Every finding on record at Schleicher County Medical Center

Based on observation, interview, and record review the facility failed to ensure residents were free from misappropriation of property from 6 (Resident #1, Resident #7, Resident #8, Resident #9, Resident #11, Resident #12) of 8 residents reviewed. The facility failed to prevent LVN H from taking narcotics from Resident #1, Resident #7, Resident #8, Resident #9, Resident #11, and Resident #12.This failure could place residents at risk of continued misappropriation of property, increased pain, and lost trust in facility staff.Findings included:Resident #1Record review of Resident #1's face sheet dated 8/4/2026, revealed an [AGE] year-old female admitted to facility on 8/16/2023. Resident #1 was diagnosed with unspecified dementia (memory or thinking skills that disrupt daily life, but the cause is unidentified), pain in left knee, pain in right knee, osteoarthritis .Record review of Resident #1's quarterly MDS Assessment, dated 5/21/2026, revealed a BIMS of 8 which indicated moderate cognitive impairment. Section J (Health Conditions) pain interview indicated Resident #1 had no pain during 5 day look back period.Record review of Resident #1's care plan, dated 5/3/2026, revealed, Focus: pain medication due to Osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and bones rub against each other), chronic pain (a condition where ongoing pain lasts longer than three to six months persisting well past the normal healing time for an injury or illness), pain in knees. Interventions: administer pain medications as ordered, review pain medication efficacy.Record review of Resident #1's physician orders, dated 8/4/2026, revealed Resident #1 was prescribed Cymbalta at bedtime, and tramadol three times daily for Chronic pain.Record review of Resident #1's MAR dated July 1-July 31st, 2026, revealed no discrepancies in medication administration.Resident #7Record review of Resident #7's face sheet, dated 8/4/2026, revealed a [AGE] year-old male admitted to facility on 7/24/2024. Resident #7 was diagnosed with unspecified osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and bones rub against each other) and vascular dementia (a decline in thinking skills caused by reduced blood flow to brain).Record review of Resident #7's quarterly MDS Assessment, dated 6/30/2026, revealed a BIMS of 3 which indicated severe cognitive impairment. Section J (Health Conditions) pain interview revealed no pain.Record review of Resident #7's care plan, dated 7/23/2026, revealed, Focus: The resident has pain related to history of fracture of right femur with surgery, osteoarthritis and contracture of right hand. Interventions: Administer pain medication as ordered, evaluate the effectiveness of pain interventions.Record review of physician orders, dated 8/4/2026, revealed an order for hydrocodone 5/325 every morning and at bedtime.Record review of Resident #7's MAR dated July 1st-July 31st 2026 revealed no discrepancies.Resident #8Record review of Resident #8's face sheet, dated 8/4/2026, revealed an [AGE] year-old female admitted to facility on 10/4/2024. Resident #8 had diagnoses of primary osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and bones rub against each other), pain unspecified, and mild neurocognitive disorder (modest decline in mental function, memory, attention, or language).Record review of Resident #8's quarterly MDS Assessment, dated 6/3/2026, revealed a BIMS of 15 indicating no cognitive impairment. Section J (Health conditions) pain interview revealed mild pain rarely. Record review of Resident #8's care plan, dated 9/20/2026, revealed, Focus: The resident has pain to her lower back and shoulder, but she has refused to have any surgery. She does see a pain management doctor. Interventions: Administer resident pain medications for order, evaluate the effectiveness of pain interventions.Record review of Resident #8's physician orders, dated 8/4/2026, revealed an order for tramadol at bedtime.Record review of Resident #8's MAR, dated July 1st-July 31st, 2026, revealed no discrepancies.Resident #9Record review of Resident #9's face sheet, dated 8/4/2026, revealed a [AGE] year-old female admitted to facility on 1/14/2025. Resident #9 had diagnoses of rheumatoid arthritis (an auto immune disease where the immune system attacks the lining of the joints), fibromyalgia (long term medical condition that causes widespread pain, extreme fatigue, and sleep or memory problems), and chronic pain syndrome (a condition where ongoing pain lasts longer than three to six months persisting well past the normal healing time for an injury or illness).Record review of Resident #9's quarterly MDS Assessment, dated 5/25/2026, revealed a BIMS of 14 indicating no cognitive impairment. Section J (Health Conditions) pain interview revealed no pain.Record review of Resident #9's care plan, dated 6/5/2026, revealed, Focus: The resident has chronic pain related to chronic pain syndrome, fibromyalgia, rheumatoid arthritis. Interventions administer pain medications as ordered, the resident's pain is aggravated by movement, evaluate the effectiveness of pain interventions.Record review of Resident #9's physician orders, dated 8/4/2026, revealed an order for Lyrica twice daily.Record review of Resident #9's MAR, dated July 1st-July 31st, 2026, revealed no discrepancies.Resident #11Record review of Resident #11's face sheet, dated 8/4/2026, revealed an [AGE] year-old female who admitted to facility on 10/7/2025. Resident #11 had diagnoses including rheumatoid arthritis (an auto immune disease where the immune system attacks the lining of the joints), fibromyalgia (long term medical condition that causes widespread pain, extreme fatigue, and sleep or memory problems), and unspecified pain.Record review of Resident #11quarterly MDS Assessment, dated 7/9/2026, revealed a BIMS of 15 indicating no cognitive impairment. Section J (Health Conditions) pain interview revealed no pain.Record review of Resident #11's care plan, dated 7/24/2026, revealed, Focus: The resident has chronic pain related to rheumatoid arthritis and fibromyalgia. Interventions: administer pain medications as ordered, evaluate the effectiveness of pain medications.Record review of Resident #11's physician orders, dated 8/4/2026, revealed an order for lyrica twice daily and tramadol two times a day.Record review of Resident #11's MAR, dated July 1st-July 31st, 2026, revealed no discrepancies.Resident #12Record review of Resident #12's face sheet, dated 08/03/26, revealed a [AGE] year-old female who was admitted to facility on 07/09/26. Resident #12 was diagnosed with chronic pain syndrome (a condition where ongoing pain lasts longer than three to six months persisting well past the normal healing time for an injury or illness) anxiety (a feeling of fear, dread, or uneasiness), polyosteoarthritis unspecified (arthritis that affects multiple joints at the same time), and myalgia (muscle pain and aches). Record review of Resident #12's annual MDS Assessment, dated 07/15/2026, revealed that Resident #12 had a BIMS of 7 indicating severe cognitive impairment. Resident #12's Section J (Health Conditions) pain interview revealed a scale of 5 out of 10 indicating moderate pain.Record review of Resident #12's care plan, dated 7/30/2026, revealed Focus: The resident has acute/chronic pain related to arthritis. Interventions: administer pain medication as ordered, evaluate effectiveness of pain interventions.Record review of Resident #12's physician orders dated 8/3/2026 revealed an order for hydrocodone. Record review of Resident #12's MAR, dated July 1-31, 2026, revealed no discrepancies noted.Record review on 8/3/2026 at (time) of facility cameras of LVN H during medication administration on 7/18/2026 revealed:7/18/2026 7:02pm- LVN H opens narcotic box removes a pill and places it on the medication cart, signs narcotic book, leaves pill in medication cup on med cart and goes in and out of room, returns to med cart and grabs pill cup, turns it upside down in her hand and places cup in trash, grabs her keys off of cart and places keys and pill in her pocket.7/18/2026 9:02pm- LVN H opens narcotic box and removes pill, sets pill behind medication cup, pushes med cup and pill back with narcotic book, signs book, picks up pill with one hand, with keys and places it in pocket.7/18/2026 10:04pm- LVN H in med room sitting at desk, texting on phone, 10:05pm pulls pill out of pocket and places in her mouth. Walked to locker to pack back, removed small gold purse, placed several pills in purse, zipped it up and placed it into backpack, took a drink and leans her head back.7/18/2026 9:25pm-LVN H in hallway, pulls two pills from narcotic box and places them on cart, signs narcotic book on two pages and closes book, picks up pills and keys at the same time and places them in her pocket.7/18/2026 4:48am- LVN H in med room, brings medication cart in med room, opens narcotic drawer, removes pill, places in med cup, signs narc book, grabs medication cup and turns cup over in her hand, throws med cup in trash, places pill in her mouth, fans face with her hands, takes drink, grabs fan and places in front of her face.During an interview on 8/3/2026 at 10:30am, the ADON stated she did not observe any signs or behavior changes in LVN H. The ADON stated MA R reported to the DON that the narcotic count was not right on 7/20/2026 at 6:00am when she was coming on to her shift. The ADON stated her and the DON reviewed video footage on 7/20/2026 from LVN H's prior shifts and observed her take several unidentified medications from the narcotics box. The ADON stated there were no residents with negative outcomes due to not receiving narcotic pain medications. During an interview on 8/3/2026 at 11:00am, MA R stated she arrived at work on 7/20/2026 for her shift and counted the narcotic box with LVN H. MA R stated the count was off on one of the sheets and LVN H stated she had just forgotten to sign it out and signed it out to correct the count. MA R stated something just did not seem right with the situation, so she reported it to the DON. MA R stated when the narcotics were counted a licensed nurse was to be present. MA R stated the narcotic count was done at the beginning and end of every shift. MA R stated she did not have any suspicions of LVN H taking medications.During an interview on 8/4/2026 at 9:30am, the DON stated MA R notified her on 7/20/2026 that she felt like something was off when MA R and LVN H counted the narcotics at change of shift. She stated on 7/20/2026 she started reviewing camera footage and observed LVN H taking several unidentified medications from the narcotics box. The DON stated there were no signs that LVN H was taking medications or working under the influence. The DON stated it was her expectation for a licensed nurse to be present with the MA when counting narcotics. The DON stated the count needed to be reconciled with narcotic sheet and the number of pills in the medication card simultaneously. The DON stated she would be doing random cart audits to verify this was being done correctly. The DON stated video audits of direct care staff will be completed daily. The DON stated failure to administer prescribed narcotic medication could cause increased pain and decreased quality of life for the residents. The DON stated there were no negative outcomes due to residents not receiving prescribed medications. During an interview on 8/4/2026 at 9:45am, the Administrator stated it was her expectation that the ADON and DON monitor medication carts and narcotic sheets to ensure compliance with narcotic count. The Administrator stated video footage from 7/17/2026 through 7/20/2026 of LVN H's shifts were reviewed on 7/20/2026 and revealed LVN H took several unidentified narcotics. The Administrator stated LVN H was terminated prior to her next shift on 7/23/2026. The police were notified on 7/20/2026 and LVN H was arrested when she arrived at facility on 7/23/2026. The Administrator stated they would be doing daily video footage audits of direct care staff. She stated they would also be monitoring the narcotic count process on video. The Administrator stated residents not receiving medications as ordered could lead to increased pain. The Administrator stated no negative outcomes resulted due to residents not receiving prescribed medication on LVN H's shift. During an interview on 8/4/2026 with LVN H she stated she felt like the facility did what they needed to do in this situation. LVN H stated she was taking the pills for self-use. LVN H stated she was unsure of how many pills she took. LVN H then stated she was no longer comfortable talking without seeking the advice of a lawyer.During an interview on 8/4/2026 at 1:24pm, the MD stated he was aware that LVN H was taking residents' narcotic medication instead of administering it. The MD stated the risk of residents not receiving prescribed medication could be withdrawal from narcotics, but it was not deadly. The MD stated he was not aware of any negative outcomes or change in condition of residents resulting from this incident.During an interview on 8/4/2026 at 1:45pm Resident #1 stated the facility had managed her pain and she has had no increase in pain.During an interview on 8/4/2026 at 1:50pm Resident #8 stated she has no increase in pain and received her medications like she was supposed to.During an interview on 8/4/2026 at 1:55pm Resident #9 stated her pain was well controlled. She denied any increase in pain.During an interview on 8/4/2026 at 2:00pm Resident #11 stated her pain was well managed by the facility and doctors. She stated she had no increase in pain recently. During an interview on 8/4/2026 at 2:10pm Resident #12 stated her pain was under control. She stated she had no increase in pain.Record review of the facilities policy titled, Controlled Substance Administration and Accountability, with a revision date of 5/6/2026, revealed: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion or accidental exposure.

Based on interviews and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 3 of 9 residents (Residents #1, #8, and #33) reviewed for advance directives. The facility failed to ensure Resident's #1, #8, and #33 Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) forms were completed correctly. This failure could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. Findings included: Resident #1Review of Resident #1's admission Record, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a neurological condition causing memory problems), closed fracture of the left and right leg, diabetes (a condition where the body cannot process insulin correctly), chronic obstructive pulmonary disease (lung disease making it difficult to breathe), seizures, heart problems, and urinary tract infections. Review of Resident #1's Significant Change MDS Assessment, dated [DATE], revealed:Resident #1's BIMS score was 8 of 15, indicating moderate cognitive impairment. Review of Resident #1's Care Plan, initiated [DATE], revealed Resident #1 was a DNR status. Review of Resident #1's Order Summary, dated [DATE], revealed orders that Resident #1 was a DNR dated [DATE]. Review of Resident #1's DNR form completed [DATE] revealed:Section A: Resident #1 signed the DNR on [DATE].Section B: Resident #1's legal agent signed the DNR on [DATE].Section Two Witnesses: The Public Notary Signed the DNR on [DATE] but no witnesses were present. Physician's Statement: Resident #1's NP signed the DNR (not a physician licensed by the Texas Medical Board) and did not include the date, his printed name, or his license number. Resident #8Record review of Resident #8's admission record dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (A loss of brain function that worsens over time and affects memory, thinking, behavior, and language), and Congestive Heart Failure (A chronic condition in which the heart does not pump blood as well as it should). Record review of Resident #8's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3, indicating cognition was severely impaired. Record review of Resident #8's quarterly care plan dated [DATE] revealed Resident #8 was a DNR status. Record review of Resident #8's medical orders reflected an OOH-DNR order dated [DATE]. Record review of Resident #8's OOH-DNR dated [DATE] revealed: Physician's Statement - Signed by Staff #D, a NP, not a physician licensed by the Texas Medical Board and did not include the date or his license number. There was no physician signature in the bottom section stating, All persons who have signed above must sign below, acknowledging that this document has been properly completed. Resident #33 Review of Resident #33's admission Record, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, high cholesterol, and heart problems. Resident #33 discharged on [DATE]. Review of Resident #33's Significant Change MDS, dated [DATE] revealed: He had long and short-term memory problems with severely impaired decision-making abilities. This was an acute onset of mental status change. Resident #33 had a life expectancy of less than 6 months. Review of Resident #33's Care Plan initiated [DATE], revealed the resident was a DNR status. Review of Resident #33's Physician Order Summary as of [DATE] revealed:Resident #33 was admitted to hospice diagnosis Alzheimer's disease dated [DATE].Resident #33 was a DNR dated [DATE]. Review of Resident #33's Facility DNR form documented.Section B: Resident #33's authorized representative signed the form, but did not date it. Physician's Statement: The NP signed the form and dated it [DATE], but did not include his license number.There were not two qualified witnesses witnessing the form as signed and valid. Review of Nurse's Notes dated [DATE] at 4:16 PM revealed: Received a call from Hospice asking if we had a copy of the DNR for the resident. Nurse informed Hospice that Nurse sent her a copy [DATE] and gave a copy to Hospice Nurse this morning when she came to get consents from the family member]. Hospice went on to explain that the DNR we had was not witnessed for the [family member] signature, therefore not valid and that resident needed to be placed on a full code status until they could get a DNR signed from the [family member] and hospice physician tomorrow. Discontinued DNR order, full code order implemented, notified ADON, charge nurse to put on 24 hour report and administration. Review of the Hospice OOH-DNR signed [DATE] revealed:Section C: Resident #33's [family member] signed and dated the OOH-DNR on [DATE].Physician's statement: The Hospice physician signed and dated the OOH-DNR on [DATE].The notary signed the form on [DATE].There were no witnesses to the signing of the form. In an interview on [DATE] at 2:53 PM the ADON said the blank OOH-DNR forms go with the resident to the clinic visit with the provider, the form was completed at the clinic visit and sent back to the facility to be scanned into the electronic medical record. The ADON said that the staff person scanning in the OOH-DNR's does not review them for accuracy/completion. Review of the Instructions for Issuing an OOH-DNR Order (included in the OOH-DNR Order) used by the facility and published by the Texas Department of State Health Services, revised [DATE], revealed:Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order was for use by qualified persons or their representatives to direct health professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. Section A - If an adult person is competent and at least [AGE] years of age he/she will sign and date the Order in Section A.Section B - If and adult person is incompetent or otherwise mentally or physically incapable of communication and has a legal guardian, agent in a medical power of attorney, or proxy in a directive to physician, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in section B.Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR by signing and dating it in Section C.Section D - If the person is incompetent and his/her attending physician has seen evidence of the person's previously issued proper directive to physicians or observed the person competently issue an OOH-DNR in a nonwritten manner, the physician may execute the Order on behalf of the person by signing and dating it in Section D-In addition, the OOH-DNR must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C or E and if applicable., have witnessed a competent adult person making an OOH-DNR Order by non-written communication to the attending physician, who must sign in section D, and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR in the presence of a notary-public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses.

Based on interviews and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 2 of 3 residents (Residents #33 and #34) reviewed for accurate medical records.The facility failed to accurately document the type of discharge for Residents #33 and #34.This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included:Resident #33 Review of Resident #33's admission Record, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, high cholesterol, and heart problems. Resident #33 discharged on [DATE].Review of Resident #33's Exit MDS, dated [DATE] documented a Death in Facility. Review of Resident #33's Nurse's Note, dated [DATE] at 8:31 AM, revealed, Nurse went in around 0818 to resident was found unresponsive, no respirations noted, no pulse, pupils were dilated and fixed, skin was cold to the touch, and there was generalized cyanosis noted. Charge nurse, RN, listened for any heart sounds and respirations for a full 2 minutes and none were noted. Resident #33 was pronounced dead at 0818 AM.Review of Resident #33's Physician's Discharge summary, dated [DATE], documented resident died in the facility.Review of Resident #33's Transfer/Discharge Report, printed [DATE], revealed he was transferred/ discharged on [DATE] to a nursing home: nursing home unknown/ TBD Resident #34Review of Resident #34's admission Record, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (a condition where blood flow to the brain is interrupted leading to brain cell damage or death), Chronic Kidney Disease (a chronic disease of the kidneys leading to kidney failure) and Vascular Dementia (a group of thinking and social symptoms that interferes with daily functioning). Resident #34 was discharged on [DATE].Review of Resident #34's Exit MDS, dated [DATE] documented a Death in Facility. Review of Resident #34's Record of Death, dated [DATE] revealed the time of Resident #34's death was 10:32 AM on [DATE].Review of Resident #34's Physician's Discharge summary, dated [DATE], documented the resident died in the facility on [DATE]. The medical provider signed the report.Review of Resident #34's Transfer/Discharge Report, completed [DATE], revealed Resident #34 was transferred/discharged on [DATE] to a nursing home: nursing home unknown/ TBD. An RN signed the report.Interview on [DATE] at 2:31 PM, the administrator said Residents #33 and #34 did pass away and the NC struggles with the electronic medical record and computers in general. The administrator confirmed NC had received training.Interview on [DATE] at 2:53 PM with the ADON and NC, the ADON said Residents #33 and #34 did die at the facility. The ADON said the charge nurse on duty at the time of a death or discharge/transfer completes the Transfer/Discharge Report, prints it, signs it, and adds it to a file for things to be scanned into the electronic medical record. The NC said she does not double-check the accuracy of records when she scans them in. Interview on [DATE] at 3:08 PM, the ADON stated the discharge summary had to be checked for the wrong box if the documentation program was checked as a drop-down screen. The ADON said whoever scanned in the discharge summary looked at it but we have a lot of paper to scan. The ADON stated any nurse could do the transfer/ discharge summary. The ADON looked at Resident #33 and #34's discharge summary and said the same nurse did each discharge summary. The ADON said it was probably on the 2p.m. - 10 p.m. shift when things always went wrong. The ADON stated the Nurse printed the discharge summary, signed it, and the summary went in the accordion file to be scanned.Review of the facility's policy Documentation in Medical Record revised [DATE], revealed in part: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 4 (Resident #21) reviewed for infection control. The facility failed to ensure Resident #21's oxygen nasal cannula tube was bagged when not in use and CNA A touched the nasal cannula with her bare hands to place it on the resident's nose. This failure could place the residents at risk of infection. Findings included:Record review of Resident #21's admission record, dated 09/24/2025, indicated she was admitted to the facility on [DATE] with diagnoses of dementia and COPD chronic obstructive pulmonary disease (COPD is an ongoing lung condition caused by damage to the lungs). She was [AGE] years of age. Record review of Resident #21's physician order report dated 09/24/2025 indicated in part: Oxygen via at 1-2 LPM via nasal cannula continuously every shift. (LPM=liters per minute). Record review of Resident #21's care plan dated 04/22/2025 indicated in part: The resident is at risk for impaired gas exchange r/t COPD, hypoxemia and cough. Resident will maintain an oxygenation saturation within personal goal range. Administer oxygen as prescribed or per standing order. (r/t = related to). Record review of Resident #21's MDS dated [DATE] indicated in part: BIMS of 3 indicating the resident had severe impairment. Functional Limitation in Range of Motion - Upper extremity (shoulder, elbow, wrist, hand) is dependent - A helper completed all the activities for the resident. Respiratory treatments - Oxygen therapy. During an observation and interview on 09/24/2025 at 10:42 AM CNA A assisted Resident #21 to her wheelchair. The resident's oxygen nasal cannula tube was seen wrapped around the oxygen tank which was attached to the back of the resident's wheelchair. CNA A took the nasal cannula with her bare hands, touched the part that goes into the resident's nasal area and then placed it on the resident's nose. CNA A said Resident #21 was not able to remove the oxygen nasal cannula and tube by herself and that some other staff member must have removed it and placed it on the oxygen tank. The CNA said they normally placed the oxygen nasal cannula tube on the oxygen tank and had never noticed a storage bag on the tank to store the oxygen nasal cannula tube. During an observation and interview on 09/24/2025 at 1:40 PM Resident #21 was awake and alert in her bed resting. The resident said she did not remove the nasal canula from her nose as she was unable to. Resident #21 said the staff were the ones that would do that and store it in the storage bag as she was unable to do that. During an interview on 09/24/2025 at 1:46 PM CNA A said that she had not noticed that Resident #21 did not have a bag on the oxygen tank to store the oxygen nasal cannula tube. CNA A said not having a bag to store the oxygen nasal cannula tube could lead to the nasal cannula becoming contaminated and possibly introduce bacteria into the resident's nose. CNA A said she had reported it to a nurse and the nurse had already placed a bag on the resident's wheelchair to store the oxygen nasal cannula tube. During an interview on 09/24/2025 at 1:52 PM RN B said when the oxygen nasal cannula tube was not in use, the staff were supposed to store it in the plastic bag. RN B said it was supposed to be stored to prevent contamination of the nasal cannula. RN B said she had recently placed a bag on Resident #21's oxygen tank so the staff could store the oxygen nasal cannula tube in it. During an interview on 09/25/2025 at 12:15 PM the ADON said it was expected for the oxygen nasal cannula tube to be stored in a bag when not in use. The ADON said the purpose of that was to prevent infections. The ADON was made aware of the observation of CNA A touching the nasal cannula with her hands and placing it on Resident #21's nose. The ADON said the aide should not have touched the nasal cannula with her hands as that could lead to contamination. The ADON said they would conduct training on making sure staff knew not to touch the nasal cannula and to store it in a bag when not in use. During an interview on 09/25/2025 at 2:44 PM the Administrator said it was expected for staff to store the oxygen nasal cannula tube in a bag when not in use. The Administrator was made aware of the observation of the oxygen tube and nasal cannula not bagged and then touched by the CNA. The Administrator said they would make sure there were enough bags to store the oxygen nasal cannula tube. The Administrator said not storing the oxygen nasal cannula tube in a bag could have an outcome of infections. Record review of the facility's policy titled Oxygen Administration and dated 05/12/2025 indicated in part: Policy - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Keep delivery devices covered in plastic bag when not in use. Record review of the facility's policy titled Infection prevention and control program dated 01/15/25 indicated in part: This facility has established and maintains 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 as per accepted national standards and guidelines. Standard precautions- All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the facility's only dry storage was sealed appropriately. These failures could place residents at risk for food-borne illness, and food contamination. Findings include: Observations of the kitchen's dry storage area on 08/13/24 at 09:37 AM, revealed One bag of southern yellow cornbread was opened. Observations of the kitchen's dry storage area on 08/14/24 at 11:27 AM, revealed the following items were not sealed: - one bag of southern yellow cornbread, -one bag of Tostitos original tortilla chips, -one bag of cereal, and -one bag of spaghetti pasta. Interview with the Dietary Manager (DM) on 08/14/24 at 11:38 AM, revealed he was not aware there was food in the dry storage that was. The DM stated that these items was recently used but was unaware how long they had been opened. The DM stated all food and items that was opened was to be dated with an opened date and if the package could not be sealed the item should be placed in a resealable bag/container and labeled if not visible through the container or bag. The DM stated the bags not being appropriately sealed could cause cross contamination. The DM stated he will take this as a chance to teach his staff. Review of the undated policy titled Food Safety Requirements stated in part, Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.

Based on interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #16) reviewed for care plans. The facility failed to have a care plan in place to accurately address Resident #16's oxygen use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Record review of admission record indicated Resident #16 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #16 had medical diagnoses that included palliative care, Cerebral infarction, unspecified severe protein-calorie malnutrition, and pain. Record review of Resident #16's Admission MDS assessment dated [DATE] revealed his Cognitive Skills for Daily Decision Making to be severely impaired - never/rarely made decisions. He required maximum assistance and was dependent on staff for all ADL's except for eating. He relied on staff for mobility. Under section O for Respiratory treatments C1. Oxygen therapy was selected while a resident at the facility. Record review of Resident #16's order summary dated August 14th, 2024 included, Oxygen @2-5 LPM via nasal cannula and may titrate for patient comfort at night at bedtime, and, While resident is up and awake, no oxygen required as long as SPO2 remains above 92%. every shift. Record review of Resident #16's care plan dated 07/24/2024 revealed no care plan for oxygen use. Interview on 08/15/24 at 01:35 PM, the DON stated she would check orders and medical diagnosis for items that should be care planned. The DON stated she had been working on care plans she took over in June since her MDS nurse did not want to do them anymore. the DON stated Resident #16s care plan addressed the under terminal illness. The DON stated she had worked on it today. The care plan was updated after surveyor intervention. Review of facility policy titled Comprehensive Care Plans dated 06-01-2024 revealed, in part: A comprehensive person-centered care plan is developed and implemented for each resident, consistent with the resident's rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles for 1 of 1 medication rooms inspected for medication storage. The medication room had opened and undated vial of Tuberculin (TB) medication in the refrigerator. This failure could place residents at risk of receiving medications that were expired and not produce the therapeutic effect. The findings were: During an observation and interview on [DATE] at 02:12 PM the medication room was inspected with RN A present. There was a small refrigerator which contained one 0.1 ml vial of Tuberculin formula which had been opened but no open date was found. The Tuberculin container indicated Once entered, vial should be discarded after 30 days. RN A said it was each nurse's responsibility to date the vials when they are opened. RN A said she was not aware the vial was undated. During an interview on [DATE] at 12:20 PM, the DON was made aware of the opened and undated TB vial located in the medication room. The DON said she was not sure as to why the vial was undated since it had been opened. The DON said it was everybody's job to monitor the refrigerator or any other medications that required an open date when opened and discarded when expired. The DON said if the staff used an expired or undated TB vial it could lead to a false TB test result. Record review of policy titled Medication storage and dated [DATE] indicated in part: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. All OTC, insulins, multi dose vials (needle puncture) should be labeled with an open date and discarded within 28 days unless the manufacturer specifies different date.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #9) of 2 residents reviewed for infection control. CNA B failed to change her gloves when going from dirty to clean during peri-care for Resident #9. CNA C failed to wash her hands prior to putting gloves on and assisting Resident #9 with personal care. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Record review of Resident #9's admission record dated 08/15/24 indicated she was admitted to the facility on [DATE] with diagnoses of stroke and chronic respiratory failure. She was [AGE] years of age. Record review of Resident #9's care plan dated 08/2024 indicated in part: Focus: The resident has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Check resident every 2 hours and PRN as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Record review of Resident #9's MDS dated [DATE] indicated in part: BIMS = 10 indicating the resident was moderately impaired Urinary continence = Frequently incontinent. Bowel continence = Always incontinent . During an observation on 08/14/24 at 02:02 PM, CNA B and CNA C performed incontinent care for Resident #9. CNA C entered the resident's room and put on a pair of gloves without first washing her hands. Both CNAs opened Resident #9's brief and rolled her to her right side. CNA B took a wet wipe and wiped the resident's rectal area which contained a smear of bowel movement on the wipe. CNA B took some skin protectant ointment and applied it to the resident's buttocks while still wearing the same soiled gloves. While still wearing the same soiled gloves CNA B took a new brief and placed it under the resident's bottom and rolled the resident back onto the brief. CNA B took some wet wipes and wiped Resident #9's vaginal area. Both CNAs then removed their gloves and washed their hands. CNA C turned the faucet on and washed her hands with water only and for approximately five seconds then turned the faucet off with her bare hands. During an interview on 08/14/24 at 02:12 PM, CNA B said she had been trained to change her gloves once they became contaminated to prevent cross contamination. CNA B said she should have changed gloves after she cleansed Resident #9's rectal area since she then touched the new brief and cleansed the resident's vaginal area. CNA B said she had forgotten to change her gloves at the appropriate time. CNA B said if she did not change her gloves then that could lead to cross contamination and the spread of germs. CNA B said they had received training on infection control to include glove changing and handwashing but again she had forgotten to change her gloves after they became contaminated. During an interview on 08/14/24 at 02:14 PM, CNA C said she had been trained on glove changes and handwashing. CNA C said she had to wash her hands for around 20 seconds with soap and water and turn off the faucet with a paper towel to prevent re-contamination of her hands. CNA C acknowledged she had washed her hands quickly and had not used soap nor closed the faucet with a paper towel after assisting Resident #9 with personal care. CNA C said she had gotten nervous and messed up. CNA C said if she did not wash her hands correctly that could lead to the spread of infections. During an interview on 08/15/24 at 12:16 PM, the DON was made aware of the incontinent care observation performed on Resident #9 by CNAs B and C. The DON said it was expected for the CNAs to wash their hands prior to and after performing personal care. The DON said staff were supposed to wash their hands for 15 to 20 seconds with soap and water. The DON said the CNAs were supposed to change their gloves and wash their hands when going from dirty to clean. The DON said the failure probably occurred because the CNAs got nervous and forgot their steps. The DON said that LVN D conducted training with the CNAs in regard to infection control and incontinent care. The DON said if the CNAs did not wash their hands or changed their gloves that could lead to the spread of infections. During an interview on 08/15/24 at 01:24 PM, LVN D said she conducted training with the staff regarding infection control such as personal care of the residents. The LVN D was made aware of the observation of incontinent care performed by CNAs B and C. LVN D said the CNAs were expected to wash their hands prior to performing resident care. LVN D said the CNAs were supposed to wash their hands for at least 20 seconds with water, soap and turn the faucet off with a paper towel to prevent recontamination of their hands. LVN D said the CNAs were expected to change their gloves and wash their hands when going from dirty to clean. LVN D said CNA B should have changed her gloves before touching the new brief and wiping Resident #9's vagina. LVN D said she believed the failure occurred because the CNAs got nervous and forgot their steps. LVN D said if the CNAs did not wash their hands or changed their gloves at the required time that could lead to cross contamination. Record review of the facility policy titled Hand hygiene dated 04/11/2023 indicated in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub also known as alcohol-based-hand-rub. Hand hygiene technique when using soap and water: a. Wet hands with water, avoid using hot water to prevent drying of skin. b. apply to hands the amount of soap recommended by the manufacturer. C. rub hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. D. rinse hands with water. E. dry thoroughly with a single use towel. F use clean towel to turn off the faucet. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves perform hand hygiene prior to donning gloves and immediately after removing gloves. Record review of the facility's policy titled Helping a resident with toileting needs and dated 06/01/2024 indicated in part: It is the practice of this facility to assist residents with toileting needs in order to maintain the resident's dignity as well as proper hygiene. Put on gloves-if you contaminate your gloves in any way during the procedure you must change into a new pair. Help with wiping and throw the paper into the trash bag or toilet. Remove your gloves and dispose of them in the trash bag. Help the resident with their clothing and assist them back into their bed or chair. Put on new gloves - help the resident wash, rinse, and dry their hands. Remove your gloves and place in the trash bag. Properly dispose of trash bag and wash your hands. Record review of the facility's document titled Standard precautions infection control dated 04/01/2023 indicated in part: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to standard precautions to prevent the spread of infections to residents, staff and visitor. Standard precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. This includes hand hygiene, selection and use of PPE (e.g., gloves, gowns, facemasks, respirators, eye protection), respiratory hygiene and cough etiquette, safe injection practices, environmental cleaning and disinfection and reprocessing of reusable resident medical equipment. Record review of the facility's policy titled Infection prevention and control program and dated 03/01/2024 indicated in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections.

Based on interview, and record review, the facility failed to ensure the resident environment remained as free from accident hazards was possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision . 1. HA A failed to ensure Resident #1 was properly transferred by two persons using a Hoyer lift. 2. The facility failed to ensure HA A was properly trained before transferring Resident #1 by Hoyer lift . The noncompliance was identified as PNC. The noncompliance began on 8/29/23 and ended on 9/4/23. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of severe injury. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female with an admitted [DATE]. Resident #1 had diagnoses which included: Alzheimer's Disease with late onset (progressive memory impairment), anemia (lack of red blood cells), dementia in other diseases classified elsewhere (impairment of brain functions), hyperlipidemia (high levels of fat in blood), chronic pain, rhinitis (stuffy nose), constipation (difficult bowel movements), hypokalemia (below normal potassium), sclerosing mesenteritis (tissue that holds the small intestines in place becomes inflamed), Cushing's syndrome (over production of cortisol), Vitamin B12 deficiency (deficient in Vitamin B12), anxiety disorder (anxiety that interferes with daily life), insomnia (sleep disorder), intermittent explosive disorder (sudden episodes of unwarranted anger), restless leg syndrome (irresistible urge to move the legs), type 2 diabetes with diabetic polyneuropathy (adult onset of the way the body processes blood sugar with damage to the small blood vessels that supply the nerves in the body), mixed obsessional acts (pervasive and invasive thoughts that cause anxious and distress), atherosclerotic heart disease of native coronary artery without angina (substances collect on inner walls of the heart arteries), localized edema (swelling due to excessive accumulation of fluid at specific site), GERD (acid reflux), hemiplegia hemiparesis (loss of strength in arm, leg and sometimes face on one side of body), unspecified hearing loss, psychotic disorder (disconnection from reality). Record review of Resident #1's electronic health record revealed the most recent Care Plan, dated 6/9/2023, revised on 9/2/23, reflected Transfer: I am an extensive assist x2 staff for transferring. I use a Hoyer lift x2 staff at all times. Record review of incident/accident report, dated 10/1/23, revealed Resident #1 had a witnessed fall, dated 9/2/23 at 1:15 PM. Record review of Resident #1's physician orders, dated 7/11/23, revealed Hoyer Lift x2 CNA for all transfers. Record review of Resident #1's progress note, dated 9/2/23 at 4:36 pm, revealed Resident returned from the ER at 1630 [4:30 pm] with no new medication changes. RSD was given a tetanus shot at the ER per RSD hitting her head on a medal piece of equipment for safety and prevention of other precautions. RSD was also given 5 staples to laceration that occurred on the back of the head from the fall Interview on 10/1/23 at 11:20 AM with RN A revealed staff were trained on Hoyer lifts. The facility had someone come in and do a whole staff meeting on it. They were also trained upon hire. There should be two people providing support to do a Hoyer lift. The facility has hospitality aides, and they could only do certain tasks when on the floor until tested . The tasks they could do was pass water and answer call lights and hand residents things. They could not do hands on anything. Hospitality aides could assist with Hoyer lifts, but they could not actually do the Hoyer lift. Interview on 10/1/23 at 12:19 PM with HA A revealed she was not trained on Hoyer Lifts prior to the incident. HA A stated CNA B supported the back of the resident and HA A pulled the Hoyer Lift backwards, operating the lift, during the incident with Resident #1 that resulted in her fall and injury. HA A stated she thought the failure was the sling was too big or not on properly resulting in the resident slipping out of the sling and hitting her head on the leg of the Hoyer. Interview on 10/1/23 at 12:59 PM with CNA B revealed CNA B had section 1 and HA A had hall 3. CNA B stated she did not put Resident #1 in the sling. CNA B had been asking HA A several times if she needed help and she would not answer or say she needed help, but CNA B kept checking on her. CNA B stated, I knocked on the door to Resident #1's room and HA A was in there with Resident #1 and Resident #1 was already in the sling in the Hoyer. So, I assisted. HA A operated the Hoyer lift. CNA B stated HA A was a HA, and she should have known not to do a one-person transfer. HA A was already in there and had not asked for help; CNA B walked in on her. The HA should be the assist and the CNA should operate the Hoyer, but she already was. CNA B stated she had not seen HA A do any Hoyer Lifts since and HA A was only allowed to observe. CNA B stated the resident went to the ER and received 5 staples in her head. CNA B stated, It is not allowed for HA to work their own floor, so I don't know why she was working her own floor. They scheduled her on her own hall because I remember I thought that was weird that she was scheduled that way. I voiced that concern to [LVN A ]. Interview on 10/1/23 at 2:42 PM with LVN A revealed, Hospitality Aide (HA) could provide water and answer lights but couldn't provide any care. LVN A stated, They can stock and let us know if someone needs something. They can pass a tray, but they can't feed until certified or if they have had feeding training. I have not ever had a CNA voice any concerns with an HA having their own hall. They are never assigned to their own area. LVN stated the expectation for Hoyer lifts were there always had to be two people and preferred them both to be certified unless they had Hoyer lift training and were checked off on the training. Hoyer lift training should be provided upon hire unless they had something provided of previous training. LVN A stated HA A was not to do Hoyer Lifts because LVN A was not aware that HA A was checked off. Interview on 10/1/23 at 2:59 PM with ADON revealed she never had a report HA worked their own floor. The ADON stated, HA can pass ice water and answer a light but if it has anything to do with transfers or care, they have to go call the CNA on the floor. If they are doing the training and they have been checked off on, they can assist with transfers, as long as it is with a certified aide or nurse. The ADON revealed, the training was eye opening on how many didn't understand the sling colors. We just believe the failure was just the sling, it was ill fitting. The ADON revealed the facility had new training and equipment to prevent it from happening again. The ADON stated CNA B was spotting and HA A was on the Hoyer. HA A should have been spotting and CNA B should have been on the remote. The ADON revealed she did not know who was supposed to be training HA A that day and the facility would start adding who it was on the schedule . ADON stated, We located this failure that day since we don't know who was supposed to be training her [HA A]. Interview on 10/1/23 at 3:39 PM with the DON revealed the DON did not know who was training on the day of the incident. The DON stated she was informed CNA B had offered to help and that was how CNA B and HA A ended up together. The DON stated, I don't want to say she was working the floor alone , but I think that is how it was. I have seen the video of what happened. I did not see what happened inside the room. [HA A] was not in the room with Hoyer alone very long before [CNA B] came and helped. HA A should have been trained upon hire on Hoyer lift transfers. The DON revealed HA A could not use a Hoyer lift and could only be there to spot and for this incident CNA B was spotting. The DON stated, I know now that HA A was working the floor on her own but did not know that before . Interview on 10/1/23 at 3:39 PM with the DON revealed the facility did a large Hoyer lift training and now require a specific aide to do the training who had a lot of experience . The facility replaced slings and put (resident's) name in them to make sure they were appropriate. The DON revealed, the facility made some administrative changes, and the aide with experience will take over the scheduling and making sure the trainings were done. CNA C was that before , but the facility was making that change . Interview on 10/1/23 at 5:13 PM with the ADM revealed the ADM interviewed HA A and asked her if she knew she couldn't transfer alone, and HA A told her she knew that . When asked why she did it, she began crying. The ADM stated she asked HA A was she comfortable with Hoyer Lift transfers and HA A informed the ADM she thought she could do it. The ADM stated when she asked HA A why she did it she just started crying. The ADM revealed HA A admitted to her she was not familiar with Hoyer's but didn't tell anyone. The ADM stated, [HA A] had her own section (hall) and that was why the facility was changing things to prevent this from happening again. Maintenance came in and checked every Hoyer and one had a loose leg and so it was replaced. The lift that was replaced was not the lift that was used for Resident #1 . Interview on 10/1/23 at 5:13 PM with the ADM revealed, We are switching up who does the schedule and so we have the ADON, and DON sign off on it now. We had training done and all direct care staff got the training; it was mandatory. Then, we made every single one of them demonstrate [how to operate a Hoyer lift] and we had them get in the sling so they could see how that felt. Record review of New Hire Orientation checklist, dated 8/28/23, for HA A reflected Skills Review and Body Mechanics: Safe Lifting/Transfer/Gait Belts and Mechanical Lifts had no documentation and were not checked off ; indicating training was not completed Record review of Safe Resident Handling/Transfers policy, dated 9/4/23, revealed, .6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly . 8. The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per the manufacturer's instructions on proper sling sizing . 10. Two staff members must be utilized when transferring residents with a mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. 12. Staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. Record review of the No Lift Policy, dated 6/04, revealed, .4. Nursing staff will receive training in the use of mechanical lifts during the orientation period. The facility took the following actions to correct the noncompliance: Record review of Staff Meeting dated 9/4/23 revealed all 16 direct care staff were in- serviced on Proper use of Hoyer lift and sit to stand. Record review of Electronic Total Lift Competency dated 9/4/23 9/6/23 revealed 16 direct care staff were checked off on; HA A checked off on 9/4/23. Record review of invoice dated 9/4/23 for one Electric Patient Lift. Record review of invoice dated 9/7/23 for 12 slings of 7 different sizes. Interview on 10/1/23 at 2:59 pm with ADON revealed The audits for the Hoyer's are being done more often and had more intense training: Two people and an employee in the Hoyer. Audits will be every three months and it was annually and at hire before. We have a designated aide will do the training who has [AGE] years of experience. We purchased new slings specifically for each patient and we have a new Hoyer and we have removed the Hoyer [Resident #1] was in because the wheels got stuck sometimes and we are ironing the names [of residents] in the slings. We have also increased monitoring and audits of Hoyer lifts. ADON revealed she does not know who was supposed to be training HA-A that day and the facility will start adding who it is on the schedule. Throughout the course of the investigation from 10/1/23-10/2/23 staff were interviewed and confirmed their understanding of the in-service training provided by the facility. Staff interviewed included two CNAs (one night shift), one HA, one LVN, one RN. Interview on 10/1/23 at 2:11 pm with family member revealed staff use 2-3 staff to transfer their resident with Hoyer Lift. Two observations were conducted of staff conducting a safe, competent Hoyer Lift transfer.

Based on interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for accidents and supervision . 1. HA A failed to ensure Resident #1 was properly transferred by two persons using a Hoyer lift. 2. The facility failed to ensure HA A was properly trained and able to demonstrate compentency in skills and techniques before transferring Resident #1 by Hoyer lift . The noncompliance was identified as PNC. The noncompliance began on 8/29/23 and ended on 9/4/23. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of severe injury. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female with an admitted [DATE]. Resident #1 had diagnoses which included: Alzheimer's Disease with late onset (progressive memory impairment), anemia (lack of red blood cells), dementia in other diseases classified elsewhere (impairment of brain functions), hyperlipidemia (high levels of fat in blood), chronic pain, rhinitis (stuffy nose), constipation (difficult bowel movements), hypokalemia (below normal potassium), sclerosing mesenteritis (tissue that holds the small intestines in place becomes inflamed), Cushing's syndrome (over production of cortisol), Vitamin B12 deficiency (deficient in Vitamin B12), anxiety disorder (anxiety that interferes with daily life), insomnia (sleep disorder), intermittent explosive disorder (sudden episodes of unwarranted anger), restless leg syndrome (irresistible urge to move the legs), type 2 diabetes with diabetic polyneuropathy (adult onset of the way the body processes blood sugar with damage to the small blood vessels that supply the nerves in the body), mixed obsessional acts (pervasive and invasive thoughts that cause anxious and distress), atherosclerotic heart disease of native coronary artery without angina (substances collect on inner walls of the heart arteries), localized edema (swelling due to excessive accumulation of fluid at specific site), GERD (acid reflux), hemiplegia hemiparesis (loss of strength in arm, leg and sometimes face on one side of body), unspecified hearing loss, psychotic disorder (disconnection from reality). Record review of Resident #1's electronic health record revealed the most recent Care Plan, dated 6/9/2023, revised on 9/2/23, reflected Transfer: I am an extensive assist x2 staff for transferring. I use a Hoyer lift x2 staff at all times. Record review of incident/accident report, dated 10/1/23, revealed Resident #1 had a witnessed fall, dated 9/2/23 at 1:15 PM. Record review of Resident #1's physician orders, dated 7/11/23, revealed Hoyer Lift x2 CNA for all transfers. Record review of Resident #1's progress note, dated 9/2/23 at 4:36 pm, revealed Resident returned from the ER at 1630 [4:30 pm] with no new medication changes. RSD was given a tetanus shot at the ER per RSD hitting her head on a medal piece of equipment for safety and prevention of other precautions. RSD was also given 5 staples to laceration that occurred on the back of the head from the fall Interview on 10/1/23 at 11:20 AM with RN A revealed staff were trained on Hoyer lifts. The facility had someone come in and do a whole staff meeting on it. They were also trained upon hire. There should be two people providing support to do a Hoyer lift. The facility has hospitality aides, and they could only do certain tasks when on the floor until tested . The tasks they could do was pass water and answer call lights and hand residents things. They could not do hands on anything. Hospitality aides could assist with Hoyer lifts, but they could not actually do the Hoyer lift. Interview on 10/1/23 at 12:19 PM with HA A revealed she was not trained on Hoyer Lifts prior to the incident. HA A stated CNA B supported the back of the resident and HA A pulled the Hoyer Lift backwards, operating the lift, during the incident with Resident #1 that resulted in her fall and injury. HA A stated she thought the failure was the sling was too big or not on properly resulting in the resident slipping out of the sling and hitting her head on the leg of the Hoyer. Interview on 10/1/23 at 12:59 PM with CNA B revealed CNA B had section 1 and HA A had hall 3. CNA B stated she did not put Resident #1 in the sling. CNA B had been asking HA A several times if she needed help and she would not answer or say she needed help, but CNA B kept checking on her. CNA B stated, I knocked on the door to Resident #1's room and HA A was in there with Resident #1 and Resident #1 was already in the sling in the Hoyer. So, I assisted. HA A operated the Hoyer lift. CNA B stated HA A was a HA, and she should have known not to do a one-person transfer. HA A was already in there and had not asked for help; CNA B walked in on her. The HA should be the assist and the CNA should operate the Hoyer, but she already was. CNA B stated she had not seen HA A do any Hoyer Lifts since and HA A was only allowed to observe. CNA B stated the resident went to the ER and received 5 staples in her head. CNA B stated, It is not allowed for HA to work their own floor, so I don't know why she was working her own floor. They scheduled her on her own hall because I remember I thought that was weird that she was scheduled that way. I voiced that concern to [LVN A]. Interview on 10/1/23 at 2:42 PM with LVN A revealed, Hospitality Aide (HA) could provide water and answer lights but couldn't provide any care. LVN A stated, They can stock and let us know if someone needs something. They can pass a tray, but they can't feed until certified or if they have had feeding training. I have not ever had a CNA voice any concerns with an HA having their own hall. They are never assigned to their own area. LVN stated the expectation for Hoyer lifts were there always had to be two people and preferred them both to be certified unless they had Hoyer lift training and were checked off on the training. Hoyer lift training should be provided upon hire unless they had something provided of previous training. LVN A stated HA A was not to do Hoyer Lifts because LVN A was not aware that HA A was checked off for that training. Interview on 10/1/23 at 2:59 PM with ADON revealed she never had a report HA worked their own floor. The ADON stated, HA can pass ice water and answer a light but if it has anything to do with transfers or care, they have to go call the CNA on the floor. If they are doing the training and they have been checked off on, they can assist with transfers, as long as it is with a certified aide or nurse. The ADON revealed, the training was eye opening on how many didn't understand the sling colors. We just believe the failure was just the sling, it was ill fitting. The ADON revealed the facility had new training and equipment to prevent it from happening again. The ADON stated CNA B was spotting and HA A was on the Hoyer. HA A should have been spotting and CNA B should have been on the remote. The ADON revealed she did not know who was supposed to be training HA A that day and the facility would start adding who it was on the schedule . ADON stated, We located this failure that day since we don't know who was supposed to be training her [HA A]. Interview on 10/1/23 at 3:39 PM with the DON revealed the DON did not know who was training on the day of the incident. The DON stated she was informed CNA B had offered to help and that was how CNA B and HA A ended up together. The DON stated, I don't want to say she was working the floor alone , but I think that is how it was. I have seen the video of what happened. I did not see what happened inside the room. [HA A] was not in the room with Hoyer alone very long before [CNA B] came and helped. HA A should have been trained upon hire on Hoyer lift transfers. The DON revealed HA A could not use a Hoyer lift and could only be there to spot and for this incident CNA B was spotting. The DON stated, I know now that HA A was working the floor on her own but did not know that before . Interview on 10/1/23 at 3:39 PM with the DON revealed the facility did a large Hoyer lift training and now require a different aide to do the training who had a lot of experience . The facility replaced slings and put (resident's) name in them to make sure they were appropriate. The DON revealed, the facility made some administrative changes, and the aide with experience will take over the scheduling and making sure the trainings were done. CNA C was that before , but the facility was making that change. Interview on 10/1/23 at 5:13 PM with the ADM revealed the ADM interviewed HA A and asked her if she knew she couldn't transfer alone, and HA A told her she knew that . When asked why she did it, she began crying. The ADM stated she asked HA A was she comfortable with Hoyer Lift transfers and HA A informed the ADM she thought she could do it. The ADM stated when she asked HA A why she did it she just started crying. The ADM revealed HA A admitted to her she was not familiar with Hoyer's but didn't tell anyone. The ADM stated, [HA A] had her own section (hall) and that was why the facility was changing things to prevent this from happening again. Maintenance came in and checked every Hoyer and one had a loose leg and so it was replaced. The lift that was replaced was not the lift that was used for Resident #1 . Interview on 10/1/23 at 5:13 PM with the ADM revealed, We are switching up who does the schedule and so we have the ADON, and DON sign off on the schedule now. We had training done and all direct care staff got the training; it was mandatory. Then, we made every single one of them demonstrate [how to operate a Hoyer lift] and we had them get in the sling so they could see how that felt. Record review of New Hire Orientation checklist, dated 8/28/23, for HA A reflected Skills Review and Body Mechanics: Safe Lifting/Transfer/Gait Belts and Mechanical Lifts had no documentation and were not checked off; indicating training was not completed. Record review of Safe Resident Handling/Transfers policy, dated 9/4/23, revealed, .6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly . 8. The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per the manufacturer's instructions on proper sling sizing . 10. Two staff members must be utilized when transferring residents with a mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. 12. Staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. Record review of the No Lift Policy, dated 6/04, revealed, .4. Nursing staff will receive training in the use of mechanical lifts during the orientation period. The facility took the following actions to correct the noncompliance: Record review of Staff Meeting dated 9/4/23 revealed all 16 direct care staff were in-serviced on Proper use of Hoyer lift and sit to stand. Record review of Electronic Total Lift Competency dated 9/4/23 9/6/23 revealed 16 direct care staff were checked off on; HA A checked off on 9/4/23. Record review of invoice dated 9/4/23 for one Electric Patient Lift. Record review of invoice dated 9/7/23 for 12 slings of 7 different sizes. Interview on 10/1/23 at 2:59 pm with ADON revealed The audits for the Hoyer's are being done more often and had more intense training: Two people and an employee in the Hoyer. Audits will be every three months and it was annually and at hire before. We have a designated aide to do the training who has [AGE] years of experience. We purchased new slings specifically for each patient and we have a new Hoyer and we have removed the Hoyer [Resident #1] was in because the wheels got stuck sometimes and we are ironing the names [of residents] in the slings. We have also increased monitoring and audits of Hoyer lifts. ADON revealed she does not know who was supposed to be training HA-A that day and the facility will start adding who it is on the schedule. Throughout the course of the investigation from 10/1/23-10/2/23 staff were interviewed and confirmed their understanding of the in-service training provided by the facility. Staff interviewed included two CNAs (one night shift), one HA, one LVN, one RN. Interview on 10/1/23 at 2:11 pm with a family member revealed staff use 2-3 staff to transfer their resident with Hoyer Lift. Two observations were conducted of staff conducting a safe, competent Hoyer Lift transfer.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication room and 1 of 1 treatment cart inspected for medication storage. The medication room had opened, undated and an expired vials of tuberculin in the medication refrigerator. The treatment cart contained insulin pens without open dates. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect, and at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings include: During an observation and interview on 06/27/23 at 05:54 PM, the medication room was inspected with LVN A present. The door was locked and LVN A unlocked the door. Inside a small refrigerator were two opened 1ml vials of Tuberculin solution. One of the vials had an open date of 05/18/23 and the other opened vial did not have an open date. The Tuberculin solution box indicated Once entered, vial should be discarded after 30 days. LVN A said she did not know if someone was assigned to inspect the refrigerator for expired and undated medications. LVN A said it was probably everyone's job to date the vials when they were opened. During an observation and interview on 06/28/23 at 11:10 AM, the nurse treatment cart was inspected with LVN B. The treatment cart was locked and the nurse unlocked it. Inside one of the drawers there were 2 opened insulin pens that had no open date on them. LVN B said she was not sure who opened the pens and they should be dated when opened. LVN B said if they administered insulins that were expired they might not be as effective. During an interview on 06/29/23 at 10:46 AM, the DON said it was her expectation for the TB vial and insulin pens to be dated when opened and disposed when expired. The DON said she was not sure if there was someone designated to inspect the medication room for expired medications or the treatment carts but that they were working on fixing that as she had just started as DON on 06/12/23. The DON said the vials and pens not being dated occurred because it was probably overlooked by the staff that opened it and did not discard the expired TB vial. The DON said if staff used an expired test solution it could give an inaccurate reading and an expired insulin could lead to the medication to being as effective. During an interview on 06/29/23 at 11:54 AM, the Administrator said it was her expectation for staff to date insulin pens and TB vials when opened. The Administrator said it was her expectation for the DON and ADON to monitor that staff were dating them. The Administrator said if staff used an expired medication it could lead to false reading and the resident not receiving the correct medication dose. Record review of the facility policy titled Labeling of medications and biologicals dated 06/28/23 indicated in part: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Labels for multi-use vials must include: The date the vial was initially opened or accessed (needle-punctured). All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Record review of the facility policy titled Insulin Pen dated 06/28/23 indicated in part: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing. Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date. Insulin pens must be dated upon opening. Insulin pens should be disposed of after 28 days or according to manufactures recommendations.

Based on observation, interview, and record review the facility failed to ensure residents with bed rails were assessed for the risk of entrapment from bed rails, failed to provide ongoing monitoring and supervision for the use of bed rails, and failed to have a care plan in place for bed rails for 1 of 1 resident (Resident #7) reviewed for the use of full (4) bed rails. 1. Resident # 7 had full side rails at her request without a developed care plan with measurable goals benefits and risks related to side rail use. 2. The facility failed to routinely assess Resident #7 for ongoing need for and risks of side rail use (including entrapment). 3. The facility failed to conduct and document routine monitoring of Resident #7 while full side rails were in use. This failure could affect residents by putting them at an increased and unnecessary risk of harm, entrapment, and injury. Findings included: Review of Resident #7's Admission Record dated 6/29/23 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admitted [DATE]. She had diagnoses which included dementia, repeated falls, macular degeneration (a degenerative condition affecting the central part of the retina resulting in distortion or loss of central vision), psychotic disorder with hallucinations, psychotic disorder with delusions, major depressive disorder, chronic pain, and Alzheimer's disease. Review of Resident #7's quarterly MDS assessment, dated 5/20/23, revealed: She had moderate difficulty hearing and used hearing aids, she had unclear speech, was usually understood and was usually able to understand others, and she had impaired vision. Her mental status exam score was 11, indicating she had moderately impaired cognition. She required extensive or 2 plus person assistance with all ADLs and required a wheelchair for mobility. She was frequently incontinent of bowel and bladder. She received a scheduled pain medication regimen and had a history of falls. She received an antidepressant daily and an opioid daily. She had documented bed rail use daily. Review of Resident #7's Bed Rail Assessment, dated 6/16/23, revealed she was non-ambulatory, her level of consciousness fluctuated, she had an alteration in safety awareness due to cognitive decline, and had a history of falls. The assessment also revealed she had poor bed mobility, difficulty with balance and trunk control, she had difficulty with postural hypotension (decreased blood pressure with a change in position), and she was visually impaired. Further review of Resident #7's chart revealed only one other bed rail assessment dated [DATE]. Review of Resident #7's Fall Risk Evaluation, dated 6/16/23, revealed a score of 19, indicating she was a high risk for falls. Review of Resident #7's Comprehensive Care Plan, revised 6/27/23, revealed no care plan for the use of full bed rails. Observation on 6/27/23 at 1:52 PM revealed Resident #7 resting quietly in bed with full bed rails up and the bed at a normal height. Resident #7's call light button was within reach. Review of Resident #7's Order Summary, dated 6/28/23, revealed the following orders: Bed in low position while resident in bed every shift (order date 4/11/23) Full rails when in bed as personal safety per resident request every shift (order date 4/11/23) Fall precautions PRN (order date 5/1/23) Donepezil HCl tablet 10mg - give 1 tablet by mouth at bedtime for dementia related to Alzheimer's (order date 2/13/23) Memantine HCl tablet 10mg - give 1 tablet by mouth two times a day related to Alzheimer's (order date 11/30/22) Sertraline HCl tablet 50mg - give 1 tablet by mouth one time a day for depression related to major depressive disorder (order date 11/30/22) Sertraline HCl tablet 100mg - give 1 tablet by mouth one time a day for depression related to major depressive disorder (order date 11/30/23) Tramadol HCl tablet 50mg - give 2 tablets by mouth at bedtime for pain (order date 2/13/23) Tramadol HCl tablet 5mg - give 2 tablets by mouth every 6 hours as needed for moderate and sever pain (order date 2/13/23) Review of Resident #7's Consent section of her electronic chart on 6/29/23 revealed a Physical Restraint Informed Consent dated 11/7/14 for full bed rails signed by the resident's spouse, a consent for full bed rail use dated 5/2/16 signed by Resident #7, and a Shared Risk Agreement - Side Rails dated 6/29/16 signed by Resident #7. In an interview on 6/29/23 at 12:37 PM, the ADON stated that Resident #7 liked to lay in bed on her side with a pillow between her knees and very rarely moved once she was comfortable, but the aides did frequent checks while she was in bed. She stated that rounds were every 2 hours and if call light went off during the night. There was no set schedule for checking the residents during the day. The ADON stated there was no official monitoring system in place for Resident #7's bed rails. She stated the nursing staff had not readdressed Resident #7's desire to have the side rails in a long time. She stated that she believed the side rails were care planned in the old EMR system but was not aware that they were not in the new EMR system that had been in use since December 2022. In an interview on 6/29/23 at 1:26 PM, the Administrator stated she was not aware of the need for routine monitoring for bed rails. She stated she was aware that some care plans were missing information but did not specifically know that Resident #7 did not have a care plan for full bed rails. She stated the former DON was responsible for creating care plans and after she was terminated in February 2023, she discovered that the care plans were not being done correctly. Review of facility policy Proper Use of Side Rails dated 2/01/23 revealed, in part: As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's need, and whether or not the use of side/bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Size and weight c. Sleep habits d. Medications e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility (in and out of bed) l. Risk of falling The use of side rails will be specified in the resident's plan of care. The facility will provide ongoing monitoring and supervision of side/bed rail use for effectiveness, assessment of need and determination when the side/bed rail will be discontinued. Responsibilities are specified as follows: a. direct care staff will be responsible for care ad treatment in accordance with the plan of care. b. a nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail. c. the interdisciplinary team will make decisions regarding when the side/bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the rail.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of one resident reviewed for infection control. LVN C failed to sanitize the bedside table and put down a barrier to prevent cross contamination. LVN C failed to sanitize scissors after they became contaminated prior to ostomy care for Resident #4. LVN C failed to wash her hands prior to donning gloves for resident care. This failure could place resident's risk for cross contamination and the spread of infection. Findings Included: Record review of Resident #4's face sheet indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including dementia, diabetes mellitus, colostomy status, localized infection of the skin and subcutaneous tissue, major depressive disorder. Record review of the MDS assessment dated [DATE] indicated Resident #4 was understood and understood others. The MDS indicated she had minimal impaired cognition based on her BIMS score of 14. The MDS indicated Resident #4 had a pressure ulcer/injury. Resident receives applications of ointments/medications for pressure ulcer/injury. Resident has indwelling catheter and colostomy. Resident requires extensive assistance for transfers, uses wheelchair for mobility. Record review of the comprehensive care plan dated 5/23/23 indicated Resident #4 has potential/actual impairment to skin integrity due to open area to ostomy stoma. Goal is that the resident will have no complications related to open skin. Interventions are to follow facility protocols for treatment of injury. Monitor/document location and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection and maceration to physician. Record review of Resident #4's physician orders dated 3/09/23 Cleanse and clean ostomy as needed. Apply thin duoderm around ostomy site for skin protection prior to applying wafer, may also use hydrocolloid gel around site for protection, change every 3 days and as needed. Perform skin assessment everyday shift on Thursdays. During an observation on 6/27/23 at 1:50 PM, LVN C entered Resident #4's room. LVN C placed supplies for colostomy bag and dressing change on the residents bedside table. It was noted by surveyor that residents abdomen was swollen, red and excoriated. LVN C stated that resident had developed a little ulcer next to the stoma and surrounding skin was irritated. LVN C then pulled scissors out of her pocket, placed the scissors in her mouth, washed her hands and donned gloves while holding the scissors in her mouth. LVN C then walked to residents bedside table and removed the moldable convex skin barrier with flange from the package. LVN C took the scissors from her mouth and cut the hole to size for placement over the stoma. LVN C then opened the skin protectant wipe package and applied to residents skin, then LVN C attached the moldable convex skin barrier to residents skin. LVN C then took the drainable pouch and attached it to the flange of the moldable convex skin barrier. LVN C doffed gloves and left the residents room to get tape, stating that wafer did not stick to skin. LVN C returned to residents room, donned new gloves, failing to wash her hands. LVN C then, applied Hypafix tape all around wafer. LVN C covered resident with blanket, then doffed gloves and washed her hands prior to leaving the room. During interview on 06/29/23 at 11:45 AM with ADON, she stated that she is responsible for nurse training regarding resident care procedures. ADON stated that her expectations for colostomy care are as follows: 1.Walk into the residents room and wash hands. 2. Clean bedside table with sanitizing wipes and lay down barrier paper. 3. Remove supplies from package and set up on barrier paper. 4. Wash hands and don clean gloves. 5. Remove soiled moldable convex skin barrier with flange and bag. 6. Wash hands and don clean gloves. 7. Pre- cut moldable convex skin barrier with flange and attach new bag. 8. Assess pain level and pre- medicate if necessary. 9. Apply skin barrier, attach moldable convex skin barrier with flange and new bag. 10. Doff gloves and wash hands. Position resident for comfort. During an interview on 06/29/23 at 12:30 PM, the Administrator stated that all staff is expected to perform proper hand hygiene prior to resident care. Administrator stated that infection control is important to the safety of the residents. Record review of the facility's policy titled Hand hygiene and revised 02/01/23 indicated in part: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. Perform hand hygiene prior to donning gloves and immediately after offing gloves. Perform hand hygiene after handling contaminated objects, before performing resident care procedures. Record review of the facility's policy titled Infection Prevention and revised 02/01/23 indicated in part: This facility has established and maintains 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.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility failed to submit PBJ staffing information to CMS for the 2nd quarter of the fiscal year 2023. The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Record review of the CMS PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 2 2023 (January 1 - March 31), dated 06/22/2023, revealed the following entry: Failed to Submit Data for the Quarter .Triggered .Triggered=No Data Submitted for the Quarter. Review of the facility's Employee List dated 6/27/23 indicated the following: 1 Administrator 5 RNs (included DON) 6 LVNs. 17 CNAs 3 Maintenance Personnel 6 Housekeeping Personnel 1 Human Resources 8 Dietary Personnel 4 Hospitality Aides 2 Medication Aides. 1 Activity Director. Record review of the facility CMS form 672 (Resident Census and Conditions of Residents) dated 06/28/23 provided by the DON indicated a total of 28 residents in the facility. During an interview on 06/29/23 at 09:14 AM, the Administrator said that a Payroll Based Journal had not been submitted by the previous DON and was one of the reasons they had terminated her. The Administrator said they were unable to tell if the previous DON had even attempted to submit the Payroll Based Journal so at this time they had no evidence to show this had been done.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of two residents reviewed for infection control practices in that: CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 10/04/22, revealed a 76- year- old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required extensive assistance with most ADLs and two-person physical assistance with transfer. Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 04/13/22 revealed she did not have a specific plan for bladder or bowel incontinence. Observation of incontinence care for Resident #1 on 10/06/22 at 11:04 a.m. revealed CNA A and CNA B washed hands and donned gloves before transferring the resident from wheelchair to bed. She did not change gloves after the transfer of the resident. CNA A removed Resident #1's brief that was soiled with fecal matter and urine. CNA A wiped the resident from front to back. CNA A made 4 strokes of clean with same soiled wipe. CNA A's gloves were visibly soiled with urine. She did not wash her hands, change gloves or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. Both CNA A and CNA B washed hands before exiting Resident #1's room. In an interview on 10/06/22 at 11:12 a.m. with CNA A, she stated cross contamination was mixing clean with dirty. She acknowledged she should have washed her hands after transferring the resident. CNA A also said she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she had been employed in the facility for 3 months and did not receive infection control training including during orientation. She said the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. During an interview with the DON on 10/06/22 at 12:15 p.m., she revealed she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand washing and change of gloves as needed. The DON explained the staff received infection control training including during orientation. Review of the facility's Hand hygiene policy dated 06/07/22 reflected, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines 1) Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standard of practice. 2) Hand hygiene is indicated and will performed under conditions listed in, but not limited to, the attached table a) Hands are visibly dirty b) Hands are visibly soiled with blood or other fluids . c) Before performing resident care procedures .

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure the dishwasher machine dispensed the correct amount of chlorine sanitizer. This failure could place residents at risk for food-borne illness and cross contamination. Findings include: During an observation and interview on 04/26/2022 at 10:32 AM, Dietary Aide A was seen washing the dishes with the automatic dishwasher. The aide said she first rinsed the pots and dishes and then ran them through the dishwasher. The aide said she would go based on how the dishes looked after they went through the dishwasher to determine if they were clean and sanitized. Dietary Aide A said she looked at the chemical containers as well to determine if the dishwasher machine had chemicals going to it. The aide said she also checked the water temperature on the dishwasher machine to see if it was working correctly. The aide said she used the test strips to check the temperature of the dishwasher water. Dietary Aide A took a chlorine test strip paper and dipped it in the water that was in the dishwasher after she ran it with a load of dishes. The aide compared the test strip results to the colors on the test strip container. The test strip was white in color and matched the 10 ppm mark on the test strip container. The aide said the color on the test strip indicated the temperature of the water and 10 ppm was correct and was good. Dietary aide A said she believed the test strips were to test the temperature of the water. The sanitizing chemical container was noted to be half to a quarter full and indicated Low temp dish machine sanitizer which was connected to the dishwasher machine. The dishwasher temperature gauge indicated 125 degrees Fahrenheit. During an observation and interview on 04/26/2022 at 10:44 AM, the Dietary Manager tested the dishwasher water with a test strip and it indicated 10ppm when compared to the colors on the test strip container. The Dietary Manager said the dishwasher machine was supposed to indicate 50ppm on the test strip so the machine was not getting enough chlorine sanitizer solution. The Dietary Manager told Dietary Aide A whenever the test strip did not indicate 50 ppm to tell someone and not just continue using the dishwasher. Dietary Aide A said when she tested the chemicals this morning the test strip had indicated 50 ppm. The Dietary Manager primed the chemical dispensing component on the dishwasher and tested the chemical again and it was 50 ppm on the test strip. The Dietary Manager said that was correct now and Dietary Aide A was not the regular dishwasher person. The Dietary Manger told the Dietary Aide to re-wash the dishes she had already washed. The aide then re-washed the dishes. During an interview on 04/28/2022 at 09:32 AM, Dietary Aide A said she had worked in the kitchen for about 1 year. The aide said she was trained by the Dietary Manager on using the dishwasher machine and checking the chemicals. The aide said she knew how to check the chemicals on the dishwasher but she got so nervous she panicked and forgot. The aide said she knew the test strips were used to measure the amount of chlorine chemical and not the water temperature. The aide said if the dishes were not sanitized correctly it could lead to the dishes not being cleaned properly and could lead to the residents coming in contact with germs and bacteria. During an interview on 04/28/22 at 09:48 AM, the Dietary Manager said Dietary Aide A received training regarding the use of the dishwasher before she used it. The manager said he trained her so he knew she knew how to check the chemicals and he had observed her doing it correctly. The manager said the aide got very nervous and just blanked out. The manager said the staff received monthly in-services on the use of the dishwasher machine. The manager said if the dishwasher was not sanitizing correctly then everything that was washed in it could continue to be contaminated. The manager said he believed the failure occurred because Dietary Aide A got very nervous and forgot the steps on how to check the dishwasher chemicals. During an interview on 04/28/22 at 11:24 AM, the Administrator said she would go into the kitchen and observe the staff working and ask them if they needed any help. The Administrator said Dietary Aide A had told her she got very nervous when the State Surveyor observed her washing the dishes. The Administrator said the failure probably occurred because the aide got nervous and did not remember the steps on how to check the dishwasher for sanitizer results. The Administrator said the staff would get more in-services and training on the use of the dishwasher. Record review of the dishwasher machine manufactures plaque located on the side of the machine indicated in part: Minimum chlorine 50 PPM. Record review of Dietary Aide A training files provided by the Dietary Manager revealed in part: Dishwasher temperature - Wash temperature must be 120. Rinse temperature must be 120. Parts per million (ppm) needs to be at 50 or greater. Make sure that all chemicals working properly. Record review of the facility policy Dishwasher temperature, dated 01/20/2020, indicated in part: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperature. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. Manufactures instructions shall be followed for machine washing and sanitizing. For low temperature dishwashers (chemical sanitization). The wash temperature shall be 120 degrees Fahrenheit. The rinse temperature shall be 120 degrees Fahrenheit. The sanitizing solution shall be 50ppm hypochlorite (chlorine) on dish surface final rinse. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift. Results of concentration checks shall be recorded.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity, and care for each resident that promoted maintenance of quality of life for 1 (Resident #1) of 1 residents reviewed for resident rights. The facility did not provide Resident #1 with customized wheel chair after she requested and was eligible for one. The facility did not provide a physical therapist to assess Resident #1 for a customized wheel chair. This failure could place residents at risk for decreased self-esteem, decreased self-worth and decreased quality of life. Findings included: Review of the undated face sheet for Resident #1 revealed a 75-year-female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Annual MDS (minimal data set) dated 02/14/2020 revealed she had a BIMS (brief interview for mental status) of 12 indicating she was able to make her needs known. Resident #1's Functional Status revealed she moves between locations in her room and adjacent corridor. She is self-sufficient once in chair requires limited assistance with one person Review of Resident #1's Care Plan dated 01/15/2020 revealed the following: Problem: I required assistance to propel wheelchair for long distances I am dependent on staff to propel my wheelchair. Goal: I will accept assistance with locomotion for the next 90 days. Intervention: Provide with appropriate level of assistance to promote my safety. Encourage me to participate in propelling wheelchair, and praise accomplishments. Assist me only when necessary. Instruct me in proper use of wheelchair. Monitor my wheelchair to make sure it fits and position my body properly, and that all its parts are in safe and working order - obtain wheelchair evaluation from Physical therapy if needed . Review of Resident #1's PASRR Comprehensive Service Plan (PCSP) Form dated 01/29/19, reflected Durable Medical Equipment (DME) PASRR evaluated, Customized wheel chair not needed, Specialized Occupational Therapy and Specialized Physical Therapy was agreed upon by the following people in attendance: Resident #1, Director of Nursing (DON), MDS Coordinator, Social Worker, Physical Therapist, Legal Authorized Representative, service coordinator for the Local Intellectual/Developmental Disability Authority (LIDDA). During the meeting Resident #1 stated she would like for LIDDA to assist her with a wheel chair that fits her well. Physical Therapist attended IDT meeting and would measure resident for an appropriate wheel chair. Order to be obtained for physical therapy to evaluate and treat as indicated for a new wheel chair. During the meeting SPT (service planning team) met and reviewed services with Resident #1 now (10/29/19) she would like to receive a Customized Wheel Chair and Service Coordination. Review of Resident #1's PASRR Comprehensive Service Plan (PCSP) Form dated 10/29/19, reflected Durable Medical Equipment (DME) Customized Manual Wheel Chair, Specialized Occupational Therapy and Specialized Physical Therapy was agreed upon by the following people in attendance: Resident #1, Director of Nursing (DON), MDS Coordinator, Social Worker, service coordinator for the Local Intellectual/Developmental Disability Authority (LIDDA). Review of an undated Authorization Request for Nursing Facility Specialized Service (NFSS) for Customized Manual Wheelchair (CWMC) revealed the pertinent information was completed but the referral physician was not identified or information completed. Review of an undated (completed after initial investigation on 02/14/2020) Authorization Request for Nursing Facility Specialized Service (NFSS) for Customized Manual Wheelchair (CWMC) revealed the pertinent information was completed and the physical therapist completed her assessment concluding: It is suspected that the patient level of independence will decline as she ages and a custom chair will be needed. If she gets a support a new chair now she may not be eligible to get another one in the future. (resident is [AGE] years old) (continuation of the PT (physical therapist) evaluation) - Nursing: The DON had already spoken with the resident. She indicated the patient needed head support a lower chair and support for her back. The patient was asked by a representative (from Passr-Dads) if she wanted a new wheelchair and the patient said yes. During an interview on 02/14/2020 at 1:15 PM with the Nursing Facility Administrator said the problem with getting Resident #1 her customized wheel chair is the physical therapist at the hospital who is contracted to the hospital refuses to assess Resident #1 for her customized wheel chair. She said it had to do with her getting paid and Administrator said she would pay her if the physical therapist would tell her how much time she would need to assess the resident. During an interview on 02/14/20 at 1:35 PM, MDS Coordinator said Resident #1 has lived at the facility since January of last year (1/29/19) and was PASRR positive at that time. She said there has been two IDT representatives that have tried to work with me but they were not able to access the portal to put in the information she needed to begin to try to get Resident #1 additional services. She said she had a new IDT represented in October 2019 and she helped me get the information into the portal. She said the problem was the physical therapist refused to assess Resident #1 unless there was a specific physician order. So, that was the delay in getting the DME to provide a customized wheel chair. She said the DON wrote a verbal order for the physical therapist to assess Resident #1 but she did not like the way the order was written. During an interview on 02/14/2020 at 2:10 PM with the Hospital Administrator he said the physical therapist is contracted by an outside staffing agency and the only way she could assess Resident #1 was to get an order from the physician. He said they do only out-patient therapy and she did not have to assess Resident #1. He recognized that failure to assess Resident #1 could be a detrimental to the welfare of Resident #1. During an interview on 02/14/2020 at 3:00 PM the IDT representative said she has been working with the MDS coordinator regarding Resident #1's PASSR since last year and been trying to get her specialized wheel chair but the IDT case worker had been changed several times and she had not been getting guidance on how to do the paper work. She said this has been an ongoing issue for a year. She said the last IDT meeting was 01/22/2020. During an interview on 03/05/2020 at 11:30 AM DME (durable medical equipment) professional said he has been trying to assist the facility but he is waiting on the completed paper work to be available. He said he has offered to assist the facility but they said they were having problems with getting the physical therapist to assess the resident. He said he is going to the facility soon to assist the resident in getting her customized wheel chair. During an interview on 03/05/2020 at 1:30 PM Resident #1 said she would like a new wheel chair and it would be better for her while at the facility and felt her rights were not considered.

Based on interview and record review, the facility failed to incorporate the recommendations from the PASRR (Preadmission Screening and Resident Review) level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for one (Residents #1) of three residents reviewed for administration. The facility failed to submit Nursing Facility Specialized Services (NFSS) request form for durable medical equipment for Resident #1 within 20 business days (delayed for over a year) of an Interdisciplinary Team (IDT) meeting on 1/29/19. This failure could place residents at risk for not receiving the needed care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of the undated face sheet for Resident #1 revealed a 75-year-female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Annual MDS (minimal data set) dated 02/14/2020 revealed she had a BIMS (brief interview for mental status) of 12 indicating she was able to make her needs known. Resident #1's Functional Status revealed she moves between locations in her room and adjacent corridor. She is self-sufficient once in chair requires limited assistance with one person Review of Resident #1's Care Plan dated 01/15/2020 revealed the following: Problem: I required assistance to propel wheelchair for long distances I am dependent on staff to propel my wheelchair. Goal: I will accept assistance with locomotion for the next 90 days. Intervention: Provide with appropriate level of assistance to promote my safety. Encourage me to participate in propelling wheelchair, and praise accomplishments. Assist me only when necessary. Instruct me in proper use of wheelchair. Monitor my wheelchair to make sure it fits and positron my body properly, and that all its parts are in safe and working order - obtain wheelchair evaluation from Physical therapy if needed . Review of Resident #1's PASRR Comprehensive Service Plan (PCSP) Form dated 01/29/19, reflected Durable Medical Equipment (DME) PASRR evaluated, Customized wheel chair not needed, Specialized Occupational Therapy and Specialized Physical Therapy was agreed upon by the following people in attendance: Resident #1, Director of Nursing (DON), MDS Coordinator, Social Worker, Physical Therapist, Legal Authorized Representative, service coordinator for the Local Intellectual/Developmental Disability Authority (LIDDA). During the meeting Resident #1 stated she would like for LIDDA to assist her with a wheel chair that fits her well. Physical Therapist attended IDT meeting and would measure resident for an appropriate wheel chair. Order to be obtained for physical therapy to evaluate and treat as indicated for a new wheel chair. During the meeting SPT (service planning team) met and reviewed services with Resident #1 now (10/29/19) she would like to receive a Customized Wheel Chair and Service Coordination. Review of Resident #1's PASRR Comprehensive Service Plan (PCSP) Form dated 10/29/19, reflected Durable Medical Equipment (DME) Customized Manual Wheel Chair, Specialized Occupational Therapy and Specialized Physical Therapy was agreed upon by the following people in attendance: Resident #1, Director of Nursing (DON), MDS Coordinator, Social Worker, service coordinator for the Local Intellectual/Developmental Disability Authority (LIDDA). Review of an undated Authorization Request for Nursing Facility Specialized Service (NFSS) for Customized Manual Wheelchair (CWMC) revealed the pertinent information was completed but the referral physician was not identified or information completed. Review of an undated (completed after initial investigation on 02/14/2020) Authorization Request for Nursing Facility Specialized Service (NFSS) for Customized Manual Wheelchair (CWMC) revealed the pertinent information was completed and the physical therapist completed her assessment concluding: It is suspected that the patient level of independence will decline as she ages and a custom chair will be needed. If she gets a support a new chair now she may not be eligible to get another one in the future. (continuation of the PT (physical therapist) evaluation) - Nursing: The DON had already spoken with the resident. She indicated the patient needed head support a lower chair and support for her back. The patient was asked by a representative (from Passr-Dads) if she wanted a new wheelchair and the patient said yes. During an interview on 02/14/2020 at 1:15 PM with the Nursing Facility Administrator said the problem with getting Resident #1 her customized wheel chair is the physical therapist at the hospital who is contracted to the hospital refuses to assess Resident #1 for her customized wheel chair. She said it had to do with her getting paid and Administrator said she would pay her if the physical therapist would tell her how much time she would need to assess the resident. During an interview on 02/14/20 at 1:35 PM, MDS Coordinator said Resident #1 has lived at the facility since January of last year (1/29/19) and was PASRR positive at that time. She said there has been two IDT representatives that have tried to work with me but they were not able to access the portal to put in the information she needed to begin to try to get Resident #1 additional services. She said she had a new IDT represented in October 2019 and she helped me get the information into the portal. She said the problem was the physical therapist refused to assess Resident #1 unless there was a specific physician order. So, that was the delay in getting the DME to provide a customized wheel chair. She said the DON wrote a verbal order for the physical therapist to assess Resident #1 but she did not like the way the order was written. During an interview on 02/14/2020 at 2:10 PM with the Hospital Administrator he said the physical therapist is contracted by an outside staffing agency and the only way she could assess Resident #1 was to get an order from the physician. He said they do only out-patient therapy and she did not have to assess Resident #1. He recognized that failure to assess Resident #1 could be a detrimental to the welfare of Resident #1 During an interview on 02/14/2020 at 3:00 PM the IDT representative said she has been working with the MDS coordinator regarding Resident #1's PASSR since last year and been trying to get her specialized wheel chair but the IDT case worker had been changed several times and she had not been getting guidance on how to do the paper work. She said this has been an ongoing issue for a year. She said the last IDT meeting was 01/22/2020. During an interview on 03/05/2020 at 11:30 AM DME (durable medical equipment) professional said he has been trying to assist the facility but he is waiting on the completed paper work to be available. He said he has offered to assist the facility but they said they were having problems with getting the physical therapist to assess the resident. He said he is going to the facility soon to assist the resident in getting her customized wheel chair. During an interview on 03/05/2020 at 1:30 PM Resident #1 said she would like a new wheel chair and it would be better for her while at the facility.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for one (Resident #6) of three residents reviewed for nebulizer breathing treatments for [MEDICAL CONDITION] conditions as evidenced by: Resident #6's nebulizer mask (used for delivering inhaled medications) was laying on resident's dressers exposed (without being secured in a bag to prevent contamination) with medication in the medication delivery nebulizer. The tops of the box which were supposed to hold the nebulizer had white powder material on top of the boxes with the nebulizer and mask on top of them. This failure could place residents at risk for developing upper respiratory infections, pneumonia, and and cross contamination. Finding Review: Review of Resident #6's undated Face Sheet revealed he was an [AGE] year-old male re-admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #6's annual MDS (minimum data set) dated 05/29/19 revealed he had a BIMS (brief interview for mental status) of 11 indicating he had moderate cognitive impairment and able to make his needs known. Annual MDS also indicated Resident #6 had shortness of breath or trouble breathing with exertion. Review of Resident #6's Care Plan dated 07/09/19 revealed the following: Problem: Ineffective breathing pattern related to [MEDICAL CONDITIONS] Goal: Resident will demonstrate an effective respiratory rate, depth and pattern. Intervention: Monitor respiratory rate, depth and effort. Review of physician orders [REDACTED]. During an observation and interview on 09/04/19 at 11:00 AM Resident #6 was resting on the side of his bed with oxygen cannula in his nose running at 2lpm (liters per minute). Resident #6's nebulizer and mask was lying on his dresser with a small amount of medication remaining inside of the nebulizer cup. The date on the mask was noted 08/15/19. There was a blue box with 3 round white crusted material on top of the box and the box was labeled nebulizer inside of the nebulizer box was paper towels with brown stained material on the paper towels and some tubing inside of the box. During an interview on 09/04/19 at 11:15 AM LVN A she said the nebulizer and mask were supposed to be in the nebulizer box and covered. She said there should not be any medication in the nebulizer cup and it should be clean inside of the box which contained the nebulizer and mask and dated appropriately. During exit conference on 09/10/19 at 5:15 PM with the Administrator and DON they confirmed the need to be more vigilant with infection control, provide tracking and trending to identify infections and make sure nebulizer and mask used by residents are properly dated and have a clean place to put them. Review of the facility's policy and procedure dated 08/01/18 titled, Nebulizer Therapy revealed the following: 1. Care of the Resident .m. Disassemble and rinse the nebulizer with water and allow to air dry. 2. Care of The Equipment .g. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag and/or plastic container at bedside.

Based on observation, interview and record review the facility failed to ensure acceptable parameters of body weight were maintained for 1 (Resident #15) of 4 residents reviewed for nutrition. The facility did not develop and implement effective interventions to address Resident #15 's significant weight loss of 28% in 5 months. This failure could place residents with unplanned weight loss at risk of not having their nutritional needs addressed. Findings included: Review of Resident #15's Face Sheet dated 04/02/19 indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Vitamin B12 deficiency [MEDICAL CONDITION], anxiety disorder, panic disorder, [MEDICAL CONDITIONS] and constipation. Admission weight was recorded as 132 lbs. Review of Resident #15 MDS assessment dated [DATE] indicated she was readmitted to the facility on [DATE] (hospitalized for [REDACTED]. She had long and short-term memory problems. She had severely impaired cognitive skills for daily decision making. She required extensive assistance with ADLs. She had range of motion impairment of one leg. She was incontinent of bowel and bladder. Active [DIAGNOSES REDACTED]. Review of Resident #15's care plan dated 06/10/19 included: Problem - Self-Care Deficit: Eating/potential for weight loss Goal(s) - Resident's intake will be 75% of all food and fluids offered per meal for the next 90 days; Resident will assist with feeding for the next 90 days; Resident will hold cup for the next 90 days Interventions - Assess history of impairment, onset, duration; Assess contributing factors: diagnosis, medications, infection, situational; Identify food; Say good things about food; Do not mix foods together; Test food temperature Problem - Refuses to Eat/Drink Goal(s) - Resident will verbalize understanding of consequences of non-compliance for the next 90 days. Interventions - Monitor intake and weight; Assess resident's understanding of situation, coping skills and support system; Emphasize positive aspects of compliance; Inform resident about risks of non-compliance; Accept resident's right to refuse, and show respect for resident's decisions Observations of Resident #15 during the survey included, in part: 09/04/19 at 11:30 AM - Resident#15 was in bed sleeping, lying on her back. Half side rails were in the up position. 09/05/19 at 12:40 PM - Resident #15 was sitting up in bed with lunch on the over-bed table. Resident not eating. She was unable to coherently answer questions regarding the food. Resident appears thin. 09/06/19 10:30 AM - Resident #15 has not been observed being offered snacks or health shakes during survey. Review of Resident #15's Nutritional Assessment form included an assessment by the dietician dated 04/24/19 that listed a weight of 132 lbs. The next entry was dated 07/18/19 and listed a weight of 109.8 lbs., down 26.2 lbs. in 30 days. Family is considering hospice .Consider health shakes of choice BID and fortified cereal. The last entry was dated 08/06/19 and listed a weight of 104 lbs., down 5.8 lbs. in 30 days. Not on hospice. Continue Regular NAS diet. Second request for health shake BID and fortified cereal. Review of the Weight Change History Report dated 09/06/19 included Resident #15's weight from 06/17/19 at 115 lbs to 09/02/19 at 95 lbs. This constituted a 17.4% weight loss in 11 weeks. (Overall, Resident #15 went from 132 lbs at initial admission on 04/01/19 to 95 lbs on 09/02/19, constituting a 28% weight loss in 5 months.) Review of physician visits with Resident #15 included a visit by the PA on 07/29/19 for a 30-day nursing home visit. The PA documented the resident was negative of chills, fatigue, fever, and weight change. On 08/01/19 Resident #15 was seen by the NP for a shingles type rash on her buttock. The NP documented the resident was well developed and nourished. Review of Resident #15's (MONTH) 2019 Physician Orders included Obtain monthly weights on the 1st of each month, and Regular NAS diet with thin liquids with a start date of 06/07/19. In an interview with the DON on 09/06/19 at 3:50 PM she said that around the first part of (MONTH) they tried the health shakes and fortified cereal, but the resident refused, saying, 'I'm not eating that[***]' She said they didn't write an order, just did a trial run one weekend. The DON acknowledged that nothing was documented in nurses' notes addressing the weight loss or any attempted interventions. There was no documentation that the physician had been notified. Review of the facility policy, Weight Monitoring, dated (YEAR), included the following, in part: Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status .unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: 1. The facility will use a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary 3. .The care plan should address the following, to the extent possible: a. Identified causes of impaired nutritional status b. Reflect the resident's personal goals and preferences c. Identify resident-specific interventions d. Time frame and parameters for monitoring e. Updated as needed such as when the resident's condition changes . f. If nutritional goals are not achieved, care planned interventions will be reevaluated . g. The resident and/or resident representative will be involved in the development of the care plan . 6. Weight Analysis: .A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (120 days) 7. Documentation: a. The physician should be informed of a significant change in weight . b. The physician should be encouraged to document the [DIAGNOSES REDACTED]. e. The Registered Dietician or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutritional progress notes. f. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate.

Based on observation, interview, and record review, the facility must ensure residents were free of any significant medication errors for one (Residents #1) of five residents reviewed for significant medication errors. 1. LVN A failed to correctly identify Resident #2 and gave her Resident #1's Levimir insulin 35 units SQ on 07/12/18 via insulin pen injection. Resident #2 was transported to the local emergency room for blood sugar monitoring 07/12/18. These failures resulted in a Past Non-Compliance Immediate Jeopardy because the facility had taken appropriate measures when LVN A discovered the medication error. The failure could affect the five diabetic residents who receive insulin by placing them at risk for [MEDICAL CONDITION], Ketoacidosis, coma, or death from not receiving insulin to control high blood sugars. Findings included: Review of Resident #1's Face Sheet dated 07/27/18 revealed she was a [AGE] year-old female admitted to the facility 04/05/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] revealed, in part, inability to complete the BIMS, inattention, she needed extensive assistance for ADL's, was incontinent of bowel and bladder and received insulin injections 7 of the last 7-day look back period. Review of Resident #1's care plan dated 07/21/18 revealed, in part, her cognitive deficit, diabetes and potential alteration in nutrition. Review of Resident #1's Physician order [REDACTED].Levimir (insulin detemir) 100 units per ml administer 35 units subcutaneously Q HS rotate sites . Review of Resident #2's Face Sheet dated 07/27/18 revealed she was an [AGE] year-old female admitted to the facility 10/12/17 with [DIAGNOSES REDACTED]. Review of Resident #2's Significant Change MDS dated [DATE] revealed, in part, her memory problem, inattention, disorganized thinking, altered level of consciousness and incontinence of bowel and bladder (No diabetes diagnosis) Review of Resident #2's care plan dated 07/21/18 revealed, in part, hoarding of objects, wandering, sleep pattern disturbance, cognitive deficit, vision and hearing impairment, fragile skin and pain. Review of Resident #2's Physician order [REDACTED]. In an interview on 07/27/18 at 11:05 a.m., the DON said LVN A had not worked at the facility long when the medication error occurred. The DON said LVN A had orientation including following another nurse for 3 nights before working independently as the charge nurse. She said around 7:30 p.m. on 07/12/18, LVN A gave Resident #2 the insulin intended for Resident #1 and then asked CNA B if it was Resident #1. CNA B informed LVN A that the resident who received the insulin was Resident #2. The DON said LVN A immediately called the emergency room and spoke with a physician who instructed her to take Resident #2 to the emergency room . The DON said CNA B took Resident #2 via wheelchair to the E.R., which is connected to the facility. She said RN C came to the facility and took over as the charge nurse and LVN A was suspended during the investigation. She said RN C gave the remainder of insulin injections that evening. In an interview on 07/27/18 at 1:44 p.m., CNA B said LVN A was standing next to a resident and asked her if the resident (Resident #2) was (name) Resident #1. CNA B said she told LVN A no, that's (name) Resident #2. And LVN A yelled to take Resident #2 to the E.R., which CNA B said she did. She said Resident #2 was a little confused, which was normal for her. In an interview on 07/27/18 at 1:49 p.m., RN D said she showed LVN A around for 2 night shifts and the 3rd night, LVN A said she was ready to go (indicating LVN A could work independently). RN D said she was not working when LVN A made the insulin medication error, but LVN A later told her she got nervous and made a mistake. In an interview on 07/27/18 at 1:55 p.m. RN C said she was the former DON of the facility and was called by the DON to go to the facility 07/12/18 in the evening. She said when she arrived, she told LVN A to give her the keys to the medication room and cart and suspended LVN A during the investigation. RN C said she took over the medication pass and gave Resident #1 her insulin injection prior to going to the E.R. to check on Resident #2. She said Resident #2 was kept at the hospital overnight. RN C said she did not think LVN A received enough orientation prior to working independently. She said she told the DON that new staff needed in-services on identifying residents. In an interview on 07/27/18 at 2:13 p.m., LVN A said 07/12/18 was her first night working by herself. She said she mistook Resident #2 for Resident #1 and performed a blood glucose on Resident #2, which she said was 140 mg/dl. She said she then gave Resident #2 35 units of Levimir insulin SQ. LVN A said CNA B walked by and LVN A asked her if the resident (Resident #2) was (name) Resident #1 and CNA B told her no, so she immediately called the E.R. and had CNA B take Resident #2 via wheelchair to the E.R. LVN A said she was suspended for the night. Review of Resident #2's hospital emergency room record dated 07/12/18 revealed, at 7:40 p.m. she was brought from the nursing facility to the emergency room after receiving 35 units of Levimir insulin given by mistake. The hospital emergency room record included Vital sign/graphic flow sheet 7:45 p.m.- 103 mg/dl (mg/dl, or milligrams per deciliter, is a measurement that indicates the amount of a particular substance (such as glucose) in a specific amount of blood. www.webmd.com accessed 08/09/18) 7:52 p.m. - 103 mg/dl 8:02 p.m.- 351 mg/dl 8:30 p.m.- 175 mg/dl 8:52 p.m.- 132 mg/dl (1/2 [MEDICATION NAME] D50 given) (50% [MEDICATION NAME] Injection, USP is a sterile, nonpyrogenic, hypertonic solution of [MEDICATION NAME] in water for injection for intravenous injection as a fluid and nutrient replenisher 50% [MEDICATION NAME] Injection is indicated in the treatment of [REDACTED]. (www.drugs.com accessed 8/6/18) 9:20 p.m.- 143 mg/dl (1/2 [MEDICATION NAME] D50 given) 9:50 p.m.- 145 mg/dl (1/2 [MEDICATION NAME] D50 given) 10:20 p.m.- 143 mg/dl (1/2 [MEDICATION NAME] D50 given) 10:50 p.m.- 150 mg/dl- (1/2 [MEDICATION NAME] D50 given) 11:20 p.m.- 127 mg/dl (1/2 [MEDICATION NAME] D50 given) Review of Resident #2's hospital emergency room record dated 07/13/18 revealed the Vital sign/graphic flow sheet for blood glucose levels: Fasting (prior to eating) Normal for person without diabetes: 70-99 mg/dl Official ADA recommendation for someone with diabetes: 80-130 mg/dl (www.diabetesselfmanagement.com accessed 08-15-18) 12:50 a.m.- 120 mg/dl 1:20 a.m.- 79 mg/dl (D10 given) (no amount documented) (When administered intravenously, solutions containing carbohydrate in the form of [MEDICATION NAME] restore blood glucose levels and provide calories.) (www.drugs.com accessed 8/6/18) 1:50 a.m.- 81 mg/dl 2:20 a.m.- 76 mg/dl 2:50 a.m.- 85 mg/dl 3:20 a.m.- 84 mg/dl 3:50 a.m.- 81 mg/dl 4:20 a.m.- 86 mg/dl 4:50 a.m.- 84 mg/dl 5:20 a.m.- 89 mg/dl 5:50 a.m.- 80 mg/dl 6:20 a.m.- 89 mg/dl 6:50 a.m.- 88 mg/dl 7:20 a.m.- 81 mg/dl 7:50 a.m.- 92 mg/dl 9:50 a.m.- 134 mg/dl 9:50 a.m.- 117 mg/dl 10:34 a.m.- 104 mg/dl 11:30 a.m.- 98 mg/dl 12:30 p.m.- 88 mg/dl 1:05 p.m.- 120 mg/dl 2:10 p.m.- 118 mg/dl 3:00 p.m.- 119 mg/dl Review of Resident #2's Nurse's Notes dated 07/12/18 at 7:30 p.m. revealed, Levimir 35 units given at this time by this LVN in error. BS (blood sugar) at the time was 140 (mg/dl). (Physician's name) notified & resident transferred to E.R. @ this time. The document was signed by LVN A. Review of the facility's Medication Error Report dated 07/12/18 revealed (Resident #2 name, physician's' name, room number date), Levimir, dosage-35 units physician's orders [REDACTED]. RSD not DM (Diabetes Mellitus). Reason for error: RSD received another RSD insulin. LVN mistaked (sic) RSD for different RSD. Would this error/did this error endanger the life or welfare of this Resident? (Yes was circled). Explain: RSD is not DM. What was the actual effect on this resident? RSD was treated in E.R. (emergency room ) with D-50, stable condition. How was the error discovered? LVN was told by CNA that RSD was (resident's name) not the correct RSD . Review of the facility's policy, Preventing Medication Errors, implemented 07/12/18 and reviewed/revised 07/19/18, revealed, .The facility will ensure its residents are free of any significant medication errors. Definitions: Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specification or acceptable professional standards and principals. Significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety .Medication administration .Identify resident by photo in the MAR (Medication Administration Record) .Compare medication source (bubble pack, vial, etc.) with MAR indicated [REDACTED].Infection control: 1. Insulin pens are for individual use only . The facility immediately sent Resident #2 to the emergency room and suspended LVN A when the medication error was discovered. The DON held an in-service 07/12/18 regarding timely insulin administration, the policy on medication error prevention and the 8 rights of medication administration. The DON initiated a Performance Improvement Project Worksheet 07/13/18 regarding the medication error which included, in part, .the facility had no system in place for identifying RSD (resident) and RSD not always able to provide nurse with identifiers due to dementia .approaches 1. Include RSD photo in diabetic TAR for RSD to be identified. 2. Add photos of new RSD. 3. Nurse completed orientation but will be required to verify RSD name with CNA or other nsg (nursing) staff prior to administering meds/insulin. 4. Moved wx (wound?) care tx (treatment) back to day shift. 5. Will have extra CNA on floor 6p-6a 3 CNA total. 6. In-service nsg staff re: med errors, change in tx (treatment), 8 rights of med admin (administration). 7. Med-nurse could admin (administer) insulin to lighten load of charge nurse. 8. Monitor nurse during med pass/admin (administration) of insulin. QAPI (Quality improvement performance improvement committee) . The facility implemented/revised its policy Preventing Medication Errors 07/12/18 and 07/19/18 as above. The facility reviewed/revised its policy, Insulin Pen, 07/17/18 which revealed, It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Policy explanation and compliance guidelines: 1. Insulin pens contain multiple doses of insulin but are used for a single resident only. 2. Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date .10. Always review physician orders [REDACTED]. Procedure .4. Verify resident identification using picture, ID bracelet, verbally, etc . The facility provided a list 08/02/18 of 5 residents with diabetes currently receiving insulin.