available to any other staff during his leaves from work. On 02/25/21 at 2:30 p.m. interview with ADON D revealed when no recommendations were provided for the month of November 2020 by the DON she should have followed up on the pharmacist recommendations from November 2020 besides asking the DON. On 02/25/21 at 2:43 p.m. interview with the facility Pharmacist Consultant revealed the facility had implemented a new email system. She sent November pharmacist recommendations to the DON on the old email address on 12/19/21. The DON did not question her on not receiving the November 2020 pharmacist recommendations. On 02/25/21 at 3:32 p.m. interview with the DON revealed he had found the email with the pharmacist recommendations from November 2020 in the old email system after interview with surveyor. On 02/26/21 at 2:10 p.m. the DON said he had not distributed the pharmacist recommendations on the dates he received recommendations due to his leave from work at different dates. The DON said he understood this failure could lead to not responding to recommendations not been addressed in a timely manner by the resident's physicians and depending on recommendation could lead to unnecessary over medications for resident. Record review of the facility policy titled Medication Therapy revised April 2007 indicated; Each resident' medication regime shall include only those medications necessary to treat existing conditions and address significant risks. Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regime for continued indications, proper dosage and duration, and possible adverse consequences.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for 1 of 5 residents (Resident #58) reviewed for comprehensive care plans in that: The comprehensive care plan for Resident# 58 did not address the bolus feeding order (delivering enteral nutrition multiple times during shifts). This failure could affect any resident who requires a comprehensive care plan. Findings include: Record review of Resident #58's Admission Record indicated Resident #58 was a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] for Resident #58 indicated; -cognitive status was moderately impaired, -was dependent on two staff for bed mobility, transfers and toilet use, personal hygiene and bathing, -had functional limitation in range of motion on both sides of upper and lower extremities, -received nutrition via feeding tube and -had a stage 4 pressure ulcer. Record review of Comprehensive Physician order [REDACTED]. an order for [REDACTED]. an order for [REDACTED]. Record review of Resident #58's care plans indicated Resident #58: requires bolus tube feeding r/t dysphagia, oropharyngeal phase. At risk for aspiration, infection to g/tube site, dehydration, infection to g/tube, date initiated 02/04/19 and revised 02/26/21. Interventions included; - Administer tube feeding formula and flushes as ordered, two times a day down time, revised date, 02/20/20. -check for tube placement by checking for stomach content (residuals), prior to administration of medications and formula, revised date, 05/28/19. -monitor/document/report PRN any s/sx of: aspiration, fever, SOB, tube dislodged, infection at tube site, date initiated, 02/04/19. -while on feedings, monitor the following; toleration of feedings, lung sounds, bowel sounds, absence or presence of drainage and/or S/S of infection at the tube site, date initiated 02/24/19 and revised on 02/26/21. Care plans did not include the bolus feeding times, formula name and amounts to be administered by staff via peg tube. Record reviews of MARs dated 02/01/21-02/28/21 for Resident # 58 indicated Resident #58 had received Glucerna 1.2 four times a day, one can at 8:00 a.m., one can at 12:00 p.m., one can at 4:00 p.m. and one can at 8:00 p.m. every day to provide 1140 kcal from 02/01/21 to 02/25/21. On 02/23/21 at 12:32 p.m. observation of Resident #58 revealed she was lying in bed. Resident #58 was not able to be understood during surveyor interview due to her speech was garbled. No tube feeding pump was in her room. Interview on 02/23/21 at 12:35 p.m. with LVN A revealed Resident #58 did not receive continuous tube feeding and did receive bolus feedings four times daily as ordered. On 02/24/21 at 10:51 a.m. interview with MDS/LVN E revealed as MDS Coordinator he was the designated staff to update all care plans and include focus areas. MDS/LVN E stated Resident #58's care plans did not include the process of feeding by staff member at different times of day. The care plan only included the interventions used in continuous tube feeding via peg. MDS/LVN E said he had not thought the interventions would be different than the orders for continuous tube feeding. On 02/26/21 at 10:21 a.m. interview with LVN F revealed Resident #58 was fed manually via a peg tube as ordered. LVN F said the bolus feeding was a very different procedure than from continuous tube feeding. LVN F said the process was more time consuming and sometimes Resident #58 refused her bolus feeding. LVN F said she would attempt to encourage Resident #58 to take her feedings. On 02/26/21 at 2:20 p.m. interview with the DON revealed that care plans should be person centered and have specific focus areas and interventions to address the focus area. The DON added the failure to develop a focused care plan with interventions for bolus feedings had the potential for residents to not receive ordered nutrition. Record review of facility policy titled Care Plans-Comprehensive revised October 2010 indicated; An individualized comprehensive care that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs is developed for each resident. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the MDS.

Based on observation, record review, and interview, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one of five residents (Resident # 8) reviewed for enteral nutrition. The facility failed to ensure staff labeled formula solution bag with the name of the formula, and date and time the formula was started and starting volume for Resident #8. This failure could place residents at increased risk of complications related to enteral feeding. Findings Include: Record review of Resident #8's Admission Record indicated Resident #8 was an [AGE] year-old male who was originally admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] for Resident #8 indicated; -cognitive status was severely impaired, -was dependent on two staff for bed mobility, transfers and toilet use, personal hygiene and bathing, -had functional limitation in range of motion on both sides of upper and lower extremities, -received nutrition via feeding tube and -had a stage 4 pressure ulcer. Record review of Resident #8's Comprehensive Physician order [REDACTED]. an order for [REDACTED]. Record review of Resident #8's care plans revised 02/16/21 indicated: The resident requires tube feeding r/t dysphagia, dementia, unspecified. Interventions included RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. On 02/23/21 at 12:20 p.m. Resident #8 was observed lying in his bed. Resident #8's formula feeding was turned off. The formula bag had no documentation on the label on bag. The formula bag had a capacity of 1000 ml and 800 ml remained in the formula bag. Interview on 02/23/21 at 12:20 pm with LVN A revealed she was the charge nurse for the wing. She said the feeding tube was disconnected because Resident #8 had just returned from a doctor's appointment and had not been connected yet. The formula bag should have been labeled with all pertinent information such as correct patient name, rate, continuous and what time the formula bag was hung and began feeding. LVN A said the formula bags were started by the night nurses. LVN A said she would throw the formula bag away because she saw the wing tip was hanging and exposed. LVN A said the formula bag was not labeled with the necessary information. Interview on 02/23/21 at 12:39 p.m. with LVN B revealed he was the floor nurse. Resident #8 had gone to his doctor visit from 8:00 a.m. to 12:00 p.m. LVN B said when Resident #8 left to his doctor's appointment the tube feeding was on downtime. LVN B added that the night nurse hung the bag and started the feeding. On 02/24/21 at 9:29 a.m. LVN B said on 02/23/21 when the paramedics came to take Resident #8 for his doctor's visit, he turned off the feeding tube and disconnected from resident's body. LVN B said he did not notice the formula bag was not labeled with information. The formula bag should have label indicating the right formula for right patient, correct rate, amount of flush, etc. Interview on 02/24/21 at 2:20 p.m. with LVN C revealed she had hung and started the formula bag for Resident #8 around 02/23/21 at 12:00 a.m. LVN C said she did not remember why she didn't label the formula bag with all the information that was required such as start time, rate, downtime, etc. On 02/26/21 at 2:15 p.m. interview with the DON revealed the failure to label or document the formula bags with information had the potential for errors, such as wrong resident, formula not verified and could deviate from nutritional requirement. The DON said a policy and procedure that addressed the labeling of a formula bag had not been developed.

Based on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for one Resident (Resident #51) of 6 residents whose medications were reviewed, in that: The facility's Pharmacist Consultant recommended a GDR for Resident #51's use of Duloxetine ([MEDICATION NAME]). The facility did not inform Resident #51's physician about the recommendation. This failure could place residents receiving medications at risk for adverse drug consequences. The findings were: Record review of Resident #51's Admission Record indicated Resident #51 was a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] for Resident #51 indicated; -cognitive status was severely impaired, -was dependent on two staff for bed mobility, transfers, dressing, toilet use, eating and personal hygiene, -had functional limitation in range of motion on both sides of upper and lower extremities and -received anti-depressant and opioid medications. Record review of Resident #51's Comprehensive Physician Orders dated active as of 02/26/21 indicated an order for [REDACTED].>- Duloxetine HCI Capsule Delayed Release Sprinkle 20 mg. Give 1 capsule by mouth two times a day for chronic pain/depression, start date; 02/23/21. Record review of Resident #51's care plans revised 02/16/21 indicated R#51: uses antidepressant medication for pain/Chronic depression. Interventions included; - Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q day and night SHIFT, revised on 01/26/21. -Evaluate use of medication at least once every 90 days for any possibility of gradual dose reduction. GDR done to reduce dosage on antidepressant for chronic pain with end goal of discontinuation. Record review of MARs for Resident #51 dated 02/01/21 -02/28/21 indicated R#51 was administered Duloxetine Capsule Delayed Release Particles 30 mg twice a day from 02/01/21-02/23/21 at 8:00 a.m. and 4:00 p.m. Record review of MARs for Resident #51 dated 02/01/21-02/28/21 indicated R#51 was administered one tablet [MEDICATION NAME] 15 mg at bedtime for appetite stimulant/depression from 02/01/21/-02/28/21. Record review of Pharmacist's Consultations revealed a recommendation letter titled Consultation Report dated 01/28/21 for Resident #51. The letter was addressed to Resident #51's physician: Repeated Recommendation from 11/19/20; Please respond promptly to assure facility compliance with Federal regulations. Receives multiple antidepressants for depression concomitantly without documentation in the medical record of an inadequate response to monotherapy; (one type of treatment) [MEDICATION NAME] 15 mg QHS and Duloxetine HCL 30 mg BID. Recommendation; Please reduce Duloxetine to 20 mg BID with the end goal of discontinuation, while monitoring for reemergence of depressive and withdrawal symptoms and optimizing therapy with [MEDICATION NAME]. Rationale for Recommendation; Evidence for the effectiveness and safety of combined antidepressant medications is limited and should only be used in certain situations. (e.g., treatment failure, dose optimization limited by side effects). The risk for drug interactions, adverse events, noncompliance, and medication errors are increased. The Consultation Report for Resident #51 indicated the Physician's Response with a checked off box: I accept the recommendations above, please implement as written. The Consultation Report indicated a signature by LVN A and dated 02/23/21. On 02/25/21 at 10:51 a.m. Resident #51 was observed in her wheelchair in the dining room by nurse's station. Resident #51 was alert and due to her cognitive impairment was unable to respond to surveyor interview. Interview on 02/25/21 at 1:34 p.m. with LVN A revealed she received pharmacist recommendations from the facility DON. The DON would receive the recommendations from the Pharmacist Consultant and then he would print reports and make copies of recommendations. The DON would provide her with the pharmacist recommendation. She was responsible to carry out pharmacist recommendations for the residents in her wing. LVN A said she did not receive the pharmacist recommendation for Resident #51 dated 11/19/20 until around 02/17/21. LVN A said she looked for the recommendation dated 11/29/20 as indicated on the recommendation dated 01/28/21. She said she was unable to find the recommendation dated 11/19/21 and asked the DON on or about 02/17/21. The DON told her he would look for the recommendation dated 11/19/20 because he had not received the recommendation. She then called Resident #51's physician on 02/23/21 and received orders from Resident #51's physician that he accepted the recommendation to GDR the medication Duloxetine to 20 mg twice a day. LVN A said she signed the Pharmacist Consultation Report dated 01/28/21 and dated 02/23/23 indicating she had contacted Resident #51's physician and he gave a verbal order over the phone to address the recommendation. Interview with the DON on 02/25/21 at 1:53 p.m. revealed he had never received the November 2020 monthly Pharmacist Consultant's recommendations from the Pharmacist Consultant via email. He said the Pharmacist Consultant would email the pharmacist recommendations, then he would print the recommendations and distribute to the corresponding charge nurses for follow up with resident physicians. The DON said he had been on leave from work intermittently and had not questioned the Pharmacist Consultant about the November pharmacy recommendations. The December 2020 and January 2021 recommendations both had been received via email. December 2020 recommendations were received via email on 12/22/20 and were distributed. January 2021 recommendations were received via email on 01/28/21 and distributed to charge nurses. Any repeated recommendations would show up after 30 days. The recommendation made on 11/19/20 for Resident #51 would not show up until January 2021. The DON said he expected his staff to get a response from resident's physician within 7 days after receiving copy of recommendation. He had not made the Pharmacist Consultant's emails available to any other staff during his leaves from work. A Consultation Summary Report indicating all recommendations made in December 2020 and January 2021 was completed to document the response dates of all recommendations. Record review of forms titled Consultation Summary Report dated 12/01/20-12/22/21 and 01/01/21-01/28/21 revealed recommendations made during the times frames indicated and the dates the responses from physicians were obtained. On 02/25/21 at 2:30 p.m. interview with ADON D revealed when no recommendations were provided for the month of November 2020 by the DON she should have followed up on the pharmacist recommendations from November 2020 besides asking the DON. On 02/25/21 at 2:43 p.m. interview with the facility Pharmacist Consultant revealed the facility had implemented a new email system. She sent November pharmacist recommendations to the DON on the old email address on 12/19/21. The DON did not question her on not receiving the November 2020 pharmacist recommendations. On 02/25/21 at 3:32 p.m. interview with the DON revealed he had found the email with the pharmacist recommendations from November 2020 in the old email system after interview with surveyor. On 02/26/21 at 2:10 p.m. the DON said he had not distributed the pharmacist recommendations on the dates he received recommendations due to his leave from work at different dates. The DON said he understood this failure could lead to not responding to recommendations not been addressed in a timely manner by the resident's physicians and depending on recommendation could lead to unnecessary over medications for the residents. Record review of the facility policy titled Medication Therapy revised April 2007 indicated; Each resident' medication regime shall include only those medications necessary to treat existing conditions and address significant risks. Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regime for continued indications, proper dosage and duration, and possible adverse consequences.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable disease and infections, for in three employees (CNA C, HK A, and HK B) of five employees observed for infection control practices. -CNA C and HK A wore incorrectly secured face masks. -HK B was not wearing a face mask while inside the facility. These failures could place residents at risk for healthcare-associated cross contamination, infections, and COVID-19 (Coronavirus). Findings included: Observation on 11/29/20 at 11:18 a.m. revealed CNA C was wearing a face mask with the bottom strap, unsecured, and hanging underneath CNA C's chin while she was walking down the hallway. In the interview at the time of the observation, CNA C said she had just finished her break and had been going to get another face mask, but was asked by another employee for assistance. CNA C said she knew that was not the right way to wear a face mask. CNA C said she had trainings on how to wear face masks and other Personal Protective Equipment PPE. Observation on 11/29/20 at 12:40 p.m., revealed HK A was wearing a face mask with the bottom strap, unsecured, and hanging underneath HK A's chin. In an interview with HK A, she stated she was returning from her lunch break and had not put on her face mask properly. HK A said she knew how to put the mask on properly and that she had received training recently on how to wear a face mask. Observation on 11/29/20 at 12:40 p.m. revealed HK B was not wearing a face mask while inside the facility. In the interview at the time of the observation, HK B said she was just returning from her lunch break and had forgotten to put on the face mask. HK Bsaid she knew she was supposed to be wearing a face mask while inside the facility. HK B said she received in service trainings about a month ago. In an interview on 11/29/20 at 1:00 p.m., the Administrator said that the staff had been in serviced repeatedly on how to properly wear a face mask and other PPE. In an interview on 11/29/20 at 1:01 p.m., the DON said staff had been given in-services on donning and doffing of PPE and the proper use of face masks in October 2020. The DON said he could not explain why the staff were not wearing their face masks properly or not at all. The DON said those employees had been working at the facility for a while and knew that face masks should be worn and worn properly. Record review revealed an inservice, conducted by the Infection Control Registered Nurse on 10/06/20, Subjects Covered: Social distancing, Facemask Dos and Don'ts, Hand hygiene, and Safely donning/doffing PPE. Further review revealed HK A, HK B, and CNA C attended these Inservices. Record review revealed an inservice, conducted by the Infection Control Registered Nurse on 10/6/20 - 10/23/20, Subject(s)/Description Covered: Training CDC COVID-19: - Using PPE Correctly for COVID - 19 You Tube Video Isolation and Quarantine: online training course. Further review revealed HK A, HK B, and CNA C attended these Inservices. Record review of the facility's, Policy - Emergency Procedure - Pandemic COVID-19, dated 08/26/20, revealed: . Reinforce adherence to infection prevention and control measures, including hand hygiene and selection and use of personal protective equipment (PPE). Have HCP demonstrate competency with putting on and removing PPE. Record review of COVID-19 Response For Nursing Facilities, Version 3.4, dated 8/12/20, revealed: Donning and Doffing of Mask or Respirator: -Secure ties or elastic bands at middle of head and neck -Fit flexible band to nose bridge -Fit snug to face and below chin -Fit-check respirator

Based on observation, interview, and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, for one Resident (R#1) of two residents reviewed for accidents. The facility did not ensure proper Pivot lift techniques were in use by Certified Nurse Aide (CNA) A and CNA B. R#1 fell from a Pivot lift sling, while operated by CNA A and CNA B. R#1 sustained an acute [MEDICAL CONDITION] hip This failure could place one resident who required the use of a Pivot Lifter for transfers at risk for serious injuries. The findings were: Record review of R#1's Admission Record Sheet, dated 10/12/16, revealed R#1 was admitted to the facility on [DATE] and re-admitted on [DATE]. R#1 was [AGE] years-old. Record review of R#1's October 2016 Physician order [REDACTED]. Record review of R#1's Minimum Data Set (MDS) Quarterly Assessment, dated 08/05/16, revealed R#1: - had moderately impaired cognition, - was totally dependent on staff for transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene, - had Functional Limitation in Range of Motion to her upper and lower extremities on one side, - had no pain in the previous five days, and - had no falls. R#1's MDS indicated walking in room and corridor had not occurred. Record review of R#1's Comprehensive care plan, revised 05/19/16, revealed R#1 required extensive assistance from two staff for bed mobility and total assistance from two staff for transfers, with the use of a pivot lift. Record review of R#1's Progress notes documented: -09/23/16 at 6:20 a.m. - Resident noted with assisted fall in her room during transfer. Resident stable and denies pain only general discomfort. No apparent injuries and all safety measures in place. -09/23/16 at 5:00 p.m. - Went into resident room to assess resident. She denied pain. She stated she had no feeling to both legs this morning and that's what caused fall she stated she still can't feel both her legs. Checked plantar for neuro check by rubbing her plantar and she could not feel my fingers on either foot. No bruising noted to feet. Did note 2 + [MEDICAL CONDITION] to left foot. Pedal pulse with faint pedal pulse palpated. advised primary nurse to notify physician. -09/23/16 at 5:22 p.m. - Spoke with physician he stated to go ahead and send resident out to hospital due to no sensation to lower legs status [REDACTED]. -09/23/16 at 6:20 p.m. - Resident out of facility being transported via stretcher to hospital accompanied by responsible party. -09/23/16 at 10:45 p.m. - Resident being admitted to hospital with [DIAGNOSES REDACTED]. -09/28/16 at 11:19 p.m. - Resident arrived via ambulance to facility, resident stated pain 3/10 at this time, report was called in by nurse at hospital, she is on a cardiac diet and is on bedrest. Record review of R#1's Minimum Data Set (MDS) Discharge Assessment, dated 09/23/16, revealed R#1: -had an unplanned discharge, with return anticipated, and -had a fall with major injury. Record review of R#1's 72 Hour Fall Monitoring sheet, dated 09/23/16, revealed R#1 was sent to the hospital. Record review of R#1's Hospital Medical Records, dated 09/24/16, documented: -Clinical information; fall -There is acute fracture in the left hip, with the fracture located at the base of the left femoral neck, extending to the intertrochanteric left hip. -Impression; Acute left proximal femur left [MEDICAL CONDITION]. Record review of the facility's, Provider Investigation Report, dated 09/23/16, for R#1 revealed: - R#1 had an assisted fall from the pivot lifter in the morning by two CNAs and had no complaints of any kind. At approximately 5:00 p.m., the resident complained of not being able to feel her feet. The Physician was notified and orders were given to transfer to the emergency room for evaluation. - R#1 was being transferred from bed to shower chair via pivot lifter. The resident was guided down to the floor. The nurse was called in for assessment. Upon interview found that the resident's leg weakened and she was not able to bear weight to complete the transfer. Record review of the facility's Progressive Discipline forms for CNA A and CNA B, dated 09/27/16, revealed CNA A and CNA B, .failed to properly secure pivot's sling with belt around resident to prevent injury and causing resident to fall and fracture hip. Due to severity of incident, this is grounds for immediate termination. Record review of R#1's October 2016 Physician order [REDACTED]. Record review of R#1's MDS Annual Assessment, dated 10/05/16, revealed R#1: - had moderately impaired cognition, - was totally dependent on staff for bed mobility, dressing, toilet use, and personal hygiene, - had Functional Limitation in Range of Motion to her upper extremities on one side, and lower extremities on both sides, - had frequent pain in the previous five days, and - had no falls. R#1's MDS indicated that: - activities of tranfers, walking in room and corridor, locomotion on and off unit had not occurred. - assessments for ability to move from sitting to lying position, lying to sitting on side of bed, standing from a sitting position, chair to bed transfer, and toilet transfer were not attempted due to medical condition or safety concerns. Record review of R#1's Care Plan/Protocol, Fracture, dated 09/28/16, documented: - fracture of neck of proximal left femur, - goal; resident will be pain free and will prevent further fracture of affected area. Record review of In-service Training Report, dated 09/25/16, revealed -Subjects covered: fall precautions -Problems, Comments, Suggestions: All appropriate equipment must be used when transferring residents, slings must be secured before transfers are performed. Record review of In-service Training Report, dated 09/25/16, revealed -Subjects covered: abuse and neglect -Problems, Comments, Suggestions: When providing care, transferring, or repositioning a resident all safety precautions must be followed and safety restraints must be in place as ordered on kardex. Falling to apply safety restraints is a form of neglect. In an interview on 10/12/16 at 9:30 a.m., the Administrator said the CNAs involved in R#1's incident had been terminated. In an interview on 10/12/16 at 10:25 a.m., R#1 said she did not remember how she fell . R#1 said there had always been two CNAs when she was transferred. Surveyor observed a sign on R#1's wall which indicated, No transfer. In an interview on 10/12/16 at 1:03 p.m., via telephone, CNA A said she had never been formally trained to use the Pivot Lifter. CNA A said two other CNAs had told her how to use the Pivot Lifter, but nobody had checked her to see if she was doing it correctly. CNA A said she was never told to use a support strap when using the Pivot Lifter. CNA A said that, when R#1 had the fall, the support strap was not used. CNA A said she would have used the second belt (support strap) if she had known about it. CNA A said she was no longer working at the facility. In an interview on 10/12/16 at 2:30 p.m., the Director of Nursing (DON) said that, after R#1's fall, the facility's Assistant Directors of Nursing (ADONs) trained the CNAs on how to use the Pivot Lifter and other transfer device equipment. The DON said the ADONs were now doing between five and ten transfer observations a week to check on transfer proficiency. In an interview on 10/12/16 at 4:30 p.m., the DON said that, after the fall, R#1 was bedfast. The DON said R#1 was not to be transferred, even for showers. The DON said that, before the fall, R#1 was able to sit in a wheelchair and participate in social, recreational, and religious activities. The DON said R#1 had not fallen for a long period of time prior to the 09/23/16 incident. Record review of Pivot Lifter operating instructions revealed: Transfer and Walking Sling; Position the sling around the patient's back so that the bottom edge of the sling is level with the base of the spine. Ensure that patient's arms are outside the sling and that the support strap is separated. Bring the support strap around the body and fasten it securely by overlapping and pressing the Velcro together. An undated list provided by the DON documented one resident who required the use of pivot lifter for transfer assistance from staff.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents, during care, for one Resident (R#1) of two residents reviewed for accidents. The facility did not ensure proper Pivot lift techniques were in use by Certified Nurse Aide (CNA) A and CNA B. R#1 fell from a Pivot lift sling, while operated by CNA A and CNA B. R#1 sustained an acute fracture of the right hip This failure could place one resident who required the use of a Pivot Lifter for transfers at risk for serious injuries. The findings were: Record review of R#1's Admission Record Sheet, dated 10/12/16, revealed R#1 was admitted to the facility on [DATE] and re-admitted on [DATE]. R#1 was [AGE] years-old. Record review of R#1's October 2016 Physician order [REDACTED]. Record review of R#1's Minimum Data Set (MDS) Quarterly Assessment, dated 08/05/16, revealed R#1: - had moderately impaired cognition, - was totally dependent on staff for transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene, - had Functional Limitation in Range of Motion to her upper and lower extremities on one side, - had no pain in the previous five days, and - had no falls. R#1's MDS indicated walking in room and corridor had not occurred. Record review of R#1's Comprehensive care plan, revised 05/19/16, revealed R#1 required extensive assistance from two staff for bed mobility and total assistance from two staff for transfers, with the use of a pivot lift. Record review of R#1's Progress notes documented: -09/23/16 at 6:20 a.m. - Resident noted with assisted fall in her room during transfer. Resident stable and denies pain only general discomfort. No apparent injuries and all safety measures in place. -09/23/16 at 5:00 p.m. - Went into resident room to assess resident. She denied pain. She stated she had no feeling to both legs this morning and that's what caused fall she stated she still can't feel both her legs. Checked plantar for neuro check by rubbing her plantar and she could not feel my fingers on either foot. No bruising noted to feet. Did note 2 + edema to left foot. Pedal pulse with faint pedal pulse palpated. advised primary nurse to notify physician. -09/23/16 at 5:22 p.m. - Spoke with physician he stated to go ahead and send resident out to hospital due to no sensation to lower legs status [REDACTED]. -09/23/16 at 6:20 p.m. - Resident out of facility being transported via stretcher to hospital accompanied by responsible party. -09/23/16 at 10:45 p.m. - Resident being admitted to hospital with [DIAGNOSES REDACTED]. -09/28/16 at 11:19 p.m. - Resident arrived via ambulance to facility, resident stated pain 3/10 at this time, report was called in by nurse at hospital, she is on a cardiac diet and is on bedrest. Record review of R#1's Minimum Data Set (MDS) Discharge Assessment, dated 09/23/16, revealed R#1: -had an unplanned discharge, with return anticipated, and -had a fall with major injury. Record review of R#1's 72 Hour Fall Monitoring sheet, dated 09/23/16, revealed R#1 was sent to the hospital. Record review of R#1's Hospital Medical Records, dated 09/24/16, documented: -Clinical information; fall -There is acute fracture in the left hip, with the fracture located at the base of the left femoral neck, extending to the intertrochanteric left hip. -Impression; Acute left proximal femur left hip fracture. Record review of the facility's, Provider Investigation Report, dated 09/23/16, for R#1 revealed: - R#1 had an assisted fall from the pivot lifter in the morning by two CNAs and had no complaints of any kind. At approximately 5:00 p.m., the resident complained of not being able to feel her feet. The Physician was notified and orders were given to transfer to the emergency room for evaluation. - R#1 was being transferred from bed to shower chair via pivot lifter. The resident was guided down to the floor. The nurse was called in for assessment. Upon interview found that the resident's leg weakened and she was not able to bear weight to complete the transfer. Record review of the facility's Progressive Discipline forms for CNA A and CNA B, dated 09/27/16, revealed CNA A and CNA B, .failed to properly secure pivot's sling with belt around resident to prevent injury and causing resident to fall and fracture hip. Due to severity of incident, this is grounds for immediate termination. Record review of R#1's October 2016 Physician order [REDACTED]. Record review of R#1's MDS Annual Assessment, dated 10/05/16, revealed R#1: - had moderately impaired cognition, - was totally dependent on staff for bed mobility, dressing, toilet use, and personal hygiene, - had Functional Limitation in Range of Motion to her upper extremities on one side, and lower extremities on both sides, - had frequent pain in the previous five days, and - had no falls. R#1's MDS indicated that: - activities of transfers, walking in room and corridor, locomotion on and off unit had not occurred. - assessments for ability to move from sitting to lying position, lying to sitting on side of bed, standing from a sitting position, chair to bed transfer, and toilet transfer were not attempted due to medical condition or safety concerns. Record review of R#1's Care Plan/Protocol, Fracture, dated 09/28/16, documented: - fracture of neck of proximal left femur, - goal; resident will be pain free and will prevent further fracture of affected area. Record review of In-service Training Report, dated 09/25/16, revealed -Subjects covered: fall precautions -Problems, Comments, Suggestions: All appropriate equipment must be used when transferring residents, slings must be secured before transfers are performed. Record review of In-service Training Report, dated 09/25/16, revealed -Subjects covered: abuse and neglect -Problems, Comments, Suggestions: When providing care, transferring, or repositioning a resident all safety precautions must be followed and safety restraints must be in place as ordered on kardex. Failing to apply safety restraints is a form of neglect. In an interview on 10/12/16 at 9:30 a.m., the Administrator said the CNAs involved in R#1's incident had been terminated. In an interview on 10/12/16 at 10:25 a.m., R#1 said she did not remember how she fell . R#1 said there had always been two CNAs when she was transferred. Surveyor observed a sign on R#1's wall which indicated, No transfer. In an interview on 10/12/16 at 1:03 p.m., via telephone, CNA A said she had never been formally trained to use the Pivot Lifter. CNA A said two other CNAs had told her how to use the Pivot Lifter, but nobody had checked her to see if she was doing it correctly. CNA A said she was never told to use a support strap when using the Pivot Lifter. CNA A said that, when R#1 had the fall, the support strap was not used. CNA A said she would have used the second belt (support strap) if she had known about it. CNA A said she was no longer working at the facility. In an interview on 10/12/16 at 2:30 p.m., the Director of Nursing (DON) said that, after R#1's fall, the facility's Assistant Directors of Nursing (ADONs) trained the CNAs on how to use the Pivot Lifter and other transfer device equipment. The DON said the ADONs were now doing between five and ten transfer observations a week to check on transfer proficiency. In an interview on 10/12/16 at 4:30 p.m., the DON said that, after the fall, R#1 was bedfast. The DON said R#1 was not to be transferred, even for showers. The DON said that, before the fall, R#1 was able to sit in a wheelchair and participate in social, recreational, and religious activities. The DON said R#1 had not fallen for a long period of time prior to the 09/23/16 incident. Record review of Pivot Lifter operating instructions revealed: Transfer and Walking Sling; Position the sling around the patient's back so that the bottom edge of the sling is level with the base of the spine. Ensure that patient's arms are outside the sling and that the support strap is separated. Bring the support strap around the body and fasten it securely by overlapping and pressing the Velcro together. An undated list provided by the DON documented one resident who required the use of pivot lifter for transfer assistance from staff.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents, for two Residents (R#2 and R#1) of six residents reviewed for accidents. 1) The facility did not ensure proper Hoyer lift techniques were in use by Certified Nurse Aide (CNA) N and CNA O. R#2 fell from an elevated Hoyer lift sling and sustained an acute fracture of the right hip while operated by CNA N and CNA O. 2) The facility did not ensure proper Hoyer lift techniques were in use by CNA D and CNA E. The wheels of R#1's wheelchair remained unlocked during a Hoyer lift transfer performed by CNA D and CNA E. These failures could place all 35 residents who needed assistance for transfers at risk for serious injuries. The findings were: 1) Record review of R#2's Admission Record Sheet, dated 05/19/16, revealed R#2 was re-admitted to the facility on [DATE]. Record review of R#2's Discharge Summary, dated 07/27/16, revealed R#2 was transferred to the hospital on [DATE]. Record review of R#2's July 2016 Physician order [REDACTED]. Arteriovenous Fistula Acquired. Record review of R#2's Admission Minimum Data Set (MDS) assessment, dated 07/15/16, revealed R#2: -had minimal difficulty hearing, -had clear speech, -was usually understood by others and was usually able to understand others, -had adequate vision, -required extensive assistance of two staff for bed mobility, eating, and toileting, -required total assistance from two staff for transfers, dressing, personal hygiene, and bathing, and -had range of motion impairment to both sides of lower extremities. Record review of R#2's Care Plan, dated 07/08/16, revealed R#2: - was at risk of developing complications related to requiring assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, bathing related to weakness, right below the knee amputation (BKA), and left above the knee amputation (AKA). Interventions/Tasks: Transfer- (R#2) requires total assistance by (2) staff assistance for transfer with a mechanical lift. - was risk for falls related to incontinence and right BKA and left AKA. Interventions/Tasks: Anticipate and meet (R#2's) needs. Assist with 2 persons for all transfers with a mechanical Hoyer lift. Be sure (R#2) call light is within reach and encourage (R#2) to use it for assistance as needed. (R#2) needs prompt response to all request for assistance. Educate (R#2)/family/caregivers about safety reminders and what to do if a fall occurs. Monitor and document any adverse side effects of medications. Record review of R#2's, Nursing Admission Screening/History, dated 07/08/16, under section ADL's/Functional Devices, revealed R#2 was a 2 person transfer with Hoyer lifter. Record review of R#2's Morse Fall Scale, dated 07/08/16, revealed R#2's score was 40, indicating moderate risk for falling. Record review of R#2's Incident/Accident Report, dated 07/27/16, revealed R#2 fell out of the Hoyer lift sling during a transfer, landing in a supine position. Record review of R#2's Incident/Accident Investigation Follow Up, dated 07/27/16, under Summary of Investigation revealed, Upon investigation spoke to CNAs, stated upon lifting Hoyer and moving the geri chair R#2 fell to the floor. CNA stated all latches were on right. R#2 leaned to the right and left latch came off and R#2 fell to the floor. Sling intact. Record review of R#2's Progress Notes, dated 07/27/16 at 1:36 p.m., by Registered Nurse (RN) M revealed, Was called into room by CNAs, upon entering room (R#2) was supine on floor, lying on a pillow. CNAs stated while lifting in Hoyer lift left strap came dislodged and (R#2) slid out of gerichair and slid to floor. Assessment was done on (R#2) and she is AO (alert and oriented) x 2 with all skin intact at this time. (R#2) remained conscious throughout and is free from signs of bruising. Will notify MD and continue to monitor. Record review of facility's Progress Notes, dated 07/27/16 at 1:38 p.m., by RN M revealed, (R#2) denies pain at this time and was transferred to bed with draw sheet and 4 person lift. (R#2) tolerated transfer well free of pain or distress. Will continue to monitor for changes in status. Record review of the facility's Provider Investigation Report, dated 08/02/16, revealed: -under section, Description of the Allegation - R#2 was being transferred from gerichair to bed with Hoyer lift, by two CNAs. The CNAs made sure the four latches/hooks clicked on the Hoyer lifter machine and, upon elevating R#2 with the sling, and completely out of the gerichair, the latch on the left side unlatched and R#2 fell to the floor. R#2 was assessed by nurse and assisted times four staff member back to gerichair chair, then to the bed. R#2 had an appointment for dialysis and when EMTs transferred R#2 to the gurney R#2 started to complain of pain to her back. EMTs transferred R#2 back to the bed. The facility placed a call to R#2's Physician, who gave orders for x-rays to R#2's back, right hip, right femur. X-rays revealed severe osteoporosis and osteoarthritis and an acute fracture of the proximal femur. -under section, Description of Injury - R#2 with a new acute fracture to the proximal femur. -under section, Description of Assessment - CNAs called the nurse to make him aware of the situation and nurse did assessment at the moment. R#2 had no discoloration, no abnormalities, nor any open areas, and no complaints of pain. -under section, Provider Response: -Made MD aware of fall -Made responsible party aware -Started in-service on Hoyer lifts -One to one education done with CNAs. -under section, Investigation Summary - Spoke to the CNAs regarding the transfer with resident and stated all four latches/hooks were clicked to the Hoyer lift when all of the sudden the latch on the left came off. Record review of the hospital, History and Physical, dated 07/27/16, revealed R#2 was very confused, demented, and bedbound, with a history of bilateral AKA. R#2 was brought to the ER (emergency room ) and admitted with right femoral neck fracture. Record review of Hospital Progress Note, dated 08/03/16, revealed follow up for right hip fracture, s/p (status [REDACTED]. Record review on hospital Progress Note dated, 08/22/16, under section Problem List included right femur fracture, status [REDACTED]. In an interview on 08/19/16 at 10:41 a.m., CNA N said a she did not remember the date of R#2's incident, but believed it happened at approximately 1:00 p.m. to 1:30 p.m. CNA N said R#2 was going to be transferred from the geri-chair to the bed with the use of a Hoyer lift, with the assistance of CNA O. CNA N said she used a medium size sling because of R#2's amputations. CNA N said she locked the geri-chair and hooked/latched the back hooks (near the head area) of the sling onto the Hoyer lift and CNA O latched the two front hooks (near the leg area) of the sling onto the Hoyer lift. CNA N said she ensured all the hooks were properly latched and it made a clicking noise when it latched properly. CNA N said CNA O maneuvered the Hoyer lift by slowly lifting R#2 from the ger-chair. When R#2 was elevated, CNA N unlocked the geri-chair and moved it backwards. Within seconds, R#2 fell to the floor. CNA N said she was not able to do anything or attempt to break the fall because she was moving the geri-chair out of the way to make room. CNA N said R#2 landed on her back and R#2's leg was on top of the leg (fork) of the Hoyer lift. CNA N said the sling was still attached to the Hoyer lift on three sides, but the latch on the bottom left side was unhooked. CNA N said she looked at the hook and it was not broken, just unlatched from the Hoyer lift. CNA N said that, when doing a transfer that she needed to first move the geri-chair out of the way, then she would assist in guiding the resident, in the sling, to the bed or chair. CNA N said she was not able to guide R#2 because the fall happened right away, while she was moving the geri-chair. CNA N said CNA O was not guiding the patient because she was operating the Hoyer lift. CNA N said she did not know how the fall could have happened, but believed it was because of R#2's weight distribution due to R#2's leg amputations, or R#2 might have moved while elevated, which led to the fall. In an interview on 09/06/16 at 12: 54 p.m., CNA N said she determined the size of the Hoyer sling to be used, based on the resident's weight. CNA N said she used a medium sling for R#2 and the sling was not damaged. CNA N said she checked the sling prior to using it for damage, lose threads, and holes, and checked the hooks. CNA N said that, if the sling was damaged, she would not use it, she would get a new sling. CNA N said the Charge Nurse would tell her if a resident had changes regarding the size of the sling. CNA N said she received training for transfers via her education and upon being hired at the facility. CNA N said she also received in-service trainings on proper transfers and other areas on a monthly basis. In an interview on 08/19/16 at 1:31 p.m., CNA O said R#2's incident happened on 07/27/16 at approximately 1:30 p.m. CNA O said she and CNA O were going to transfer R#2 from geri-chair to the bed with the use of a Hoyer lift. CNA O said she ensured the hooks of the sling were latched correctly, they both verified it was latched on all four sides. CNA O said she started to operate the Hoyer lift by lifting R#2 from the geri-chair . CNA N was moving the geri-chair backwards, for the Hoyer lift to work more efficiently. CNA O said the geri-chair needed to be moved to operate the Hoyer lift, and then the CNA would come back to guide the resident in the sling. CNA O said the fall happened too fast. CNA O said R#2 slipped from the sling and landed on her back on the floor. R#2's amputated leg landed on the Hoyer lift leg. CNA O said the sling became unlatched from the left side. CNA O said she informed the Charge Nurse, RN M. CNA O said she believed the incident happened because of R#2's weight distribution because R#2 did not have legs and R#2 attempting to move. On 08/19/16 at 1:40 p.m., CNA N reenacted R#2's incident, with the assistance of CNA L. Surveyor observed the gerichair to be towards the wall near bed C. CNA N checked the Hoyer lift battery and verified the sling and hooks. CNA N placed the hooks to the latch and ensure it locked correctly. CNA L moved the Hoyer lift near the gerichair. CNA L slowly started to elevate the sling, which was in a laying position. CNA N removed the gerichair from behind. Surveyor observed the sling was unattended by both staff at this time. Surveyor observed the Hoyer lift sling moved from a laying position to a sitting position immediately. At this time, CNA N said that, when the Hoyer lift sling moved to a sitting position, that was when the left hook unlatched and R#2 fell out of the sling. In an interview on 09/06/16 at 10:54 a.m., CNA O said she used a medium size sling for R#2, because of her weight. CNA O said the Charge Nurse would tell her what sling to use, depending on the resident. CNA O said, if the sling did not fit well on the resident, she would inform the Charge Nurse. CNA O said that, prior to using a sling, she checked the hooks, and checked for loose threads, holes, or worn areas, and would inform the Charge Nurse to request another sling to use. CNA O said she received her training for transfers and other ADL care at school and when she was hired at the facility. In an interview on 08/19/16 at 3:20 p.m., Licensed Vocational Nurse (LVN) P said R#2's incident happened on 07/27/16, between 1:00 p.m. and 1:15 p.m. LVN P said she was called by LVN Q to come to the room. LVN P said CNA N, CNA O, and RN M were in R#2's room. LVN P said she saw R#2 in a supine position on the floor. LVN P said CNA N and CNA O told her that R#2 slipped off the sling because the left lower latch came unlatched. LVN P said CNA N was moving the geri-chair towards the wall, while CNA O started to move the Hoyer lift and R#2 was elevated when the fall happened. LVN P said she saw that the Hoyer lift, sling, and hooks were not damaged. LVN P said R#2 was not able to voice what happened and only said lleventame (pick me up). LVN P said R#2 did not complain of pain. LVN P said R#2 started to complain of pain when EMS arrived to pick up R#2 for dialysis and R#2 was given pain medication, and doctor was informed and ordered x-rays. LVN P said R#2's weight went more to one side because R#2 had a right below the knee amputation and a left above the knee amputation in which more weight went to the right side, causing the hook to unlatch. In an interview on 08/22/16 at 9:59 a.m., Registered Nurse (RN) M said he was the Charge Nurse for R#2 on the day of the incident. RN M said he was called into R#2's room by CNA O. RN M said when he entered R#2's room, he saw R#2 was on the floor, with a pillow under R#2's head. RN M said R#2 was on the floor in between the Hoyer lift and the geri-chair. RN M said he assessed R#2 on the floor and R#2 denied having pain or discomfort. RN M said he observed the sling to be attached to the Hoyer lift with three latches only; it was unlatched on the left side bottom. RN M said the sling and hooks were intact. RN M said CNA N and CNA O told him all four latches were secured, but the left latch came unhooked when they were transferring R#2 from the geri-chair to the bed. RN M said CNA N and CNA O said it might have come unhooked due to R#2's weight. RN M said R#2 had more weight on the right side due to R#2's weight of her femur/slightly below the knee and left above the knee amputation. RN M said he spoke with LVN Q to inquire about the proper procedures when an incident happened. RN M said R#2 was re-assessed by LVN P and then transferred by four person transfer to the bed. RN M said he did not ask who placed the pillow underneath R#2's head, but believed it was one of the CNAs. RN M said when incidents happened, the staff was educated to not move the patient, for the resident's safety. In an interview on 08/22/16 at 10:33 a.m., CNA N said she placed the pillow underneath R#2's head because she got scared regarding R#2's fall and wanted to keep R#2 comfortable. CNA N said she knew that she was not to move a resident after a fall, until the Charge Nurse told her. In an interview on 08/22/16 at 1:39 p.m., surveyor attempted to interview R#2 at the hospital, however R#2 said she felt weak. Surveyor observed R#2 to be nonresponsive and lethargic. In an interview on 08/23/16 at 8:02 a.m., the Maintenance Director said he was not notified to check the Hoyer lift regarding R#2's incident. The Maintenance Director said he heard about the incident through CNAs commenting about it. The Maintenance Director said he did not have a specific schedule when he inspected the Hoyer lifts. The Maintenance Director said the nursing staff informed him verbally, or by documenting on the maintenance log kept at each of the nurses' stations, to check the Hoyer lift and if needed, repair it. The Maintenance Director said the facility had six to seven Hoyer lifts. In an interview on 08/23/16 at 8:20 a.m., LVN P said she did not tell Maintenance to check the Hoyer lift after R#2's incident. LVN P said R#2's incident was discussed during the morning meeting and Maintenance was aware. LVN P said she did not know if Maintenance checked the Hoyer lift. Surveyor inquired about R#2 having a pillow placed underneath her head. LVN P said she was unaware a pillow was placed under R#2 after the incident occurred. LVN P said CNAs were not allowed to move a resident after a fall because the Charge Nurse needed to assess first for the resident's safety. In an interview on 09/06/16 at 1:15 p.m., LVN P said R#2 used a medium size sling because of the resident's weight. LVN P said the CNA staff and Charge Nurses could both determine what color of sling to use for a resident. LVN P said the color was red for a small sling, yellow for a medium sling, green for a large sling, and purple for an extra-large sling. LVN P said she did not believe the CNAs needed to inform the Charge Nurse when a different color of sling was used. LVN P said there was no documentation of what color of slings were being used for the residents. LVN P said the nursing staff would check for proper fit (not too loose or too tight) and use the sling that best fit the resident. LVN P said R#2's sling was not damaged and was in good condition, and that staff continued to use the sling for other residents. In an interview on 08/23/16 at 10:21 a.m., the Director of Nursing (DON) said R#2 was a two person transfer with the use of a Hoyer lift. The DON said R#2 was being transferred from geri-chair to bed when R#2 fell to the floor. The DON said R#2 was elevated on the Hoyer lift when the CNA moved the geri-chair, and R#2 fell . The DON said R#2's incident was an accident because R#2 tended to move more to the right side of her body. The DON said R#2 was assessed by RN M and LVN P. The DON said LVN P checked the sling and hook and it was intact. The DON said EMS transportation arrived for R#2's dialysis appointment and EMS transportation did not want to transport R#2 to dialysis because R#2 complained of pain. The DON said R#2's doctor was contacted again and x-rays were ordered. The DON said results of x-rays results were received and R#2 was sent to the hospital. The DON said it was an accident because the Hoyer lift was used in the morning and there were no issues reported with the Hoyer lift, the CNAs' stories were consistent regarding the incident, and the CNAs transferred R#2 correctly. The DON said that, when transferring using a Hoyer, the first CNA would operate the Hoyer lift. The second CNA would move the geri-chair out of the area, then assist to guide the patient to a safe position. The DON said residents could not be moved when an incident happened and the CNAs were not allowed to move the patient, to avoid further injuries. The DON said she did not know R#2 had a pillow placed underneath her head after the incident happened. In an interview on 09/06/16 at 8:59 a.m., the Director of Rehab said R#2 was not assessed for occupational or physical therapy because there were no orders for R#2 to be evaluated for rehab services. The Director of Rehab said the nursing department trained the CNAs for Hoyer lift transfers. The Director of Rehab said R#2's care was discussed during the IDT meetings and R#2's medical condition was stable from the last time she was at the facility. The Director of Rehab said no staff reported difficulty in transferring R#2. The Director of Rehab said, from her experience, she was not aware if there was a specific sling or Hoyer lift to be used for patients who had amputations. In an interview on 09/06/16 at 10:35 a.m., Central Supply staff said she checked the slings for damage daily and as needed. The Central Supply staff said there was no documentation to show she was checking the slings. The Central Supply staff said the CNAs checked the slings for damage and wear/tear. In an interview on 09/06/16 at 10:21 a.m., the DON said the CNAs checked daily if the Hoyer lift and sling were working. The DON said the CNAs checked the slings for any damage, like holes, loose threads, and fraying, and are told not to use the slings if they are damaged. The DON said a damaged sling would be replaced with a new sling. The DON said R#2 was not assessed for rehab services because no orders were needed as there was no change in her condition. The DON said there were no issues in transferring R#2 prior to the incident. The DON said no staff reported having difficulty in transferring R#2. The DON said she was unaware of the use of slings designed specifically for residents with amputations; the facility had always used the regular slings. The DON said that, upon admission, a resident was weighed and assessed to determine the use of a Hoyer lift by the Charge Nurse. The DON said the CNAs determined what color of sling to use based the resident's weight. Record review of the facility's policy, Lifting Machine, Using a Portable, revised October 2010, revealed: -The purpose of this procedure is to help lift resident using a manual lifting device. -Steps in the Procedure included: .3. Transfer a resident from chair to bed, you should: g. Move the lifter away from the chair Record review of facility's Safety and Supervision of Residents, revised December 2007, under section Policy Statement revealed the following: Record review of the facility's policy, Safety and Supervision of Residents, revised December 2007, revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision to prevent accidents are facility-wide priorities . 1. Our facility-oriented approach to safety address risks for groups of residents. 2. Safety risks and environmental hazards are identified on an on-going basis through a combination of employee training, employee monitoring, and reporting process; QA&A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QA&A/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained and inserviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents . Record review of the facility's policy, Use of Slings for Transfer, dated 12/04/14, revealed: -Slings are used for the safety and well-being of the resident(s). Slings are used to address the special needs of the resident according to care plan. -1. 'Slings' are defined as a canvas needed to cradle resident to provide safe transfer from surfaces. 2. 'Slings' should be attached as per manufacturer recommendations on weight. 3. 'Slings' are checked by staff as they perform care prior, during, and post care. -Section on Maintenance of Slings indicated: 1. 'Slings' are checked by staff while care is provided. Abnormalities, will be reported to charge nurse or central supply. 2. 'Slings' are monitored by central supply designee on a weekly basis and as needed for checking of sling abnormalities or malfunction. Record review of the facility's undated policy, Reusable Slings Standard and Fullback, revealed, The slings are approved for a load of 300 Kg (660 lbs) or 500 Kg (1100 lbs) for the extra extra large size sling. SLING MUST BE INSPECTED EACH AND EVERY TIME BEFORE BEING APPLIED ON RESIDENT FOR ANY WEAR OR TEAR. IN THIS CASE DISPOSE OF THE SLING. 2) Record review of R#1's Admission Record Sheet, dated 05/19/16, revealed R#1 was admitted to the facility on [DATE]. Record review of R#1's August 2016 Physician order [REDACTED]. Record review of R#1's Quarterly MDS assessment, dated 07/29/16, revealed R#1: -had highly impaired hearing, -had unclear speech, -was rarely/never understood by others and was rarely/never able to understand others, -had highly impaired vision, -had short and long term memory problems, -was severely impaired for daily decision making, -required total assistance of two staff for bed mobility, transfer, dressing, toilet use, and bathing, and -had range of motion impairment to both sides of upper and lower extremities. Record review of R#1's Care Plan, dated 08/10/16, revealed R#1 had ADL (activities of daily living) self-care performance deficit related to Dementia, Limited Mobility, and Alzheimer's. Intervention/Tasks indicated R#1 was totally dependent on two staff with Hoyer lift (mechanical lift) for all transferring. Record review of the facility's, Morse Fall Scale, dated 08/04/16, revealed R#1 scored 30 on the evaluation. The Morse Fall Scale form indicated the category of moderate risk for falling. On 08/19/16 at 4:31 p.m., surveyor observed R#1's room door to be closed. Surveyor knocked on R#1's door prior to entering R#1's room and observed the privacy curtain closed. Surveyor asked the staff what type of care was being provided. CNA D said they were about to transfer R#1. Surveyor observed R#1 lying on the bed. CNA D and CNA E placed the lift sling from the left side first, rolled R#1 over to place the sling to the right side. CNA D placed the Hoyer lift near the bed and latched the hook onto the Hoyer lift then she re-checked the hooks latched. CNA D slowly lifted the Hoyer lift with R#1 on the sling and CNA E guided R#1 towards the wheelchair. Surveyor observed the wheelchair wheels were unlocked, CNA D operated the Hoyer lift while R#1 was being slowly brought down, to position R#1 in the wheelchair. CNA D was holding onto the boom of the Hoyer lift, while CNA E attempted four times to place R#1's wheelchair in a position for the transfer. The wheelchair wheels remained unlocked. CNA E positioned wheelchair properly and was standing behind the unlocked wheelchair while R#1 was positioned on to the wheelchair. In an interview on 08/19/16 at 4:40 p.m., CNA D and CNA E said the wheelchair wheels should be locked at all times for resident safety, to prevent falls or injuries. CNA D and CNA E said they forgot to lock the wheelchair. In an interview on 08/19/16 at 4:42 p.m., surveyor attempted to interview R#1, however R#1 did not respond. In an interview on 08/19/16 at 4:48 p.m., LVN F said that, when transferring a resident, the wheelchair needed to be locked for resident safety at all times. In an interview on 08/23/16 at 10:21 a.m., the DON said wheelchairs and geri-chairs were to be locked at all times, because the wheelchair/geri-chairs could move, causing injury to the resident. Record review of the facility's policy, Lifting Machine, Using a Portable, revised October 2010, revealed: -The purpose of this procedure is to help lift resident using a manual lifting device. -Steps in the Procedure included: 3. Transfer a resident from bed to chair, you should: a. Position the chair. If it is a wheelchair, be sure the wheels are locked . The facility provided an undated list which indicated 35 residents who were transferred with a Hoyer lift.

Based on observation, interview, and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, for two Residents (R#2 and R#1) of six residents reviewed for accidents. 1) The facility did not ensure proper Hoyer lift techniques were in use by Certified Nurse Aide (CNA) N and CNA O. R#2 fell from an elevated Hoyer lift sling and sustained an acute [MEDICAL CONDITION] hip while operated by CNA N and CNA O. 2) The facility did not ensure proper Hoyer lift techniques were in use by CNA D and CNA E. The wheels of R#1's wheelchair remained unlocked during a Hoyer lift transfer performed by CNA D and CNA E. These failures could place all 35 residents who needed assistance for transfers at risk for serious injuries. The findings were: 1) Record review of R#2's Admission Record Sheet, dated 05/19/16, revealed R#2 was re-admitted to the facility on [DATE]. Record review of R#2's Discharge Summary, dated 07/27/16, revealed R#2 was transferred to the hospital on [DATE]. Record review of R#2's July 2016 Physician order [REDACTED]. Arteriovenous Fistula Acquired. Record review of R#2's Admission MDS assessment, dated 07/15/16, revealed R#2: -had minimal difficulty hearing, -had clear speech, -was usually understood by others and was usually able to understand others, -had adequate vision, -required extensive assistance of two staff for bed mobility, eating, and toileting, -required total assistance from two staff for transfers, dressing, personal hygiene, and bathing, and -had range of motion impairment to both sides of lower extremities. Record review of R#2's Care Plan, dated 07/08/16, revealed R#2: - was at risk of developing complications related to requiring assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, bathing related to weakness, right [MEDICAL CONDITION] (BKA), and left above the knee amputation (AKA). Interventions/Tasks: Transfer- (R#2) requires total assistance by (2) staff assistance for transfer with a mechanical lift. - was risk for falls related to incontinence and right BKA and left AKA. Interventions/Tasks: Anticipate and meet (R#2's) needs. Assist with 2 persons for all transfers with a mechanical Hoyer lift. Be sure (R#2) call light is within reach and encourage (R#2) to use it for assistance as needed. (R#2) needs prompt response to all request for assistance. Educate (R#2)/family/caregivers about safety reminders and what to do if a fall occurs. Monitor and document any adverse side effects of medications. Record review of R#2's, Nursing Admission Screening/History, dated 07/08/16, under section ADL's/Functional Devices, revealed R#2 was a 2 person transfer with Hoyer lifter. Record review of R#2's Morse Fall Scale, dated 07/08/16, revealed R#2's score was 40, indicating moderate risk for falling. Record review of R#2's Incident/Accident Report, dated 07/27/16, revealed R#2 fell out of the Hoyer lift sling during a transfer, landing in a supine position. Record review of R#2's Incident/Accident Investigation Follow Up, dated 07/27/16, under Summary of Investigation revealed, Upon investigation spoke to CNAs, stated upon lifting Hoyer and moving the geri chair R#2 fell to the floor. CNA stated all latches were on right. R#2 leaned to the right and left latch came off and R#2 fell to the floor. Sling intact. Record review of R#2's Progress Notes, dated 07/27/16 at 1:36 p.m., by Registered Nurse (RN) M revealed, Was called into room by CNAs, upon entering room (R#2) was supine on floor, lying on a pillow. CNAs stated while lifting in Hoyer lift left strap came dislodged and (R#2) slid out of gerichair and slid to floor. Assessment was done on (R#2) and she is AO (alert and oriented) x 2 with all skin intact at this time. (R#2) remained conscious throughout and is free from signs of bruising. Will notify MD and continue to monitor. Record review of facility's Progress Notes, dated 07/27/16 at 1:38 p.m., by RN M revealed, (R#2) denies pain at this time and was transferred to bed with draw sheet and 4 person lift. (R#2) tolerated transfer well free of pain or distress. Will continue to monitor for changes in status. Record review of the facility's Provider Investigation Report, dated 08/02/16, revealed: -under section, Description of the Allegation - R#2 was being transferred from gerichair to bed with Hoyer lift, by two CNAs. The CNAs made sure the four latches/hooks clicked on the Hoyer lifter machine and, upon elevating R#2 with the sling, and completely out of the gerichair, the latch on the left side unlatched and R#2 fell to the floor. R#2 was assessed by nurse and assisted times four staff member back to gerichair chair, then to the bed. R#2 had an appointment for [MEDICAL TREATMENT] and when EMTs transferred R#2 to the gurney R#2 started to complain of pain to her back. EMTs transferred R#2 back to the bed. The facility placed a call to R#2's Physician, who gave orders for x-rays to R#2's back, right hip, right femur. X-rays revealed severe [MEDICAL CONDITION] and [MEDICAL CONDITION] and an acute [MEDICAL CONDITION] femur. -under section, Description of Injury - R#2 with a new acute fracture to the proximal femur. -under section, Description of Assessment - CNAs called the nurse to make him aware of the situation and nurse did assessment at the moment. R#2 had no discoloration, no abnormalities, nor any open areas, and no complaints of pain. -under section, Provider Response: -Made MD aware of fall -Made responsible party aware -Started in-service on Hoyer lifts -One to one education done with CNAs. -under section, Investigation Summary - Spoke to the CNAs regarding the transfer with resident and stated all four latches/hooks were clicked to the Hoyer lift when all of the sudden the latch on the left came off. Record review of the hospital, History and Physical, dated 07/27/16, revealed R#2 was very confused, demented, and bedbound, with a history of bilateral AKA. R#2 was brought to the ER (emergency room ) and admitted with right femoral neck fracture. Record review of Hospital Progress Note, dated 08/03/16, revealed follow up for right [MEDICAL CONDITION], s/p (status [REDACTED]. Record review on hospital Progress Note dated, 08/22/16, under section Problem List included right femur fracture, status [REDACTED]. In an interview on 08/19/16 at 10:41 a.m., CNA N said a she did not remember the date of R#2's incident, but believed it happened at approximately 1:00 p.m. to 1:30 p.m. CNA N said R#2 was going to be transferred from the geri-chair to the bed with the use of a Hoyer lift, with the assistance of CNA O. CNA N said she used a medium size sling because of R#2's amputations. CNA N said she locked the geri-chair and hooked/latched the back hooks (near the head area) of the sling onto the Hoyer lift and CNA O latched the two front hooks (near the leg area) of the sling onto the Hoyer lift. CNA N said she ensured all the hooks were properly latched and it made a clicking noise when it latched properly. CNA N said CNA O maneuvered the Hoyer lift by slowly lifting R#2 from the ger-chair. When R#2 was elevated, CNA N unlocked the geri-chair and moved it backwards. Within seconds, R#2 fell to the floor. CNA N said she was not able to do anything or attempt to break the fall because she was moving the geri-chair out of the way to make room. CNA N said R#2 landed on her back and R#2's leg was on top of the leg (fork) of the Hoyer lift. CNA N said the sling was still attached to the Hoyer lift on three sides, but the latch on the bottom left side was unhooked. CNA N said she looked at the hook and it was not broken, just unlatched from the Hoyer lift. CNA N said that, when doing a transfer that she needed to first move the geri-chair out of the way, then she would assist in guiding the resident, in the sling, to the bed or chair. CNA N said she was not able to guide R#2 because the fall happened right away, while she was moving the geri-chair. CNA N said CNA O was not guiding the patient because she was operating the Hoyer lift. CNA N said she did not know how the fall could have happened, but believed it was because of R#2's weight distribution due to R#2's leg amputations, or R#2 might have moved while elevated, which led to the fall. In an interview on 09/06/16 at 12: 54 p.m., CNA N said she determined the size of the Hoyer sling to be used, based on the resident's weight. CNA N said she used a medium sling for R#2 and the sling was not damaged. CNA N said she checked the sling prior to using it for damage, lose threads, and holes, and checked the hooks. CNA N said that, if the sling was damaged, she would not use it, she would get a new sling. CNA N said the Charge Nurse would tell her if a resident had changes regarding the size of the sling. CNA N said she received training for transfers via her education and upon being hired at the facility. CNA N said she also received in-service trainings on proper transfers and other areas on a monthly basis. In an interview on 08/19/16 at 1:31 p.m., CNA O said R#2's incident happened on 07/27/16 at approximately 1:30 p.m. CNA O said she and CNA O were going to transfer R#2 from geri-chair to the bed with the use of a Hoyer lift. CNA O said she ensured the hooks of the sling were latched correctly, they both verified it was latched on all four sides. CNA O said she started to operate the Hoyer lift by lifting R#2 from the geri-chair . CNA N was moving the geri-chair backwards, for the Hoyer lift to work more efficiently. CNA O said the geri-chair needed to be moved to operate the Hoyer lift, and then the CNA would come back to guide the resident in the sling. CNA O said the fall happened too fast. CNA O said R#2 slipped from the sling and landed on her back on the floor. R#2's amputated leg landed on the Hoyer lift leg. CNA O said the sling became unlatched from the left side. CNA O said she informed the Charge Nurse, RN M. CNA O said she believed the incident happened because of R#2's weight distribution because R#2 did not have legs and R#2 attempting to move. On 08/19/16 at 1:40 p.m., CNA N reenacted R#2's incident, with the assistance of CNA L. Surveyor observed the gerichair to be towards the wall near bed C. CNA N checked the Hoyer lift battery and verified the sling and hooks. CNA N placed the hooks to the latch and ensure it locked correctly. CNA L moved the Hoyer lift near the gerichair. CNA L slowly started to elevate the sling, which was in a laying position. CNA N removed the gerichair from behind. Surveyor observed the sling was unattended by both staff at this time. Surveyor observed the Hoyer lift sling moved from a laying position to a sitting position immediately. At this time, CNA N said that, when the Hoyer lift sling moved to a sitting position, that was when the left hook unlatched and R#2 fell out of the sling. In an interview on 09/06/16 at 10:54 a.m., CNA O said she used a medium size sling for R#2, because of her weight. CNA O said the Charge Nurse would tell her what sling to use, depending on the resident. CNA O said, if the sling did not fit well on the resident, she would inform the Charge Nurse. CNA O said that, prior to using a sling, she checked the hooks, and checked for loose threads, holes, or worn areas, and would inform the Charge Nurse to request another sling to use. CNA O said she received her training for transfers and other ADL care at school and when she was hired at the facility. In an interview on 08/19/16 at 3:20 p.m., Licensed Vocational Nurse (LVN) P said R#2's incident happened on 07/27/16, between 1:00 p.m. and 1:15 p.m. LVN P said she was called by LVN Q to come to the room. LVN P said CNA N, CNA O, and RN M were in R#2's room. LVN P said she saw R#2 in a supine position on the floor. LVN P said CNA N and CNA O told her that R#2 slipped off the sling because the left lower latch came unlatched. LVN P said CNA N was moving the geri-chair towards the wall, while CNA O started to move the Hoyer lift and R#2 was elevated when the fall happened. LVN P said she saw that the Hoyer lift, sling, and hooks were not damaged. LVN P said R#2 was not able to voice what happened and only said, levantame (pick me up). LVN P said R#2 did not complain of pain. LVN P said R#2 started to complain of pain when EMS arrived to pick up R#2 for [MEDICAL TREATMENT] and R#2 was given pain medication, and doctor was informed and ordered x-rays. LVN P said R#2's weight went more to one side because R#2 had a right [MEDICAL CONDITION] and a left above the knee amputation in which more weight went to the right side, causing the hook to unlatch. In an interview on 08/22/16 at 9:59 a.m., Registered Nurse (RN) M said he was the Charge Nurse for R#2 on the day of the incident. RN M said he was called into R#2's room by CNA O. RN M said when he entered R#2's room, he saw R#2 was on the floor, with a pillow under R#2's head. RN M said R#2 was on the floor in between the Hoyer lift and the geri-chair. RN M said he assessed R#2 on the floor and R#2 denied having pain or discomfort. RN M said he observed the sling to be attached to the Hoyer lift with three latches only; it was unlatched on the left side bottom. RN M said the sling and hooks were intact. RN M said CNA N and CNA O told him all four latches were secured, but the left latch came unhooked when they were transferring R#2 from the geri-chair to the bed. RN M said CNA N and CNA O said it might have come unhooked due to R#2's weight. RN M said R#2 had more weight on the right side due to R#2's weight of her femur/slightly below the knee and left above the knee amputation. RN M said he spoke with LVN Q to inquire about the proper procedures when an incident happened. RN M said R#2 was re-assessed by LVN P and then transferred by four person transfer to the bed. RN M said he did not ask who placed the pillow underneath R#2's head, but believed it was one of the CNAs. RN M said when incidents happened, the staff was educated to not move the patient, for the resident's safety. In an interview on 08/22/16 at 10:33 a.m., CNA N said she placed the pillow underneath R#2's head because she got scared regarding R#2's fall and wanted to keep R#2 comfortable. CNA N said she knew that she was not to move a resident after a fall, until the Charge Nurse told her. In an interview on 08/22/16 at 1:39 p.m., surveyor attempted to interview R#2 at the hospital, however R#2 said she felt weak. Surveyor observed R#2 to be nonresponsive and lethargic. In an interview on 08/23/16 at 8:02 a.m., the Maintenance Director said he was not notified to check the Hoyer lift regarding R#2's incident. The Maintenance Director said he heard about the incident through CNAs commenting about it. The Maintenance Director said he did not have a specific schedule when he inspected the Hoyer lifts. The Maintenance Director said the nursing staff informed him verbally, or by documenting on the maintenance log kept at each of the nurses' stations, to check the Hoyer lift and if needed, repair it. The Maintenance Director said the facility had six to seven Hoyer lifts. In an interview on 08/23/16 at 8:20 a.m., LVN P said she did not tell Maintenance to check the Hoyer lift after R#2's incident. LVN P said R#2's incident was discussed during the morning meeting and Maintenance was aware. LVN P said she did not know if Maintenance checked the Hoyer lift. Surveyor inquired about R#2 having a pillow placed underneath her head. LVN P said she was unaware a pillow was placed under R#2 after the incident occurred. LVN P said CNAs were not allowed to move a resident after a fall because the Charge Nurse needed to assess first for the resident's safety. In an interview on 09/06/16 at 1:15 p.m., LVN P said R#2 used a medium size sling because of the resident's weight. LVN P said the CNA staff and Charge Nurses could both determine what color of sling to use for a resident. LVN P said the color was red for a small sling, yellow for a medium sling, green for a large sling, and purple for an extra-large sling. LVN P said she did not believe the CNAs needed to inform the Charge Nurse when a different color of sling was used. LVN P said there was no documentation of what color of slings were being used for the residents. LVN P said the nursing staff would check for proper fit (not too loose or too tight) and use the sling that best fit the resident. LVN P said R#2's sling was not damaged and was in good condition, and that staff continued to use the sling for other residents. In an interview on 08/23/16 at 10:21 a.m., the Director of Nursing (DON) said R#2 was a two person transfer with the use of a Hoyer lift. The DON said R#2 was being transferred from geri-chair to bed when R#2 fell to the floor. The DON said R#2 was elevated on the Hoyer lift when the CNA moved the geri-chair, and R#2 fell . The DON said R#2's incident was an accident because R#2 tended to move more to the right side of her body. The DON said R#2 was assessed by RN M and LVN P. The DON said LVN P checked the sling and hook and it was intact. The DON said EMS transportation arrived for R#2's [MEDICAL TREATMENT] appointment and EMS transportation did not want to transport R#2 to [MEDICAL TREATMENT] because R#2 complained of pain. The DON said R#2's doctor was contacted again and x-rays were ordered. The DON said results of x-rays results were received and R#2 was sent to the hospital. The DON said it was an accident because the Hoyer lift was used in the morning and there were no issues reported with the Hoyer lift, the CNAs' stories were consistent regarding the incident, and the CNAs transferred R#2 correctly. The DON said that, when transferring using a Hoyer, the first CNA would operate the Hoyer lift. The second CNA would move the geri-chair out of the area, then assist to guide the patient to a safe position. The DON said residents could not be moved when an incident happened and the CNAs were not allowed to move the patient, to avoid further injuries. The DON said she did not know R#2 had a pillow placed underneath her head after the incident happened. The DON said new employees are required to watch videos for General Orientation and the staff is monitored throughout the 90 day probation. The DON said staff was re-trained if needed and if staff continued to be non-complaint with CNA responsibilities, would not continue with employment. The DON said during the 90 day period, the staff was monitored and observed by nursing administration. Staff was corrected and re-inserviced. The DON said there is no documentation on how staff was monitored other than the competency skills done yearly. In an interview on 09/06/16 at 8:59 a.m., the Director of Rehab said R#2 was not assessed for occupational or physical therapy because there were no orders for R#2 to be evaluated for rehab services. The Director of Rehab said the nursing department trained the CNAs for Hoyer lift transfers. The Director of Rehab said R#2's care was discussed during the IDT meetings and R#2's medical condition was stable from the last time she was at the facility. The Director of Rehab said no staff reported difficulty in transferring R#2. The Director of Rehab said, from her experience, she was not aware if there was a specific sling or Hoyer lift to be used for patients who had amputations. In an interview on 09/06/16 at 10:35 a.m., Central Supply staff said she checked the slings for damage daily and as needed. The Central Supply staff said there was no documentation to show she was checking the slings. The Central Supply staff said the CNAs checked the slings for damage and wear/tear. In an interview on 09/06/16 at 10:21 a.m., the DON said the CNAs checked daily if the Hoyer lift and sling were working. The DON said the CNAs checked the slings for any damage, like holes, loose threads, and fraying, and are told not to use the slings if they are damaged. The DON said a damaged sling would be replaced with a new sling. The DON said R#2 was not assessed for rehab services because no orders were needed as there was no change in her condition. The DON said there were no issues in transferring R#2 prior to the incident. The DON said no staff reported having difficulty in transferring R#2. The DON said she was unaware of the use of slings designed specifically for residents with amputations; the facility had always used the regular slings. The DON said that, upon admission, a resident was weighed and assessed to determine the use of a Hoyer lift by the Charge Nurse. The DON said the CNAs determined what color of sling to use based the resident's weight. Record review of the facility's policy, Lifting Machine, Using a Portable, revised October 2010, revealed: -The purpose of this procedure is to help lift resident using a manual lifting device. -Steps in the Procedure included: .3. Transfer a resident from chair to bed, you should: g. Move the lifter away from the chair Record review of facility's Safety and Supervision of Residents, revised December 2007, under section Policy Statement revealed the following: Record review of the facility's policy, Safety and Supervision of Residents, revised December 2007, revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision to prevent accidents are facility-wide priorities . 1. Our facility-oriented approach to safety address risks for groups of residents. 2. Safety risks and environmental hazards are identified on an on-going basis through a combination of employee training, employee monitoring, and reporting process; QA&A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QA&A/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained and inserviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents . Record review of the facility's policy, Use of Slings for Transfer, dated 12/04/14, revealed: -Slings are used for the safety and well-being of the resident(s). Slings are used to address the special needs of the resident according to care plan. -1. 'Slings' are defined as a canvas needed to cradle resident to provide safe transfer from surfaces. 2. 'Slings' should be attached as per manufacturer recommendations on weight. 3. 'Slings' are checked by staff as they perform care prior, during, and post care. -Section on Maintenance of Slings indicated: 1. 'Slings' are checked by staff while care is provided. Abnormalities, will be reported to charge nurse or central supply. 2. 'Slings' are monitored by central supply designee on a weekly basis and as needed for checking of sling abnormalities or malfunction. Record review of the facility's undated policy, Reusable Slings Standard and Fullback, revealed, The slings are approved for a load of 300 Kg (660 lbs) or 500 Kg (1100 lbs) for the extra extra large size sling. SLING MUST BE INSPECTED EACH AND EVERY TIME BEFORE BEING APPLIED ON RESIDENT FOR ANY WEAR OR TEAR. IN THIS CASE DISPOSE OF THE SLING. 2) Record review of R#1's Admission Record Sheet, dated 05/19/16, revealed R#1 was admitted to the facility on [DATE]. Record review of R#1's August 2016 Physician order [REDACTED]. Record review of R#1's Quarterly MDS assessment, dated 07/29/16, revealed R#1: -had highly impaired hearing, -had unclear speech, -was rarely/never understood by others and was rarely/never able to understand others, -had highly impaired vision, -had short and long term memory problems, -was severely impaired for daily decision making, -required total assistance of two staff for bed mobility, transfer, dressing, toilet use, and bathing, and -had range of motion impairment to both sides of upper and lower extremities. Record review of R#1's Care Plan, dated 08/10/16, revealed R#1 had ADL (activities of daily living) self-care performance deficit related to Dementia, Limited Mobility, and Alzheimer's. Intervention/Tasks indicated R#1 was totally dependent on two staff with Hoyer lift (mechanical lift) for all transferring. Record review of the facility's, Morse Fall Scale, dated 08/04/16, revealed R#1 scored 30 on the evaluation. The Morse Fall Scale form indicated the category of moderate risk for falling. On 08/19/16 at 4:31 p.m., surveyor observed R#1's room door to be closed. Surveyor knocked on R#1's door prior to entering R#1's room and observed the privacy curtain closed. Surveyor asked the staff what type of care was being provided. CNA D said they were about to transfer R#1. Surveyor observed R#1 lying on the bed. CNA D and CNA E placed the lift sling from the left side first, rolled R#1 over to place the sling to the right side. CNA D placed the Hoyer lift near the bed and latched the hook onto the Hoyer lift then she re-checked the hooks latched. CNA D slowly lifted the Hoyer lift with R#1 on the sling and CNA E guided R#1 towards the wheelchair. Surveyor observed the wheelchair wheels were unlocked, CNA D operated the Hoyer lift while R#1 was being slowly brought down, to position R#1 in the wheelchair. CNA D was holding onto the boom of the Hoyer lift, while CNA E attempted four times to place R#1's wheelchair in a position for the transfer. The wheelchair wheels remained unlocked. CNA E positioned wheelchair properly and was standing behind the unlocked wheelchair while R#1 was positioned on to the wheelchair. In an interview on 08/19/16 at 4:40 p.m., CNA D and CNA E said the wheelchair wheels should be locked at all times for resident safety, to prevent falls or injuries. CNA D and CNA E said they forgot to lock the wheelchair. In an interview on 08/19/16 at 4:42 p.m., surveyor attempted to interview R#1, however R#1 did not respond. In an interview on 08/19/16 at 4:48 p.m., LVN F said that, when transferring a resident, the wheelchair needed to be locked for resident safety at all times. In an interview on 08/23/16 at 10:21 a.m., the DON said wheelchairs and geri-chairs were to be locked at all times, because the wheelchair/geri-chairs could move, causing injury to the resident. Record review of the facility's policy, Lifting Machine, Using a Portable, revised October 2010, revealed: -The purpose of this procedure is to help lift resident using a manual lifting device. -Steps in the Procedure included: 3. Transfer a resident from bed to chair, you should: a. Position the chair. If it is a wheelchair, be sure the wheels are locked . The facility provided an undated list which indicated 35 residents who were transferred with a Hoyer lift.

Based on observation, interview, and record review, the facility failed to ensure that a resident who entered the facility with a pressure ulcer received the necessary care and services to promote healing and prevent the development of new ulcers, for one of five Sample Residents with pressure ulcers (SR#2). SR#2 had three Stage 2 pressure ulcers on his coccyx on 03/07/11. SR#2's written plan of care indicated to avoid having SR#2 sit on the gerichair for more than one hour and change and reposition SR#2 every two hours. On 03/21/11 SR#2 sat on the gerichair for more than two hours. From 03/21/11 to 03/22/11 SR#2 developed seven more Stage 2 pressure ulcers to his coccyx. Failure to provide services to promote pressure ulcer healing and prevent pressure ulcers from developing could place the nine facility-identified residents with pressure ulcers at risk for worsening of existing pressure ulcers or development of new pressure ulcers. Findings included: SR#2's Face Sheet revealed SR#2 was originally admitted to the facility on [DATE]. SR#2's Physician's History and Physical dated 06/18/10 indicated [DIAGNOSES REDACTED]. Facility Braden Scale For Predicting Pressure Sore Risk in Home Care dated 08/17/10 indicated SR#2 had a total score of eight on the Braden Scale. The score key of the Braden Scale indicated a score of nine or below indicated Severe Risk for pressure sores. SR#2's Care Plan Conference Summary dated 09/22/10 indicated SR#2 had no pressure ulcers. SR#2's Care Plan dated 09/22/10 and reviewed 12/15/10 revealed he was at risk for skin breakdown secondary to immobility and bowel incontinence. The care plan goal was to maintain good skin integrity for 90 days. The care plan interventions indicated to turn and reposition every two hours and to avoid having resident up in the gerichair longer than one hour at a time. SR#2's Care Plan Conference Summary dated 12/15/10 indicated SR#2 had no pressure ulcers. SR#2's Minimum Data Set (MDS) Resident Assessment And Care Screening dated 01/07/11 indicated SR#2: - was in a, "persistent vegetative state/no discernible consciousness", - had impaired mobility on both sides, upper and lower extremities, - was totally dependent on staff for activities of daily living (ADLs - i.e. dressing, transfers, mobility, locomotion, eating), - was incontinent of bladder and bowel, - had active [DIAGNOSES REDACTED]. - received nutrition via feeding tube (tube surgically inserted through the abdomen and into the stomach for provision of fluids, nutrition, and medications, - had no pressure ulcers, - had pressure reducing devices for chair and bed, - was on a turning/repositioning program, and, - had application of ointments/medications other than to feet. SR#2's Weekly Summary Nursing assessment dated [DATE] indicated SR#2 had no pressure ulcers (under Skin Conditions Assessment). Nurses Notes dated 02/07/11 at 3:00 a.m. indicated SR#2 was noted with a "coccyx sore." Nurses Notes further documented that the skin protocol was initiated, wound treatment was provided and a message was left with SR#2's Physician. SR#2's weekly skin assessment dated [DATE] indicated SR#2's pressure ulcer was newly acquired, acute and this was the initial assessment of the pressure ulcer. SR#2's (Product Name) Wound Assessment System dated 02/07/11 indicated a, "Newly Acquired", "open area to coccyx" with no drainage, no odor, periwound clear, and wound base red. SR#2's (Product Name) Wound Assessment System dated 02/07/11 showed wound location was on SR#2's coccyx, with a dressing in place. No measurements were documented. The nurse's note narrative for the assessment indicated, "Resident to be repositioned every two hours and or as needed." Telephone Order dated 02/07/11 at 7:00 a.m. for SR#2 indicated to apply [MEDICATION NAME] ointment to coccyx skin twice a day until healed. An initial Care Plan/Protocol for Loss Of Skin Integrity dated 02/06/11 was initiated and signed and dated 02/07/11. The Care Plan/Protocol for Loss of Skin Integrity Approach/Plan indicated as follows: 1. Notify M.D. (Medical Doctor) and family of change in condition. 2. Assess skin condition and document in resident chart. 3. Wash hands prior to and post providing care to resident. 4. Treat affected areas as ordered by physician (skin care protocol if applicable). 5. Observe for signs of infection daily; (redness, swelling, warm to touch, tenderness, and drainage. If symptoms are present, notify M.D...." SR#2's Nursing Admission assessment dated [DATE] at 6:30 p.m. indicated SR#2 had a Stage 2 pressure ulcer on the coccyx (Stage 2 - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.). SR#2's weekly skin assessment dated [DATE] indicated two new pressure ulcers had developed on SR#2's coccyx and treatment continued to be the same. First pressure ulcer measurements were 0.4 centimeters (cm) x 1.4 cm (pressure ulcer not previously documented). Second pressure ulcer measured 1.0 cm x 0.9 cm (pressure ulcer previously documented). Third pressure ulcer measured 0.4 cm x 1.7 cm (pressure ulcer not previously documented). There was no documentation to indicate SR#2's Physician was made aware of the two newly developed pressure ulcers. The assessment also contained no new recommendations for treatment. SR#2's (Product Name) Wound Assessment System dated 03/21/11 indicated SR#2 had three pressure ulcers on the coccyx. On 03/22/11 at 10:45 a.m., surveyor and Wound Care nurse/Licensed Vocational Nurse (LVN) "F" reviewed SR#2's medical record and it was noted that SR#2 had developed pressure ulcers in the facility. Surveyor asked LVN "F" why SR#2's Physician was not made aware of the two new pressure ulcers found on 03/07/11. LVN "F" said she thought SR#2 had developed the two (new at the time of 03/07/11) pressure ulcers at the hospital (SR#2 was admitted to the hospital from 02/07/11 to 02/23/11). LVN "F" said she must have gotten confused about where SR#2 had developed the pressure ulcers. On 03/21/11 at 11:45 a.m. surveyor observed SR#2 sitting on a gerichair in his room. The gerichair was not equipped with any pressure relief device/cushion. On 03/21/11 at 12:00 p.m., in an interview with SR#2's Responsible Party (RP) "X", RP "X" said SR#2 had been sitting on the gerichair since she arrived at 10:30 a.m. that morning. RP "X" said Certified Nurse Aide (CNA) staff told her SR#2 had been sitting on the gerichair that long because "they" had been waxing the floors. On 03/22/11 at 9:45 a.m., during wound care for SR#2, CNA "E" and CNA "W", who worked on 03/21/11, were present in the room assisting the wound care nurse. An interview with CNA "E" and CNA "W" was conducted. Wound Care Nurse, (LVN "F") was present in the room when surveyor interviewed CNA "E" and CNA "W." Surveyor asked CNA "E" and CNA "W" why SR#2 had been sitting on the gerichair from 11:00 a.m. to the time surveyor observed SR#2 to be on the gerichair at 12:00 p.m. on 03/21/11. CNA "E" said they had put SR#2 back into bed at 1:00 p.m. on 03/21/11. Surveyor asked CNA "E" and CNA "W" if they were aware SR#2 was not to sit on the gerichair longer than one hour. CNA "E" said they were aware but staff was waxing the floors at the time and could not put SR#2 back into bed. Surveyor explained to CNA "E" and "W" that surveyor had observed SR#2 on the gerichair in his room and no one had been waxing the floors. CNA "E" and "W" both said at that time they were in the dining room assisting residents with their meals. CNA "E" said after they were finished in the dining room on 03/21/11, they went and put SR#2 back into bed. LVN "F" said the next time staff could wait to have the floors waxed and or place SR#2 back into bed instead of leaving SR#2 in the gerichair longer than one hour. On 03/22/11 at 09:45 a.m., surveyor observed SR#2's skin condition with LVN "F." It was noted SR#2 had seven new pressure ulcers on the coccyx. Surveyor observed 10 Stage 2 pressure ulcers on SR#2's coccyx. Surveyor observed the pressure ulcers' surrounding tissue was macerated white-grayish in color, wound bases were red. LVN "F" said the areas were "open areas" and traced the areas onto the transparent Wound Skin Assessment Graph. LVN "F" did not measure the areas. Surveyor measured the areas after being traced unto the graph. The measurements were as follows: 1) pressure ulcer on the sacral area measured 0.5 cm x 0.4 cm. 2) pressure ulcer on the coccyx measured 2.0 cm x 1.5 cm. 3) pressure ulcer located on the coccyx and right inner buttock area measured 1.0 cm x 0.6 cm. 4) pressure ulcer on the right upper inner buttock area measured 0.9 cm x 0.6 cm. 5) another pressure ulcer on the right upper inner buttock area measured 0.4 cm x 0.3 cm. 6) pressure ulcer on the right buttock area measure 1.0 cm x 1.0 cm. 7) another pressure ulcer on the right buttock area measured 0.6 cm x 0.5 cm. 8) pressure ulcer on the coccyx and left buttock area measured 0.6 cm x 0.4 cm. 9) another pressure ulcer on the coccyx and left buttock area measured 0.7 cm x 0.4 cm. 10) another pressure ulcer on the left buttock area measured 1.9 cm x 0.5 cm. Surveyor asked LVN "F" if the open areas were pressure ulcers and LVN "F" said "yes." LVN "F" said she had done SR#2's wound care the day before (03/21/11) and SR#2 had only three pressure ulcers. LVN "F" said the seven other pressure ulcers were new. During this time, surveyor asked CNA "E" and CNA "W" if SR#2 had the seven pressure ulcers on his coccyx on 03/21/11 and they both said, "no." On 03/22/11 LVN "F" documented on SR#2's 03/22/11 Wound Skin Assessment Graph that SR#2 had Stage 2 Pressure Ulcers and initiated another care plan as per doctor orders, which specified to reposition SR#2 every hour, avoid having SR#2 up on gerichair for more than one hour, to place an air-mattress in bed and a gel-cushion for the gerichair. LVN "F" documented on SR#2's (Product Name) Wound Assessment System dated 03/22/11 and indicated SR#2 had 10 Stage 2 pressure ulcers to the coccyx (the seven new ones and the three pressure ulcers that were previously documented on). The pressure ulcers were described to have no tunneling, no slough (layer of dead tissue separated from surrounding living tissue), no odor, wound base was red and there was maceration to surrounding tissue. No measurements were documented. On 03/22/11, LVN "F" called and notified SR#2's Physician of the above new findings and obtained new orders. SR#2's Telephone Orders dated 03/22/11 at 1:00 p.m. indicated: - Air mattress daily due to "Stage 2 wounds." - "Egg Crate" to gerichair due to "Stage 2 wounds." - Vitamin C 500 mg (milligram) one table via [DEVICE] ([MEDICAL CONDITION] tube). - Zinc 220 mg one table via [DEVICE] ([MEDICAL CONDITION] tube). Interview with the Director of Nurses (DON) on 03/22/11 at 10:50 a.m. revealed nursing staff should have put SR#2 into bed from the gerichair and repositioned as care planned to promote pressure ulcer healing and or prevent pressure ulcer development. On 04/04/11 at 11:40 a.m., surveyor asked LVN "F" how SR#2 developed the seven new pressure ulcers on the coccyx on 03/22/11. LVN "F" said from the length of time SR#2 was sitting on the gerichair (more than two hours). On 04/05/11 at 9:00 a.m., interview with LVN "F" revealed the facility had decided the "open areas" on SR#2's coccyx on 03/22/11 were not pressure ulcers but were, "open areas" caused by excoriation, which was caused by friction shear. An interview with the DON, the Assistant Director of Nurses (ADON) "A" and LVN "F" on 04/05/11 at 9:40 a.m. revealed SR#2 developed the "open areas" on 03/22/11 by "a combination of things" which included sitting on the chair longer than SR#2 was supposed to, from being incontinent of stool at that time "too long" and the "heat and moisture" from the incontinent brief. Facility Policy and Procedures for Skin and Wound Management for Prevention of Pressure Ulcers and General Preventive Measures (Revised October 2010) indicated as follows: 3. For a person in a chair: a. Change position at least every hour; b. Use foam, gel or air cushion as indicated to relieve pressure. Facility Policy and Procedures for Skin and Wound Management for Residents with Risk Factors (Revised October 2010) indicated as follows: 3. Risk Factor -- Bedfast a. Change position at least every two hours and more frequently as needed. 4. Risk Factor -- Chairfast c. Change position at least every hour. 5. Risk Factor -- Immobility a. See bed-fast and chair-fast. 8. Risk Factor -- Lowered Mental Awareness a. Choose preventive actions appropriate to individual risk factors and adjust for cognitive impairment of the resident. Facility Policy and Procedures for Skin and Wound Management Pressure Ulcer Treatment Definitions and Descriptions defined a Stage 2 Pressure Ulcer as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister providing a further description indicating it presents "as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation...." (Revised October 2010). Surveyor requested the facility policy regarding the facility's definitions of pressure ulcer, excoriation, and friction shear. A policy was provided on 04/06/11 at 11:40 a.m. by the DON. Facility Classification of Skin Issues indicated as follows: "1) Pressure Area - Skin breakdown at a pressure point due to lack of circulation A) Usually occurs when resident stays in same position for extended period of time 2) Excoriation - Area of skin which can become open superficially almost like an abrasion A) Can also be caused by scratching 3) Friction Shear - Friction is the rubbing of two surfaces which causes shearing of the skin. A) When repositioning resident and pulling the pad up can cause the friction shear to the skin." After surveyor reviewed the Classification of Skin Issues provided, signed and dated 04/06/11 by the DON, an interview with the DON was conducted. The DON said after she reviewed the Classification of Skin Issues, SR#2's previously documented "excoriation" of the skin on the coccyx (which were described as "open areas" and "excoriation") were not seven excoriations of the skin, but were seven "pressure ulcers." At the time of exit on 04/07/11 at 5:00 pm., the facility was given the opportunity to provide further information concerning the development of SR#2's ten pressure ulcers. No additional information was provided. Review of the facility's CMS 672 form revealed nine residents were identified with pressure ulcers.

Based on observation, interview, and record review, the facility failed to ensure that a resident who entered the facility with a pressure ulcer received the necessary care and services to promote healing and prevent the development of new ulcers, for one of five Sample Residents with pressure ulcers (SR#2). SR#2 had three Stage 2 pressure ulcers on his coccyx on 03/07/11. SR#2's written plan of care indicated to avoid having SR#2 sit on the gerichair for more than one hour and change and reposition SR#2 every two hours. On 03/21/11 SR#2 sat on the gerichair for more than two hours. From 03/21/11 to 03/22/11 SR#2 developed seven more Stage 2 pressure ulcers to his coccyx. Failure to provide services to promote pressure ulcer healing and prevent pressure ulcers from developing could place the nine facility-identified residents with pressure ulcers at risk for worsening of existing pressure ulcers or development of new pressure ulcers. Findings included: SR#2's Face Sheet revealed SR#2 was originally admitted to the facility on [DATE]. SR#2's Physician's History and Physical dated 06/18/10 indicated [DIAGNOSES REDACTED]. Facility Braden Scale For Predicting Pressure Sore Risk in Home Care dated 08/17/10 indicated SR#2 had a total score of eight on the Braden Scale. The score key of the Braden Scale indicated a score of nine or below indicated Severe Risk for pressure sores. SR#2's Care Plan Conference Summary dated 09/22/10 indicated SR#2 had no pressure ulcers. SR#2's Care Plan dated 09/22/10 and reviewed 12/15/10 revealed he was at risk for skin breakdown secondary to immobility and bowel incontinence. The care plan goal was to maintain good skin integrity for 90 days. The care plan interventions indicated to turn and reposition every two hours and to avoid having resident up in the gerichair longer than one hour at a time. SR#2's Care Plan Conference Summary dated 12/15/10 indicated SR#2 had no pressure ulcers. SR#2's Minimum Data Set (MDS) Resident Assessment And Care Screening dated 01/07/11 indicated SR#2: - was in a, "persistent vegetative state/no discernible consciousness", - had impaired mobility on both sides, upper and lower extremities, - was totally dependent on staff for activities of daily living (ADLs - i.e. dressing, transfers, mobility, locomotion, eating), - was incontinent of bladder and bowel, - had active [DIAGNOSES REDACTED]. - received nutrition via feeding tube (tube surgically inserted through the abdomen and into the stomach for provision of fluids, nutrition, and medications, - had no pressure ulcers, - had pressure reducing devices for chair and bed, - was on a turning/repositioning program, and, - had application of ointments/medications other than to feet. SR#2's Weekly Summary Nursing assessment dated [DATE] indicated SR#2 had no pressure ulcers (under Skin Conditions Assessment). Nurses Notes dated 02/07/11 at 3:00 a.m. indicated SR#2 was noted with a "coccyx sore." Nurses Notes further documented that the skin protocol was initiated, wound treatment was provided and a message was left with SR#2's Physician. SR#2's weekly skin assessment dated [DATE] indicated SR#2's pressure ulcer was newly acquired, acute and this was the initial assessment of the pressure ulcer. SR#2's (Product Name) Wound Assessment System dated 02/07/11 indicated a, "Newly Acquired", "open area to coccyx" with no drainage, no odor, periwound clear, and wound base red. SR#2's (Product Name) Wound Assessment System dated 02/07/11 showed wound location was on SR#2's coccyx, with a dressing in place. No measurements were documented. The nurse's note narrative for the assessment indicated, "Resident to be repositioned every two hours and or as needed." Telephone Order dated 02/07/11 at 7:00 a.m. for SR#2 indicated to apply [MEDICATION NAME] ointment to coccyx skin twice a day until healed. An initial Care Plan/Protocol for Loss Of Skin Integrity dated 02/06/11 was initiated and signed and dated 02/07/11. The Care Plan/Protocol for Loss of Skin Integrity Approach/Plan indicated as follows: 1. Notify M.D. (Medical Doctor) and family of change in condition. 2. Assess skin condition and document in resident chart. 3. Wash hands prior to and post providing care to resident. 4. Treat affected areas as ordered by physician (skin care protocol if applicable). 5. Observe for signs of infection daily; (redness, swelling, warm to touch, tenderness, and drainage. If symptoms are present, notify M.D...." SR#2's Nursing Admission assessment dated [DATE] at 6:30 p.m. indicated SR#2 had a Stage 2 pressure ulcer on the coccyx (Stage 2 - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.). SR#2's weekly skin assessment dated [DATE] indicated two new pressure ulcers had developed on SR#2's coccyx and treatment continued to be the same. First pressure ulcer measurements were 0.4 centimeters (cm) x 1.4 cm (pressure ulcer not previously documented). Second pressure ulcer measured 1.0 cm x 0.9 cm (pressure ulcer previously documented). Third pressure ulcer measured 0.4 cm x 1.7 cm (pressure ulcer not previously documented). There was no documentation to indicate SR#2's Physician was made aware of the two newly developed pressure ulcers. The assessment also contained no new recommendations for treatment. SR#2's (Product Name) Wound Assessment System dated 03/21/11 indicated SR#2 had three pressure ulcers on the coccyx. On 03/22/11 at 10:45 a.m., surveyor and Wound Care nurse/Licensed Vocational Nurse (LVN) "F" reviewed SR#2's medical record and it was noted that SR#2 had developed pressure ulcers in the facility. Surveyor asked LVN "F" why SR#2's Physician was not made aware of the two new pressure ulcers found on 03/07/11. LVN "F" said she thought SR#2 had developed the two (new at the time of 03/07/11) pressure ulcers at the hospital (SR#2 was admitted to the hospital from 02/07/11 to 02/23/11). LVN "F" said she must have gotten confused about where SR#2 had developed the pressure ulcers. On 03/21/11 at 11:45 a.m. surveyor observed SR#2 sitting on a gerichair in his room. The gerichair was not equipped with any pressure relief device/cushion. On 03/21/11 at 12:00 p.m., in an interview with SR#2's Responsible Party (RP) "X", RP "X" said SR#2 had been sitting on the gerichair since she arrived at 10:30 a.m. that morning. RP "X" said Certified Nurse Aide (CNA) staff told her SR#2 had been sitting on the gerichair that long because "they" had been waxing the floors. On 03/22/11 at 9:45 a.m., during wound care for SR#2, CNA "E" and CNA "W", who worked on 03/21/11, were present in the room assisting the wound care nurse. An interview with CNA "E" and CNA "W" was conducted. Wound Care Nurse, (LVN "F") was present in the room when surveyor interviewed CNA "E" and CNA "W." Surveyor asked CNA "E" and CNA "W" why SR#2 had been sitting on the gerichair from 11:00 a.m. to the time surveyor observed SR#2 to be on the gerichair at 12:00 p.m. on 03/21/11. CNA "E" said they had put SR#2 back into bed at 1:00 p.m. on 03/21/11. Surveyor asked CNA "E" and CNA "W" if they were aware SR#2 was not to sit on the gerichair longer than one hour. CNA "E" said they were aware but staff was waxing the floors at the time and could not put SR#2 back into bed. Surveyor explained to CNA "E" and "W" that surveyor had observed SR#2 on the gerichair in his room and no one had been waxing the floors. CNA "E" and "W" both said at that time they were in the dining room assisting residents with their meals. CNA "E" said after they were finished in the dining room on 03/21/11, they went and put SR#2 back into bed. LVN "F" said the next time staff could wait to have the floors waxed and or place SR#2 back into bed instead of leaving SR#2 in the gerichair longer than one hour. On 03/22/11 at 09:45 a.m., surveyor observed SR#2's skin condition with LVN "F." It was noted SR#2 had seven new pressure ulcers on the coccyx. Surveyor observed 10 Stage 2 pressure ulcers on SR#2's coccyx. Surveyor observed the pressure ulcers' surrounding tissue was macerated white-grayish in color, wound bases were red. LVN "F" said the areas were "open areas" and traced the areas onto the transparent Wound Skin Assessment Graph. LVN "F" did not measure the areas. Surveyor measured the areas after being traced unto the graph. The measurements were as follows: 1) pressure ulcer on the sacral area measured 0.5 cm x 0.4 cm. 2) pressure ulcer on the coccyx measured 2.0 cm x 1.5 cm. 3) pressure ulcer located on the coccyx and right inner buttock area measured 1.0 cm x 0.6 cm. 4) pressure ulcer on the right upper inner buttock area measured 0.9 cm x 0.6 cm. 5) another pressure ulcer on the right upper inner buttock area measured 0.4 cm x 0.3 cm. 6) pressure ulcer on the right buttock area measure 1.0 cm x 1.0 cm. 7) another pressure ulcer on the right buttock area measured 0.6 cm x 0.5 cm. 8) pressure ulcer on the coccyx and left buttock area measured 0.6 cm x 0.4 cm. 9) another pressure ulcer on the coccyx and left buttock area measured 0.7 cm x 0.4 cm. 10) another pressure ulcer on the left buttock area measured 1.9 cm x 0.5 cm. Surveyor asked LVN "F" if the open areas were pressure ulcers and LVN "F" said "yes." LVN "F" said she had done SR#2's wound care the day before (03/21/11) and SR#2 had only three pressure ulcers. LVN "F" said the seven other pressure ulcers were new. During this time, surveyor asked CNA "E" and CNA "W" if SR#2 had the seven pressure ulcers on his coccyx on 03/21/11 and they both said, "no." On 03/22/11 LVN "F" documented on SR#2's 03/22/11 Wound Skin Assessment Graph that SR#2 had Stage 2 Pressure Ulcers and initiated another care plan as per doctor orders, which specified to reposition SR#2 every hour, avoid having SR#2 up on gerichair for more than one hour, to place an air-mattress in bed and a gel-cushion for the gerichair. LVN "F" documented on SR#2's (Product Name) Wound Assessment System dated 03/22/11 and indicated SR#2 had 10 Stage 2 pressure ulcers to the coccyx (the seven new ones and the three pressure ulcers that were previously documented on). The pressure ulcers were described to have no tunneling, no slough (layer of dead tissue separated from surrounding living tissue), no odor, wound base was red and there was maceration to surrounding tissue. No measurements were documented. On 03/22/11, LVN "F" called and notified SR#2's Physician of the above new findings and obtained new orders. SR#2's Telephone Orders dated 03/22/11 at 1:00 p.m. indicated: - Air mattress daily due to "Stage 2 wounds." - "Egg Crate" to gerichair due to "Stage 2 wounds." - Vitamin C 500 mg (milligram) one table via [DEVICE] ([MEDICAL CONDITION] tube). - Zinc 220 mg one table via [DEVICE] ([MEDICAL CONDITION] tube). Interview with the Director of Nurses (DON) on 03/22/11 at 10:50 a.m. revealed nursing staff should have put SR#2 into bed from the gerichair and repositioned as care planned to promote pressure ulcer healing and or prevent pressure ulcer development. On 04/04/11 at 11:40 a.m., surveyor asked LVN "F" how SR#2 developed the seven new pressure ulcers on the coccyx on 03/22/11. LVN "F" said from the length of time SR#2 was sitting on the gerichair (more than two hours). On 04/05/11 at 9:00 a.m., interview with LVN "F" revealed the facility had decided the "open areas" on SR#2's coccyx on 03/22/11 were not pressure ulcers but were, "open areas" caused by excoriation, which was caused by friction shear. An interview with the DON, the Assistant Director of Nurses (ADON) "A" and LVN "F" on 04/05/11 at 9:40 a.m. revealed SR#2 developed the "open areas" on 03/22/11 by "a combination of things" which included sitting on the chair longer than SR#2 was supposed to, from being incontinent of stool at that time "too long" and the "heat and moisture" from the incontinent brief. Facility Policy and Procedures for Skin and Wound Management for Prevention of Pressure Ulcers and General Preventive Measures (Revised October 2010) indicated as follows: 3. For a person in a chair: a. Change position at least every hour; b. Use foam, gel or air cushion as indicated to relieve pressure. Facility Policy and Procedures for Skin and Wound Management for Residents with Risk Factors (Revised October 2010) indicated as follows: 3. Risk Factor -- Bedfast a. Change position at least every two hours and more frequently as needed. 4. Risk Factor -- Chairfast c. Change position at least every hour. 5. Risk Factor -- Immobility a. See bed-fast and chair-fast. 8. Risk Factor -- Lowered Mental Awareness a. Choose preventive actions appropriate to individual risk factors and adjust for cognitive impairment of the resident. Facility Policy and Procedures for Skin and Wound Management Pressure Ulcer Treatment Definitions and Descriptions defined a Stage 2 Pressure Ulcer as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister providing a further description indicating it presents "as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation...." (Revised October 2010). Surveyor requested the facility policy regarding the facility's definitions of pressure ulcer, excoriation, and friction shear. A policy was provided on 04/06/11 at 11:40 a.m. by the DON. Facility Classification of Skin Issues indicated as follows: "1) Pressure Area - Skin breakdown at a pressure point due to lack of circulation A) Usually occurs when resident stays in same position for extended period of time 2) Excoriation - Area of skin which can become open superficially almost like an abrasion A) Can also be caused by scratching 3) Friction Shear - Friction is the rubbing of two surfaces which causes shearing of the skin. A) When repositioning resident and pulling the pad up can cause the friction shear to the skin." After surveyor reviewed the Classification of Skin Issues provided, signed and dated 04/06/11 by the DON, an interview with the DON was conducted. The DON said after she reviewed the Classification of Skin Issues, SR#2's previously documented "excoriation" of the skin on the coccyx (which were described as "open areas" and "excoriation") were not seven excoriations of the skin, but were seven "pressure ulcers." At the time of exit on 04/07/11 at 5:00 pm., the facility was given the opportunity to provide further information concerning the development of SR#2's ten pressure ulcers. No additional information was provided. Review of the facility's CMS 672 form revealed nine residents were identified with pressure ulcers.