Every finding on record at Stephenville Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 2 of 2 residents (Resident #13 and Resident #25) and 2 of 2 staff (CNA A and CNA B) reviewed for infection control. The facility failed to ensure proper infection prevention techniques were used by CNA A when providing peri-care by not performing hand hygiene before and after peri-care for Resident #13. The facility failed to ensure proper infection prevention techniques were used by CNA A when providing peri-care by utilizing the same soiled wipe several times to clean the peri area for Resident #13. The facility failed to ensure proper infection prevention techniques were used when CNA A failed to follow peri-care standards of practice when going from dirty to clean for Resident #13. The facility failed to ensure proper infection prevention techniques were used by CNA B when providing peri-care by utilizing the same soiled wipe several times to clean the peri area for Resident #25. The facility failed to ensure proper infection prevention techniques were used when CNA B failed to follow peri-care standards of practice when going from dirty to clean for Resident #25. The facility failed to ensure proper infection prevention techniques were used by CNA B when providing peri-care by applying cream to peri-area with contaminated gloves for Resident #25.Findings included: During an observation on 09/24/2025 at 1:20 PM, CNA A wheeled Resident #13 into the shower room. CNA A donned gloves with no hand hygiene prior. CNA A assisted resident to a standing position while resident held on to a grab bar. CNA A removed Resident #13's brief and placed it in the trash can. CNA A wiped resident from front to back down the labia. CNA A then wiped again down right groin and then wiped again down left groin, all with the same wipe. CNA A discarded wipe and did not remove gloves. CNA A then placed clean brief on the resident. CNA A removed gloves and wheeled the resident out of the shower room with no hand hygiene. During an observation on 09/24/2025 at 2:35 PM, CNA B entered Resident #25's room. CNA B sanitized hands and donned gloves. CNA B assisted resident to bed using a gait belt. CNA B unfasted Resident #25's brief and tucked it between the resident's legs. CNA B wiped front to back down resident's labia. CNA B then folded the wipe and wiped right groin then folded wipe and wiped left groin. CNA B stuffed wipe in between the resident's legs in the brief. CNA B rolled the resident over, did not wipe buttocks and removed brief. CNA B did not change gloves or sanitize hands. CNA B placed a new brief and rolled resident back over. CNA B applied cream to resident's labia with unchanged gloves. Record review of personnel files on 09/25/2025 showed no evidence of skill competency checkoffs for CNA A. Further review revealed infection control training in February 2025. Record review of personnel files on 09/25/2025 showed no evidence of skill competency checkoffs for CNA B. Further review revealed infection control training in February 2025. During an interview on 09/25/2025 at 10:20 AM, the ADON stated that hands should have been washed prior to and after peri-care. She stated gloves should have been changed and hands sanitized before applying a clean brief. ADON stated that gloves should have been changed, and hands sanitized prior to applying any cream to a clean peri-area. During an interview on 09/25/2025 at 10:30 AM, the Administrator stated her expectation was for peri-care to be performed correctly and all infection-control policies be followed. She stated hands should always be washed before and after; and cleaning should always be worked from dirty to clean. She stated that yearly competencies were completed with all staff. She stated the DON and ADON were responsible to ensure competencies were completed. She stated this failure could lead to the spread of infection. Review of facility's policy titled Perineal Care, dated 01/01/2025 revealed: Policy: It is the practice of this facility to provide perineal care to all incontinent residents during bath and as needed in order to promote cleanliness and comfort, prevent infection to the extends possible, and to prevent and assess from skin breakdown. Policy Explanation and Compliance Guidelines.2. Gather supplies as needed.b. Disposable Cleaning Cloth Method.6. Perform hand hygiene and put on gloves. 11. Females.b. open package and obtain the wet cloth. Separated the residents' labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back. D. Repeat on opposite side using a new disposable wipe. E. Clean urethral meatus and vaginal orifice using a new disposable wipe with each stroke. 16> Remove gloves and discard. Perform hand hygiene.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food items out of original containers were dated and labeled. The facility failed to ensure the Vegetable Freezer and the Meat Freezer's temperatures were taken and recorded on 09/20/2025, 09/21/2025, 09/22/2025 and 09/23/2025. These failures could place residents at risk for food borne illnesses. Findings included: During an observation on 9/23/2025 between 9:30 AM and 10:00 AM of the kitchen revealed: Freezer #1:3 packages of bologna that did not have a date1 package of Ham that did not have a date Freezer #2:1 bag of egg rolls out of the original container that was not sealed and did not have a date Vegetable Freezer:The temperature log for the Vegetable Freezer revealed no temperature checks for 9/20/2025, 9/21/2025, 09/22/2025, and 09/23/2025 were completed. 3 bags of Zucchini out of original container that was not labeled with a date3 bags of breaded okra out of original container that was not labeled with a date. Meat Freezer:The temperature log for the Meat Freezer revealed no temperature checks for 9/20/2025, 9/21/2025, 09/22/2025, and 09/23/2025 were completed. During an interview on 09/23/2025 at 10:00 AM, the DM stated her expectation was that all freezers were checked daily, and the temperatures logged on the temperature log daily. The DM stated food items out of original container should have been labeled with a received date, expiration date, and an item description. The DM stated dietary staff were responsible to take records temperatures and labelling food items. The DM stated she was responsible for monitoring staff and monitored by making random checks. The DM stated residents could have been affected by receiving food that might have been spoiled. The DM stated what led to failure was new kitchen staff. During an interview on 09/25/2025 at 10:43 AM, the ADMN stated her expectation was that food was labeled per policy and that freezer temperatures were to be taken and recorded daily. The ADMN stated dietary staff were responsible for labeling food and taking and recording freezer temperatures daily. The ADMN stated the DM was responsible for monitoring dietary staff. The ADMN stated residents could have been affected by poor food safety. The ADMN stated what led to failure was a new cook did not record freezer temperatures and oversight by staff for not labeling food items per policy. Record review of facility policy titled, Food Storage, dated 1/1/2025 revealed, Food storage practices will follow Centers for Medicare & Medicaid Services (CMS), Food and Drug Administration (FDA) Food Code, and state/local health department requirements. All foods must be covered, labeled, and dated upon receipt and after opening.Thermometers must be placed in freezers, checked, and logged at least daily. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 09/25/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD. (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling.

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent survey of the facility including any plans of correction without identifying information about complainants or residents reviewed for resident rights affecting 40 residents. The facility failed to ensure the three preceding years of any surveys, certifications, and complaint investigations with plans of correction were posted for residents, family members, and visitors to review without identifying information about complainants or residents. This failure could place residents at risk for not reviewing the findings from State surveys and investigations conducted in the facility without asking to review the reports. Findings included: During an observation and record review on 09/25/2025 at 9:45 AM, the last State survey results, plan of correction, and report of contact dated 04/14/2022, were in a black 3-ring binder in a wall pocket located by the main entrance door. During an interview on 09/25/2025 at 10:42 AM, the Administrator stated the policy was for recent survey results to be made available for public review with signage indicating where to locate the results. She stated her expectations were for the results to be in the binder. The Administrator stated she asked the BOM recently to check the binder and was told by the BOM the survey results were by the front door. The Administrator could not answer why the required survey results were not included in the binder. The Administrator explained the effect on residents may be if a resident wanted to review the results, they would not be able to. The Administrator stated she was responsible for ensuring the results were available. During an interview on 09/25/2025 at 10:51 AM, the BOM stated she started in her current position six weeks ago. She recalled the Administrator asked her to check the binder. She stated she only checked to make sure the binder was in the wall pocket. She stated she did not open the binder to verify the dates on the survey results. The BOM stated the Administrator was responsible for maintaining the survey results binder. She was unable to state what effect the failure to make the survey results available had on residents. Review of facility policy titled Facility Required Postings, dated 01/01/2023, revealed 2. The facility must also post the following: . j. Most Recent Survey Results of the Facility.

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 1 of 1 kitchen reviewed. 1. The floors were soiled with food particles and grease beneath the appliances and stainless-steel shelf units throughout the kitchen. This failure could place residents that received meals prepared in the facility kitchen at risk for foodborne illness and a decline in health status. The findings included: Observation on 07/29/2024 at 9:25 AM revealed food particles on the floor in the dry storage area and grease on the floor beneath the appliances and stainless-steel shelf units throughout the kitchen. In an interview on 07/29/2024 at 9:35 AM the Dietary Manager stated, the dietary staff is supposed to follow a daily cleaning schedule and initial the form after completing the cleaning tasks and I follow up to ensure the tasks are completed. She further stated, kitchen sanitation is important because it prevents foodborne illness and I do most of the cleaning myself. Record review of the daily cleaning logs dated July 2024, used for all the kitchen cleaning duties revealed all cleaning duties for the morning of 07/29/2024 had been completed and initialed by the kitchen staff that completed the cleaning. In an interview on 07/31/2024 at 2:10 PM, the DON stated, I expect the dietary staff to follow their cleaning schedule and company policy. In an interview on 07/31/2024 at 2:00 PM, the Administrator stated, dietary staff is supposed to follow company policy and the kitchen cleaning schedule. She further stated, by not following the kitchen cleaning schedule could put the residents at risk for foodborne illness . Review of the facility's Policy titled Sanitation Inspection dated, 01/01/2024 revised 01/17/2024 revealed [in-part]: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements. 3. The sanitation program will provide for inspections to be conducted of the food service areas. 4. Inspections will be conducted but not limited to the following areas: a. Dry storage b. Freezer c. Refrigerator d. Dish room e. Pot wash f. Main production area g. Food preparation area h. General dietary observations Review of the U.S. Food and Drug Administration, 2017 Food Code, reflected: Preventing Contamination from the Premises 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location. (2) Where it is not exposed to splash, dust, or other contamination . Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location. (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS 7-202.12, 7-206.12, and 7-206.13; and (D) Eliminating harborage conditions.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (ID #20) reviewed for comprehensive care plans. 1. Resident #20 had an indwelling urinary catheter in place when he was admitted to the facility and the indication for use, care, and monitoring of input and output were not included in the comprehensive care plan. 2. Resident #20 had an admission order for the antidepressant medication of Cymbalta 60 mg by mouth daily, and it was not included in the comprehensive care plan. 3. Resident #20's Admission MDS Assessment, dated 4/19/24, had a care plan decision dated 4/24/24 to include all triggered care areas on the assessment summary in the comprehensive care plan. The care plan did not address all triggered care areas. These failures placed the residents at risk for not receiving necessary care and services to meet his individual needs and to promote a feeling of wellbeing during daily life within his living environment. The findings included: Review of Resident #20's Admission Record, dated 7/31/24, revealed an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: hypothyroidism (thyroid disorder); diabetes; hyperlipidemia (high cholesterol); dementia; depression; hypertension (high blood pressure); atrial fibrillation (irregular heart beat); gastro-esophageal reflux disease (back-up of stomach acid into the throat); obstructive and reflux uropathy (urine flow is blocked through the ureter, bladder, or urethra and urine flows backward into the kidneys causing swelling); and benign prostatic hyperplasia (noncancerous enlargement of the prostate gland that pushes against the urethra and bladder, blocking the flow of urine). Review of Resident #20's active Physician Orders revealed an order dated 4/12/24 for Duloxetine 60 mg by mouth at bedtime related to depression (Cymbalta - antidepressant medication). There were orders dated 4/12/24 for catheter care every shift and 4/30/24 to change the indwelling urinary catheter every 30 days. Review of Resident #20's Medication Administration Record, dated July 2024, revealed it included the order for Duloxetine 60 mg by mouth at bedtime at 8:00 PM, with the order start date of 4/12/24. The medication was documented as administered daily at bedtime as ordered. Review of Resident #20's Treatment Administration Record, dated July 2024, revealed it included the orders to change the Foley catheter (indwelling urinary catheter) every 30 days on the evening shift and to provide Foley catheter care every shift. The start dates were not documented. The catheter was documented as being changed on 7/29/24, and catheter care was documented as provided every shift daily. Review of Resident #20's Admission MDS Assessment, dated 4/19/24, revealed the resident had a BIMS score of 8 out of 15 (mild cognitive impairment), had an indwelling urinary catheter, and received antidepressant medication. Review of Resident #20's Admission MDS Assessment CAA Triggers Summary, signed and dated 4/25/24 by the DON, revealed the following triggered care areas: cognitive loss/dementia; visual function; communication; functional abilities for self-care and mobility; urinary incontinence and indwelling catheter; psychosocial well-being; falls; nutritional status; pressure ulcer/injury; psychotropic drug use; and pain. The CAA Triggers Summary documented a care plan decision, dated 4/24/24, to include the triggered care areas in the resident's care plan. Review of Resident #20's care plan dated 4/15/24 revealed documentation the resident had been placed on enhanced barrier precautions related to implanted medical device(s) indwelling urinary catheter. The goals were for the resident not to have a decline in psychosocial wellbeing related to being placed on EBP, not being restricted from out-of-room activities and remaining free from MDRO infections. Review of Resident #20's comprehensive care plan, dated 4/24/24, revealed it did not address the triggered care areas of communication, functional abilities for self-care and mobility, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury, psychotropic drug use, and pain. The care plan did not address the indication for use for the indwelling urinary catheter, catheter care, monitoring input and output, or changing the catheter every 30 days per the physician's orders. The care plan addressed the resident's diagnosis of depression and documented an approach to administer medications as ordered and to monitor for side effects and effectiveness but did not address Resident #20's order for the antidepressant medication of Cymbalta. Observation on 7/29/24 at 11:00 AM revealed disposable gowns in a box on the wall outside the door to Resident #20's room. A sticker with EBP for enhanced barrier precautions was on the door frame to the side of the box. Resident #20 was lying on his back in bed, with his eyes open. The resident attempted to speak, but his voice was very soft and low and his speech was not understandable. A urinary catheter drainage bag was in a dignity bag hanging from the side of the bed frame. In an interview on 7/31/24 at 3:50 PM, the DON stated the ADON had been responsible for completing the MDS assessments, baseline care plans, and comprehensive care plans and had done it for the past 8 years. The DON stated the ADON had left during November 2023 and her positioned had not been filled. The DON stated the MDS Coordinator in a sister-facility had been completing the MDS assessments remotely. The DON stated she had been learning to do care plans and was now completing the comprehensive care plans. Review of the facility's policy and procedure for Comprehensive Care Plans, dated as revised 1/01/2024, revealed the following [in part]: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record .

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1(Resident #21) of 8 residents reviewed for infection control, in that: LVN A and LVN B failed to follow EBP (enhanced barrier precautions) signage instructions for Resident #21 by not donning a gown when providing incontinent care, and while performing wound care to Resident #21. This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #21's electronic face sheet dated 7/31/2024 reflected he was a [AGE] year-old male admitted to the facility 0n 2/17/21. His diagnoses included: Colostomy (a surgically created opening in the large intestine which is sutured to an opening through the abdominal wall to create an alternate opening for feces to leave the body), diarrhea, cerebral infarct (a stroke that occurs due to disrupted blood flow to the brain causing parts of the brain to die off), hemiplegia and hemiparesis of right side (hemiplegia refers to complete paralysis of one side of the body and hemiparesis refers to partial weakness on one side of the body). Record review of Resident #21's active physician orders dated 7/31/2024 included an order dated 4/15/2024 which stated: May be placed on Enhanced Barrier Precautions related to colostomy and pressure injury. Record review of Resident #21's comprehensive person-centered care plan reflected a problem start date of 04/22/2024 reflected Problem: Enhanced Barrier precautions, Goal: Resident will remain free of MDROs, Interventions: gloves or gowns will be made available immediately outside of the resident's room. high contact activities include dressing, bathing providing hygiene, changing briefs, or assisting with toileting, care of devices such as catheters, central line, feeding tubes, tracheostomy, or ventilator tubes, and providing wound care. During an observation on 07/30/2024 at 1:43 PM of Resident #21's room revealed he had a sign which indicated he was on EBP at the head of his bed and gowns were available outside his door. Resident #21 was not interviewable. Review of the EBP sign on Resident #21's wall at the head of his bed reflected STOP, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing briefs and assisting with toileting .Wound Care: Any skin opening requiring a dressing .indwelling medical devices. During an observation on 07/30/2024 at 03:41 PM wound care and incontinent care was provided by LVN A and LVN B on Resident #21. Both nurses sanitized their hands and donned gloves prior to the provision of incontinent care to Resident #21. LVN A and LVN B did not wear a gown. Gowns were observed to be available outside of the resident's room, and a sign that specified the precautions staff should take for EBP was posted at the head of Resident #21's bed. The 2 LVNS's removed the urine soiled brief and performed peri-care. They removed their gloves and performed hand hygiene before donning new gloves and placing a new brief underneath the resident and turning him on to his rt side to perform wound care. LVN B provided the wound care and LVN A assisted. Neither LVN A nor LVN B donned a gown prior to performing wound care. In an interview on 07/30/2024 at 3:48 PM with LVN A and LVN B, both LVN A and LVN B stated they had recently been in-serviced on Enhanced Barrier Precautions. They stated that Resident's with a wound, ventilator, trach, or catheter or any other type of invasive medical device should be on EBP. LVN A and LVN B stated they failed to wear the gown because they were nervous with the surveyor watching them. In an interview on 07/31/24 at 3:52 PM, the DON/Infection Preventionist stated she it was her expectation that the LVN's should have worn a gown and other PPE as stipulated on the sign in the resident's room. She stated she had in-services on enhanced Barrier Precautions on 4/3/24, 4/22/24, and again on 5/10/24 for all staff. Copies of the policy and Inservice attendance sheets were provided by the DON. In an interview on 7/30/ 24 at 3:55 PM the facility administrator stated it was her expectation that the LVN's A and B should have worn a gown and other PPE as stipulated on the sign in Resident #21's room. The Administrator stated both LVN's should have known that they should wear a gown when providing care for Residents on EBP. She stated the failure occurred because both LVN's were nervous about performing the procedure in front of the surveyor. Record review of the facility policy and procedure titled Enhanced Barrier Precautions, dated Reviewed/Revised 04/01/2024, reflected It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .all staff receive training at least annually and are expected to comply with all designated precautions .an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds .High-contact resident care activities include: . changing briefs or assisting with toileting .wound care; any skin opening requiring a dressing indwelling medical devices. Review of website https://www.cdc.gov/preventmdro on 7/20/24, revealed the following: Multi drug resistant organism transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP may be indicated when contact precautions do not apply for residents with any of the following: wounds or indwelling medical devices regardless of multidrug resistant organism colonization status

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 4 of 5 months reviewed. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 5 (11/27/2022, 12/11/2022, 01/07/2023, 03/11/2023 and 03/19/2023) of 151 days. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of facility's RN nursing schedule from 11/01/2022 to 03/31/2023, revealed no evidence of RN coverage on 11/27/2022, 12/11/2022, 01/07/2023, 03/11/2023 and 03/19/2023. During an interview on 05/17/23 at 02:42PM, the DON stated on 11/27/2022, 12/11/2022, 01/07/2023, 03/11/2023 and 03/19/2023 the facility did not have 8 hours of RN coverage. The DON stated the facility used agency staff to fill in when they need an RN. The DON stated the contracted agency sent a LVN instead of the requested RN, without notifying the DON of the change. The DON stated she was responsible for making and monitoring the schedule. The DON stated she did not feel there was a negative effect on residents, because she or one of the other RN's were available to come at any time and staff also had access to a RN thru telehealth consult services. The DON stated what led to the failure was the staffing agency not notifying when they scheduled a LVN instead of the requested RN. The DON further stated the facility lost one of their full-time weekend RNs due to the RN having to take medical leave. The DON also stated there was an inability to hire a fulltime weekend RN. The DON stated since August 2022 the facility had been searching for a full time RN and had not been able to hire a full time RN. Review of facility policy titled, Nursing Services-Registered Nurse (RN) dated October 2022 revealed The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day 7 days per week.

Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #11, Resident #30, and Resident #2) of 13 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of a bolster (long padded cushion with sides) on the bed for safety and positioning for Resident #11. 2. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of a bed alarm in the bed and the use of a geri-chair for safety and positioning for Resident #30. 3. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of a pommel cushion (cushion in a wheelchair) for safety and positioning for Resident #2. These failures could affect the residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Resident #11 Review of Resident #11's electronic face sheet accessed 05/16/2023, revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Epilepsy (seizures), anxiety, and profound intellectual disabilities. Review of Resident #11's Quarterly MDS dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score interview not conducted. Section I: Active Diagnosis: Epilepsy. Section P: Restraints and Alarms No restraints or alarms used. Section G: Bed mobility: Total dependence with two-person physical assist. Review of Resident's #11's electronic care plan initiated 04/16/2020, revealed no evidence of a focus, objective, or interventions related to the use of a bolster (long padded cushion with sides) in bed for safety and positioning. During an observation on 05/16/2023 at 09:40 AM, revealed Resident #11 lying in bed with a bolster cushion in place on bed underneath resident. Resident was unable to answer questions. Resident #30 Review of Resident #30's electronic face sheet accessed 05/16/2023, revealed resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: Alzheimer's, dementia, and psychotic disorder. Review of Resident #30's Admission MDS dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score of 03 indicating severe cognitive impairment. Section I: Active Diagnosis: Alzheimer's and Dementia. Section P: Restraints and Alarms No restraints or alarms used. Section G: Bed mobility: Extensive assistance with two-person physical assist. Review of Resident's #30's electronic care plan initiated 03/30/2023, revealed no evidence of a focus, objective, or interventions related to the use of a bed alarm and the use of a geri-chair for safety and positioning. During an observation on 05/16/2023 at 09:45 AM, revealed Resident #30 lying in bed with a bed alarm in place under blanket on her bed. During an observation on 05/17/2023 at 2:00 PM, revealed Resident #30 sitting in a geri-chair. Resident was unable to answer questions. Resident #2 Review of Resident #2's electronic face sheet accessed 05/16/2023, revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: muscle wasting, reduced mobility, and anxiety. Review of Resident #2's Annual MDS dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score of 09 indicating moderate cognitive impairment. Section I: Active Diagnosis: anxiety and depression. Section P: Restraints and Alarms No restraints or alarms used. Section G: Bed mobility: Extensive assistance with two-person physical assist. Transfer: Extensive assistance with two-person physical assist. Review of Resident's #2's electronic care plan initiated 09/18/2019, revealed no evidence of a focus, objective, or interventions related to the use of a pommel cushion for safety and positioning. During an observation and interview on 05/16/2023 at 11:30 AM, revealed Resident #2 sitting in a wheelchair with pommel cushion in place underneath resident with a hump in the middle to keep him from sliding out. Resident stated it was to keep him from sliding out of his chair. During an interview on 05/17/2023 at 2:30 PM, the DON stated the MDS nurse was responsible for all other care plans including updating and adding new or acute problems. She stated she was ultimately responsible for ensuring that care plans were updated. The DON stated all positioning and safety devices should have been care planned. She stated not having accurate care plans could lead to residents not receiving the care that they need. During an interview on 05/17/2023 at 2:40 PM, the MDS nurse stated she was responsible for all other care plans including updating and adding new or acute problems. She stated the bolster, bed alarm, and pommel cushion devices were used to prevent residents from falling and used for positioning and safety. She stated geri-chairs, bed alarms, bolsters, and wheelchair cushions should have been care planned. She stated she just missed them somehow. Record review of the facility's policy titled Comprehensive revised October 2022 revealed: Policy: It is the policy. Of this facility. To develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet residents, medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidance: 1. The care planning process will include an assessment of the residents' strengths and needs and will incorporate the residents personal and cultural preferences and developing goals of care period services provided or arranged by the facility, as outlined by the Comprehensive care plan, they will be culturally competent, and trauma informed .3. The comprehensive care plan will describe, at a minimal, the following: a. The services that are to be furnished to attain or maintain the residents highest practical. Physical, mental, and psychosocial well-being .6. The comprehensive care plan will include measurable objectives and timeframes to meet the residents needs as identified in the residence comprehensive assessment period. The objectives will be utilized to monitor the resident progress period. Alternative interventions will be documented comma as needed period .

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 for 1 of 1 kitchen reviewed, in that: The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: Record Review of facility MDS Resident 672 dated 05/15/2023 revealed, there were 31 out of 35 residents that ate from the kitchen. During observation on 05/15/2023 between 9:54 AM and 12:30 PM, the DA performed no hand hygiene. During the preparation of meals and while transporting trays to hallway, he was touching residents bare utensils, touching his face, pulling up his mask, and picking trash up off of the floor. There was also no wearing of gloves during these tasks. During observation on 05/15/2023 at 9:54 AM, of 1 of 1 pantry contained: 1 16 oz bag of coconut dated 8/6 with sell by Mar-04-2023. 1 clear bag of uncooked noodles not labeled dated 4/11/23. 1 clear bag of uncooked noodles not labeled dated 4/21/23. 1 clear bag of labeled Nilla dated 4/17. 1 sealed container labeled sugar with number 22233, with an empty cup for a scoop placed inside, and 1 container of butter with date of 4/25/23 During observation on 05/15/2023 at 10:00 AM, #1 of 5 freezers contained: 1 gallon clear freezer bag with what appeared to be frozen burritos, dated 9/27. (no year) 1 gallon clear freezer bag with what appeared to be frozen pancakes not labeled or dated. 1 gallon clear freezer bag with what appeared to be frozen tortillas not labeled or dated. 1 gallon clear freezer bag with what appeared to be frozen biscuits not labeled or dated. 1 gallon clear freezer bag with frozen labeled pastries, dated 3/21, (no year) and 1 loaf of frozen wheat bread not dated. During observation on 05/15/2023 at 10:10 AM, Refrigerator #1 of 1 contained: 1 bag of shredded lettuce with receive date of 5/9. 1 container of grape jelly not labeled and not dated 1 container labeled tortellini with alfredo dated 5/14/23 with no use by date. 1 container labeled cheese slices dated 5/12/23 with no use by date. 1 container labeled mechanical sausage and eggs was dated 5/15/23, and no use by date. 3 pkgs of egg mix dated 5/9/23 with no use by date. 1 opened container of BBQ sauce with a receive date of 5/5 with no open date. 1 opened container of Salsa with a receive date of 9/5 with no open date. 1 opened container of mayonnaise with a receive date of 5/2/23 with no open date. 1 opened container of Cole Slaw Dressing with a receive date of 2/7/23 with no open date. 1 opened container of Buttermilk Ranch Dressing with a receive date of 5/9/23 with no open date. 1 opened container of Italian Dressing with a receive date of 04/28/23 with no open date. 1 opened container of yellow mustard with a receive date of 04/14/23 with no open date. 1 opened container of Teriyaki sauce with a receive date of 8/6/22 with no open date. 1 small bag of what appeared to be shredded cabbage with no label dated 5/12. 1 small bag of what appeared to be shredded carrots with no label dated 5/12, and 1 clear bag contained 3 heads of brown lettuce with a smeared dated. During interview on 05/15/2023 at 10:30 AM, the DM stated all items should have an open date. The dates on the products were the received date, with no open dates. The lettuce she stated needed to be thrown away as it had turned brown. She stated, the dietary staff had training over all policy and procedures for hand hygiene as well as how to date all products whether receiving or opening. During interview on 05/15/2023 at 10:30 AM, the Cook stated the received date as well as the open and expiration/shelf-life date, should be on the food items where applicable. During interview on 05/15/2023 at 10:44 AM, the DA stated with the one date written on the clear gallon freezer bag, he would not have known if the date was the receiving or open date. The DA also stated, he has never marked the use by date on products but it was usually a 5-day shelf life. During observation and interview on 05/15/2023 at 12:24 PM, the Cook, after filling the warmer with resident trays, opened the door from the kitchen to hallway, with gloved hands, for the DA. He pushed the food warmer out to the hallway. The Cook then went to the pail of bleach water in the sink and dipped her gloved hands without drying. She then continued to serve on the line and stated, that was how she sanitized her hands. She proceeded to touch the residents bread for sandwiches as well as sliced cheese and the tops of plates During an observation and interview on 05/15/2023 at 12:30 PM, the DA, while on the serving line, ungloved and touched the unwrapped utensils. When interviewed, DA stated he was not to touch resident's utensils with ungloved hands. He stated he did not have to wear gloves if he did not want to. The DA was then observed to remove his facial mask while on the serving line without performing hand hygiene afterward. When the DA returned back to the serving line, observation of no handwashing, hand hygiene or gloves were observed. He then, as well, had handled residents sandwich bread, cheese, and tops of plates. During an interview on 05/16/23 at 10:02 AM, the DM stated her expectation was for kitchen staff to perform hand hygiene between kitchen tasks. She stated kitchen staff were to wear gloves at all times while on serving line. He stated the bleach water pail should never had been an option for hand sanitizing and had never been previously brought up in in-services. The DM stated the failure occurred with herself as DM and her expectations were for kitchen staff to date all products as needed, perform hand hygiene, and to follow the training and in-services regarding all kitchen expectations. During an interview on 05/16/2023 at 10:15 AM, the Admin stated the protocols for kitchen hand hygiene were to always wash hands when needed with changing of gloves for different tasks that are performed. She also stated the protocols were stated clearly in the policy for Received, Open and Use by dates and should always be monitored. The monitoring should have been done, first by the DM, and herself. The Admin stated the failures occurred was at the Cooks level as well as the DA. The kitchen staff and the DM all had been re-educated. The expectations she stated, was more education and in-services and for kitchen staff to perform hand hygiene, change out gloves, and having all products dated when received, open and/or use by dates. Record Review of facility In-service Record dated 01/05/2023, revealed: DM as presenter, addressed: DA and Cook attended, Items are not being dated After you open an item, put in bag, date and label it. Do not put anything in Fridge or Freezer without a date. Record Review of facility In-service Record dated 04/07/2023, revealed: DM as presenter, addressed: DA and Cook attended, When you open something, put remaining in Ziplock bag with label and date. Everything in Fridge and Freezer dated and labeled with date on viewed side. Record Review of facility In-service Record dated 05/15/2023, revealed: DM as presenter, addressed: . DA and Cook attended, When you open an item, put open date. Label and date items you put in refrigerator and freezer using a sticker. . You can use a sharpie or a sticker, must be able to read. Record Review of facility In-service Record, Topic-Sanitation, dated 05/15/2023, revealed: DM as presenter, addressed: DA and Cook attended, Food prep sinks are not used for hand washing. Wash hands often. Before and after every task. When serving or get something on your hands, go to hand washing sink and wash hands, dry with paper towels. Wash hands if you touch anything, if wearing gloves, you must change gloves. Working with gloves on, is the same as bare hands. Cross contamination-for transfer of harmful bacteria from one person, object or place to another. Keep it Clean-wash hands with soap and hot water before and after handling food. Record Review of facility Dietary Cook Job Description dated 2023, Department of Food and Nutrition Services, Major Duties and Responsibilities: . .Ensures that food procedures are followed in accordance with established policies Additional Tasks . Follows appropriate safety and hygiene measures at all times to protect residents and themselves . Follows established infection control policies and procedures . Maintains food storage areas in a clean and properly arranged manner at all times. Record Review of facility Dietary Aid Job Description dated 2023, Department of Food and Nutrition Services, Major Duties and Responsibilities; . Ensures that food procedures are followed in accordance with the stablished policies. The dietary aid assists with the service and delivery of food trays to designated areas, cleaning of the kitchen per established protocols, and proper washing and cleaning of food utensils and dishes . Additional Tasks: . . Follows appropriate safety and hygiene measures at all times to protect residents and themselves . . Follow established infection control policies and procedures. Record Review of facility Policy, Dry Storage and Supplies dated 2012, revealed: . 3. Dry bulk food (e.g., flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Scoops should not be left in food containers or bins. Containers are cleaned regularly. 4. Open packages of food are stored in closed containers with tight covers and dated as to when opened. Record Review of facility Policy, Storage Refrigerators dated 2012, revealed: . .5. food must be covered when stored, with a date label identifying what is in the container. 6. Frozen food that has been thawed will be used within three days of thawing. Record Review of facility Policy, food Safety dated 2012, revealed: . 11. Gloves must be worn for preparation and service of foods that do not require further cooking. Record Review of facility Policy, Maintaining a Sanitary Tray Line dated 2023, revealed: . .Compliance Guidelines: . .3. During tray assembly, staff shall: . .c. Wear gloves when handling food items, particularly when direct contact between the hands and food occurs or when handling ready to eat food such as salads, fruits, sandwiches, breads, etc. d. Use gloves that fit properly. e. Wash hands before and after wearing or changing gloves. f. Change gloves when activities are changed, or when the type of food being handled is changed, or when leaving the workstation. g. Change gloves after sneezing, coughing or touching face, hands, or hair with gloved hands. Record Review of facility Policy, Hand Washing dated 2012, revealed: . .5. Food preparation sinks are not to be used for hand washing. According to the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 5/24/23), FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; . (D) . after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; . (E) After handling soiled EQUIPMENT or UTENSILS; . (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #17) of 4 residents reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #17's wanderguard. These failures could affect residents by placing them at risk for not receiving care and services to meet their needs The findings included: Review of Resident #17's electronic face sheet revealed a [AGE] year-old male admitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 17's MDS dated [DATE], revealed: Section C-BIMS score of 4 meaning, severe cognitive impairment; Section E- Resident had wandered 1-3 days. Review of Resident #17's electronic physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #17's electronic care plan dated 1/14/2022 on 04/12/2022 revealed no evidence of interventions for placement for a Wanderguard. Review of Resident #17's electronic care plan dated 1/14/2022 on 04/13/2022 revealed, Wander Alert: Wanderguard monitor placement to R wrist Q shift and PRN, CAN, Date initiated 04/12/2022, Revision on 04/13/2022. Review of Resident #17's Wandering assessment dated [DATE] revealed: a score of 12, High Risk for Wandering. Observation on 04/12/22 at 2:30 PM revealed that Resident #17 was wearing a wanderguard on his right wrist. During observation and interview on 04/12/22 at 2:30 PM with Activities Director, the AD was sitting in front of door in the dining area, with back to door facing Resident #17. AD was talking with Resident #17. AD stated that she was blocking door during the fire alarm test so Resident #17 would not be able to exit the building, while the locks were down due to the fire alarm testing. During interview on 04/13/22 at 03:31 PM with ADON, she stated she was not sure when Resident #17 started wearing a wanderguard. ADON stated she thinks it was after the incident on 3/17/21 where Resident #17 got out of the building. ADON stated the placement of wanderguard should be documented in progress notes, and there should be a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON stated that wanderguard should be documented in physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 04/13/22 at 03:44 PM with ADMN, she stated wanderguards should be documented in care plan, have a physician order, and a Wander Risk Assessment completed. ADMN stated the nurse on shift is responsible for putting order in chart, and the DON is responsible to ensure the order was entered. ADMN stated that another risk assessment would not have been completed since he was already a high risk for wandering. ADMN stated placement of the wanderguard was a last resort, they had been adjusting medications to regulate his behaviors. During interview on 04/14/22 at 11:04 AM with ADMN, she stated they narrowed down that the wanderguard was placed on resident either March 25th or 28th. ADMN stated what led to failure of the care plan not being updated with wanderguard, is the incident occurred during shift change and that each nurse thought the other nurse updated his electronic medical chart. ADMN stated the care plan can be updated without a MDS update because the placement of Wanderguard was not a significant change it was an intervention, because the behaviors already existed. During interview on 04/14/22 at 11:40 PM with ADON, she stated she is responsible for updating MDS. ADON explained that the MDS would not have been updated because the MDS guidelines states there needs to be more than one incident to be considered a significant change. ADON stated she was not sure when the wanderguard was put on but stated that they narrowed it down to either the 25 or 28th. ADON stated that either of those dates were both greater than 14 days to when the Care Plan needed to be updated. ADON stated the care plan was updated on the 12th. ADON stated that she had a list of items she needed to ensure were updated on Care Plans and she had given the list to the person that was assisting while the DON was on vacation. Record review of policy titled, Comprehensive Care Plans dated 02/13/07 revealed: The facility will develop a comprehensive care plan for each resident that includes measurable short term and long-term objectives and timetables to meet a residents medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: Services/Interventions that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. Problem statements to identify services that are required to main the residence highest practicable physical, mental, and psychological wellbeing.

Based on observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 4 (Resident #17) residents whose records were reviewed for accuracy and completeness. The facility failed to ensure Resident #17 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents at risk of having errors in care and treatment. Findings included: Review of Resident #17's electronic face sheet revealed a [AGE] year-old male admitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 17's MDS dated [DATE], revealed: Section C-BIMS score of 4 meaning, severe cognitive impairment; Section E- Resident had wandered 1-3 days. Review of Resident #17's electronic physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #17's electronic care plan on 4/12/2022 revealed no evidence of interventions for placement for a Wanderguard. Review of Resident #17's Wandering assessment dated [DATE] revealed: a score of 12, High Risk for Wandering. Observation on 04/12/22 at 2:30 PM revealed that Resident #17 was wearing a wanderguard on his right wrist. During observation and interview on 04/12/22 at 2:30 PM with Activities Director, she was sitting in front of door with back to door facing Resident #17. AD stated that she was blocking door during the fire alarm test so Resident #17 would not be able to exit the building, while the locks were down due to the fire alarm testing. During interview on 04/13/22 at 03:31 PM with ADON, she stated she was not sure when Resident #17 started wearing a wanderguard. ADON stated she thinks it was after the incident on 3/17/21 where Resident #17 got out of the building. ADON stated the placement of wanderguard should be documented in the progress notes, and there should be a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON stated the nurse on duty is responsible for entering orders. ADON stated that wanderguard should be documented in physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During interview on 04/13/22 at 03:44 PM with ADMN, she stated wanderguards should be documented in care plan, have a physician order, and a Wander Risk Assessment completed. ADMN stated the nurse on shift is responsible for putting (Physician's) order in chart, and the DON is responsible to ensure orders were entered. During interview on 04/14/22 at 11:04 AM with ADMN, she stated they narrowed down that the wanderguard was placed on resident either March 25th or 28th. ADMN stated what led to failure of the wanderguard not being entered is the incident occurred during shift change and each nurse thought the other nurse had entered information into his electronic medical chart. Record review of policy titled; Amended Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . ANY orders received by the physician are put in the computer. Record review of policy titled, Elopement Prevention dated 10/27/10 revealed: Wanderguard System (locking or alarming) Placement of Resident's device to alarm the system will be verified each shift and documented on treatment or other flow record.

Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity, for one (Resident#28) of 2 residents reviewed for dignity issues., in that: The facility did not place Resident # 28's urinary catheter drainage bag away from the entrance room door and/or in a privacy bag to screen urine collection from view. This failure could place residents at risk of feeling uncomfortable or embarrassed. The findings included: Record review of Resident #28's Admission Record, dated 2/28/2018, revealed Resident #28 was a [AGE] year-old male who was admitted to the facility 3/28/2018. Resident #28's diagnosis's included Diabetes with other circulatory complications, [MEDICAL CONDITION] (unspecified), Retention of urine, Spinal Stenosis, Lumbar region with [MEDICAL CONDITION] Claudication, unspecified abnormalities of gait and mobility, [MEDICAL CONDITION], Hypertension, Non-ST elevation [MEDICAL CONDITION] Infarction, [MEDICAL CONDITIONS] of native Coronary Artery without [MEDICAL CONDITION] Pectoris, generalized muscle weakness, other lack of coordination, unspecified injury of unspecified kidney, [MEDICAL CONDITION] of right and left lower limb, difficulty in walking, unsteadiness on feet, chronic venous hypertension with inflammation of bilateral lower extremities, major [MEDICAL CONDITION]. Record review of Resident #28's Quarterly Minimum Data Set (MDS) assessment, dated 10/17/2018, revealed Resident #28 had independent cognition, required extensive assistance from two staff members for bed mobility, transfers, dressing and toilet use, and had an indwelling catheter. Record review of Resident #28's Care Plan, initiated 3/19/2018, revealed Resident#28 had an indwelling catheter due to retention of urine. Interventions included, Position catheter bag and tubing below the level of the bladder and away from the entrance room door. Observation on 10/31/2018 at 10:20 a.m., revealed Resident #28 in the farthest bed from the door/hallway, laying supine facing the door/hallway, with his eyes closed. Resident # 28's room door was open. Resident #28's catheter bag was hooked to the bed rail facing the door. The catheter bag was half-full of urine and in full view from the hallway. Resident #28's catheter bag was not covered with a privacy bag Certified Nurse Aide (CNA) A and CNA B came into the room and provided catheter care but did not place the catheter drainage bag in a privacy cover. Observation on 10/31/2018 at 2:05 p.m. revealed Resident #28 was wearing shorts and a tee-shirt while ambulating with a walker in the hall. Resident # 28's catheter drainage bag was secured to his leg without a privacy cover On 11/01/2018 at 10:37 a.m. during an interview Resident #28 stated it bothered him to ambulate in the facility without the drainage bag being covered. On 11/01/2018 at 10:45 a.m., during an interview CNA A stated catheter bags were covered when residents were in wheelchairs. On 11/01/2018 at 12:10 p.m., during an interview in her office the DON stated it was a violation of the resident's dignity when the resident's catheter bag was not covered. Record review of the facility's policy titled, Statement of Resident Rights, undated, revealed: -You, the resident, do not give up any rights when you enter a Health Care Center. The Health Care Center must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing Health Care Center employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the Health Care Center administrator or with the Texas Department of Human Services. You have a right to privacy .

Based on observation, interview and record review, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for three (Resident #1, Resident #11, and Resident #12) of three residents who were provided incontinence care by three (CNA D, CNA E, and CNA F) of four CNAs observed. 1. CNA D failed to use proper technique, cleansing with a clean wipe with each swipe, while she provided incontinence care to Resident #1. 2. CNA E failed to use proper technique, cleansing with a clean wipe with each swipe, while she provided incontinence care to Resident #12. 3. CNA F failed to use proper technique, cleansing with a clean wipe with each swipe, while she provided incontinence care to Resident #11. These failures could affect the 25 residents with incontinence, who resided on the Front and Back Hall where CNAs D, E, and F worked, by placing them at risk for the development or worsening of UTIs. Findings included: 1. Resident #1's MDS assessment, dated 08/31/16, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident required extensive assistance of two or more people for toilet use. He was always incontinent of bowel and frequently incontinent of bladder. Review of Resident #1's care plan, dated 09/29/16, reflected he was incontinent of bowel. A care planned intervention included to encourage the resident to sit on the toilet to evacuate bowels if possible. An observation of incontinence care for Resident #1 on 10/26/16 at 10:25 a.m. revealed CNA D and CNA E entered the room, washed their hands, and donned gloves. CNA D removed the soiled brief and cleaned the right and left groin folds with separate wipes. She disposed of the soiled wipes in a nearby trash can. Using a clean disposable wipe, CNA E cleansed the right and left side of the penis. Using the same wipe, which had a small amount of brown substance on it, she then cleaned the meatus (urethral opening) and tip of the penis. An interview with CNA D on 10/26/16 at 10:35 a.m. revealed the penis should be wiped with a new disposable wipe after each swipe. CNA D stated she should clean one side of the penis and dispose of the wipe. Then she should clean the other side of the penis and dispose of the wipe. Finally she should clean the tip of the penis with a new wipe and dispose of the wipe. 2. Resident #12's MDS assessment, dated 09/14/16, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident required extensive assistance of two or more staff for toilet use and was always incontinent of bladder and bowel. Resident #12's Care Plan, dated 04/19/16, reflected the resident was incontinent of bowel. A care plan intervention included to check the resident every two hours and assist with toileting as needed. An observation on 10/25/16 at 1:20 p.m. revealed CNA D used disposable moistened wipes to cleanse the folds of Resident #12's groin from top to bottom, while leaving the soiled disposable wipe between the resident's legs once finished with each swipe. CNA D proceeded to clean the right and left side of the penis, then the meatus, with the same disposable wipe. An interview with CNA D on 10/26/16 at 10:35 a.m. revealed when performing incontinence care, a new disposable wipe should be used after each swipe. 3. Resident #11's MDS assessment, dated 10/06/16, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident required extensive assistance of two or more staff for toilet use and was always incontinent of bladder and bowel. Resident #11's Care Plan, dated 09/27/16, reflected the resident was incontinent of bowel and bladder. A care plan intervention included to use disposable briefs for incontinence. An observation on 10/27/16 at 9:15 a.m. revealed CNA F, while providing incontinence care, wiped both sides of the penis first and then the tip of the penis with the same disposable wipe. Interview with CNA F on 10/27/16 at 9:32 a.m. revealed she believed she did nothing wrong during the observation of incontinence care. 4. An interview on 10/27/16 at 10:00 a.m. with the DON revealed CNAs should use a new disposable wipe with each swipe starting at the tip of the penis. She revealed the CNAs should have been in-serviced over proper incontinence care, but since she was new to the building, she was not sure where the in-services were located. 5. Review of the binder labeled 'In-Services' revealed there were no recent in-services done with the CNAs over incontinence care. DON stated that all of the in-services should be in the binder. 6. The Texas Curriculum for Nurse Aides in Long Term Care (Third Edition) dated 07/01/05, in the section ' PERINEAL CARE/INCONTINENT CARE--MALE WITH OR WITHOUT CATHETER Procedural Guideline #25 ' reflected: The nurse aide .appropriately and gently washes, rinses and dries the tip of the penis, starting at the urethra first and working outward in a circular motion. 7. A list provided by DON on 10/27/16 reflected 25 residents were incontinent of bladder and/or bowel on the Front and Back Halls where CNAs D, E, and F worked.

Based on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless that individual is competent to provide nursing and nursing related services; and that individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State for one (NA I) of four nurse aides reviewed for training and competency. The facility failed to ensure NA I had the appropriate training/competency to continue working in the facility once his four months of employment ended. NA I was hired on [DATE] and continued working a per diem schedule through [DATE]. This failure could affect all 35 residents and result in residents receiving inappropriate care and treatment. Findings included: Review of the employee record for NA I reflected a hire date of [DATE] and no evidence of a current CNA certification for NA I. The Nurse Aide Registry dated [DATE] revealed an expired CNA certificate dated [DATE]. Review of the employee record for NA I revealed he worked as a CNA for 5 years. His application revealed he graduated from a community college nursing school on [DATE]. Interview with the Administrator on [DATE] at 2:55 p.m. revealed there were two staff who were nurse aides. He stated the nurse aides work with a CNA. The Administrator said the nurse aides provide hands on care when they worked with a CNA. The nurses aides do not feed residents. The interview revealed NA I was once a CNA. and usually worked on Sundays. The Administrator said NA I was in nursing school at a local college. Interview with the DON on [DATE] at 3:00 p.m. revealed NA I usually worked on Sundays and on a per diem basis. She stated he worked with a CNA. Review of the Time Detail Report ated [DATE] on [DATE] confirmed NA I ' s date of hire as [DATE]. Review of the Time Detail Report revealed that NA I worked 22 shifts after the four month period, ending [DATE]. The dates worked were:0 [DATE], [DATE],0 [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON and dated [DATE], reflected the census was 35.

Based on observation, interview and record review the facility failed to ensure the activity program was directed by a qualified professional who was licensed, registered, had qualified work experience or had completed a training course approved by the State for one of one Activity Directors. The Activity Director failed to have a state-approved training course for an Activity Director or previous qualified education or work experience. This failure could place all 35 residents at risk of receiving inappropriate activities. Findings included: Review of the Activity Director's employee file on 9/2/16, the employee signed the activity director job description. Nothing was found in her file that credentialed her to be a qualified Activity Director. Interview with the Activity Director on 10/26/16 at 12:10 p.m. confirmed she started as the Activity Director on 9/2/16 She stated she was in process of enrolling into an activity education program. In an interview on 10/27/16 at 7:50 a.m. the Activity Director stated the Activity Director stated she did not have any training. She stated the previous Activity Director oriented her for about a week from 9/5/16 through 9/9/16. The interview revealed that on 9/9/16, she started on her own as the Activity Director. During an interview on 10/27/16 at 9:35 a.m., the Administrator stated the Activity Director had not received the state-approved training course for Activity Directors. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON and dated 10/25/16, reflected the census was 35.

Based on observation and interview , it was determined the facility failed to provide a safe, sanitary, and functional environment for both residents and visitors as evidenced by the following: Multiple pot holes with loose gravel in the facility parking lot. Visitors had to walk around the pot holes. The parking spots were situated where visitors did not have a choice but to walk around the pot holes. Irregularly oblong shaped broken cement approximately 25 feet long x 4 feet wide x 1 inch deep noted directly outside of the kitchen on the external facility grounds. These failures affected the facility's 35 residents along with staff and visitors placing them in an unsafe and hazardous external environment, which could lead to an increase in incidents and accidents at the facility. Findings included: On 10/25/16 at 9:10 a.m, upon driving and exiting the car prior to initial entry in the facility, multiple pot holes with loose gravel was observed in the parking lot. Observation of the parking lot on 10/25/16 at 12:00 p.m. revealed multiple pot holes with loose gravel was noted in the facility parking lot. Interview with the Maintenance Manager on 10/25/16 at 12: 40 p.m. revealed garbage trucks caused the holes in the parking lot. He stated the dumpster was moved to the end of the parking lot near the street to avoid further damage to the parking lot. The Maintenance Manager stated the facility was supposed to get a new parking lot but due to weather issues, it was postponed. Observation of the parking lot directly outside of the kitchen on 10/25/16 at 12:45 p.m. revealed and irregularly oblong shaped broken cement approximately 25 feet long x 4 feet wide x 1 inch deep was noted on the facility ground. Interview with the Maintenance Director on 10/25/16 at 12:45 p.m. revealed a grease trap was buried under the ground and installed about a year ago. The broken cement is directly above the underground grease trap. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON and dated 10/25/16, reflected the census was 35.

Based on observation, interview, and record review, the facility failed to ensure one (Resident #1) of six residents, who were reviewed for medication administration, was free of significant medication errors. LVN A failed to administer the correct medications to Resident #1, which resulted in LVN A administering 11 medications/supplements to Resident #1 that were not prescribed to the resident, including [MEDICATION NAME] ER which the resident had listed as an allergy. Resident #1 experienced generalized aching and increased temperature as a result of her allergy to [MEDICATION NAME] ER from 07/09/16 through the evening of 07/10/16. She complained of unusual sleepiness from 07/10/16 through 07/12/16. The failure could affect the 34 residents, who received their medications from LVN A, by placing the residents at risk for adverse drug reactions, overdose, and change in condition. Findings included: Resident #1's MDS assessment, dated 07/05/16, reflected the resident was a [AGE] year-old-female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had moderate cognitive impairment and required the assistance of one person with ADLs. An Investigation of Injury worksheet, dated 07/09/16, reflected LVN A had prepared Resident #2's medications. He refused them and LVN A placed the small cup that contained the medications in a drawer of the medication cart. She then prepared Resident #1's medications and placed them in a small cup. Another resident needed her assistance so LVN A placed Resident #1's medication cup in the drawer of the medication cart. Each medication cup had the resident's name written on the cup. LVN A took Resident #2's medication cup and gave his medication to Resident #1 by mistake. The physician on call was notified. The facility's only ADON signed the form. A sheet of paper attached to the Investigation of Injury sheet reflected Resident #1 was administered the following eleven medications which were not prescribed for her: - [MEDICATION NAME] 60 mg (antidepressant); - [MEDICATION NAME] ER 1500 mg (anticonvulsant); - [MEDICATION NAME] 15 mg (hypnotic); - [MEDICATION NAME] 100 mg (antipsychotic); - Trazadone 50 mg (antidepressant); - [MEDICATION NAME] 500 mg (antidiabetic); - [MEDICATION NAME] 50 mg (antihypertensive); - Klonopin 0.25 mg (anticonvulsant); - Potassium Chloride 16 mEq (potassium supplement); - [MEDICATION NAME] 25 mg (anticonvulsant); and - [MEDICATION NAME] 10 mg (antiemetic) Additional notations made on the page reflected neurological checks, FSBS every two hours for six hours, vital signs every 15 minutes to be done with neurological checks. The Neurological Assessment sheet used to monitor Resident #1 from 07/09/16 through 07/11/16 reflected neurological checks were completed and documented every 15 minutes for the first hour, every 30 minutes for the next hour, every hour for the next two hours, then once per shift. The assessment consisted of checking the resident's vital signs, pupils, extremities and using the Glasgow coma scale. On 07/09/16 the resident had a gradual drop in blood pressure within the first two hours following medication administration, with a low blood pressure of 98/51. Her temperature was elevated at 98.1 initially, followed by a return to normal temperatures for this resident 96.4 by 8:55 p.m. She remained alert and oriented according to the assessment data. Only one blood sugar evaluation was found documented in the progress notes at 11:42 p.m., and it was within normal limits. A Medication Error Form, dated 07/09/16 and written by LVN A, reflected she was storing medication for another resident (Resident #2) who had said he would take the medication later. She prepared Resident #1's medications, but the resident had been in the restroom so she stored the medications in the medication cart. She then got distracted by someone and administered the wrong medication to Resident #1. A progress note dated 07/11/16 written by a psychiatric clinician reflected Resident #1 demonstrated a neutral affect and mood but appeared lethargic. Resident #1 had stated she had received the wrong medication. The clinician utilized behavioral relaxation techniques so client (Resident #1) may more effectively calm herself in the future when she begins feeling anxious. Resident #1's June 2016 MAR indicated [REDACTED] An interview 08/03/16 at 11:15 a.m. with Resident #1 revealed she had [MEDICAL CONDITION] and her neurologist had told her she could not take [MEDICATION NAME]. She had previously experienced a side effect to the medication which manifested as increased temperature and general aching. After receiving Resident #2's medications on the evening of 07/09/16 She had difficulty sleeping because she was unable to be given her [MEDICATION NAME] having received Resident #2's [MEDICATION NAME]. She stated she was anxious all night afraid she would have a worsened reaction to the [MEDICATION NAME]. She did not have diabetes and she said no-one monitored her blood sugar after she was given Resident #2's [MEDICATION NAME]. An interview 08/03/16 at 10:14 a.m. with the Administrator revealed LVN A had worked on two of the two resident halls and may be scheduled to work on either hall. On the evening of 07/09/16 at approximately 8:00 p.m. the DON notified the Administrator a medication error had been made. She came immediately to the facility and discovered the DON and ADON were at the facility investigating the incident. LVN A was suspended. On 07/12/16 The DON said she had checked LVN A off on medication pass techniques that same day. On 07/13/16 the Administrator saw LVN A administering medications in the facility. The DON and ADON told the Administrator that it was fine for LVN A to return to work. They were short-staffed that day and had called LVN A in to work. The Administrator sent LVN A home as she was still on suspension. She had told the DON and ADON if they did not want to work the floor they could go home too. They both put in their 30 day notice and the Administrator walked them out of the building that same day. LVN A resigned on 07/14/16. An interview on 08/03/16 at 9:05 a.m. with LVN B revealed she had worked on 07/10/16 from 7:00 a.m. to 3:00 p.m. She stated she monitored Resident #1, and the resident had appeared alert and oriented and without pain. LVN A had come into the facility and watched LVN B give medications to four residents. She did not see LVN A again that day. On 07/11/16 LVN A returned to work and administered medications. When the Administrator saw LVN A was giving medications, she made her leave. An interview on 08/03/16 at 4:40 p.m. with LVN A revealed she had been an LVN since 2012. On 07/09/16, she had prepared both Resident #1 and Resident #2's medications and placed them in medication cups. Neither resident was ready to take their medications at the time and she placed the medication cups in the drawer of the medication cart labelled with the resident's names. After she had administered Resident #1's medications, she realized she had given her Resident #2's medications in error. She notified the resident, the DON and the physician on call. The physician did not feel Resident #1 needed to go to the hospital emergency room because she took many similar medications to Resident #2. He ordered neurological monitoring, FSBS and vital sign checks be performed. She did not give Resident #1 any of her evening medications. LVN A revealed she had been checked-off on administering medications during orientation. A telephone interview with the DON on 08/08/16 at 2:50 p.m. revealed on 07/09/16 at 7:00 p.m. LVN A had notified her that she had made a medication error. The DON and ADON went to the facility. When they arrived, LVN A had already assessed the resident and notified the physician on call. She began checking off nurses on medication administration, but was unable to remember the date she did the check-offs. She typed a new medication administration procedure and had the nurses sign understanding. On 07/10/16, she had LVN A watch LVN B pass medications for a couple of hours. She was unable to do an in-service or complete the medication administration check-offs. LVN A returned to work on 07/13/16 and the DON had intended to supervise her while she administered medications but the Administrator sent LVN A home. She (DON) resigned that same day. She believed the medication error was purely accidental because there was so much going on that LVN A got side-tracked and did not complete her usual safety checks prior to administering the medication. When asked if there was any education regarding ensuring the resident was available and ready to take their medications prior to putting the residents' medications into a cup, the DON replied That's just standard nursing practice, but, I don't believe that's in our policies. The facility's current Medication Administration Procedures policy and procedures, dated 2003, reflected the following: .3. Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from its unit dose packaging in advance lessens the ability to positively identify the medication and increases the chance of drug administration errors and contamination. 4. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered The Resident Census and Conditions of Residents Form CMS-672, dated 08/03/16, reflected a census of 34 residents.

Based on interview and record review, the facility failed to designate a RN nurse to serve as DON on a full time basis, and utilize the services of a registered nurse for fifteen of thirty-four days in July and August 2016. 1. The facility failed to designate a RN to act as a director of nursing when the current DON resigned on 07/13/16. 2. The facility failed to have a registered nurse on duty 15 days between 07/14/16 and 08/03/16. These failures placed all 34 residents receiving nursing care services at risk for not having their nursing medical needs met. Findings included: A review of the staffing schedule from 07/01/16 through 07/31/16 reflected two RNs worked alternating weekends for eight hours each day. The schedule reflected there was no eight hour RN coverage on 07/14/16, 07/15/16, 07/18/16, 07/19/16, 07/20/16, 07/21/16, 07/22/16, 07/25/16, 07/26/16, 07/27/16, 07/28/16, 07/29/16, 08/01/16, 08/02/16, 08/03/16. An interview on 08/03/16 at 1:53 p.m. with the Administrator revealed she had no RN working at the facility during the week, since 07/14/16. The DON and ADON put in their notice of resignation on 07/13/16. The Administrator did not want them to complete their 30 day notice so the DON and ADON left after completing their shift that day. The Administrator said Registered Nurse (RN) coverage since 07/13/16 consisted of two RNs working alternating weekends for eight hours each day. The Administrator said there was no RN available for the nursing staff to contact in the case of a medical concern. The Administrator stated she posted the DON position on 07/14/16 on social media and on employment websites. She had not hired a new DON. The Resident Census and Conditions of Residents Form CMS-672, dated 08/03/16, and unsigned, reflected a census of 34 residents.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident #5) of 14 residents, who were reviewed for medication administration, was free of significant medication errors. LVN D failed to ensure she was administering the correct medications to Resident #5 on 09/03/15, which resulted in LVN D administering eight medications/supplements to Resident #5 that were not prescribed to the resident. These medications/supplements belonged to Resident #12 and included: [MEDICATION NAME] (hypnotic), [MEDICATION NAME] (supplement used to treat [MEDICAL CONDITION]), [MEDICATION NAME] (antipsychotic), Cranberry (supplement used for UTIs), [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (anticonvulsant), and Klonopin (anticonvulsant). Resident #5 remained non-responsive from 09/03/15 through 09/04/15 as a result of the significant medication error. The failure to correctly administer physician-ordered medications could affect the 16 residents, who received their medications from LVN D, by placing the residents at risk for adverse drug reactions, overdose, and change in condition. Findings included: Resident #5's MDS assessment, dated 07/07/15, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact and required extensive assistance with her ADLs. An interview on 09/02/15 at 2:45 p.m. with Resident #5 revealed she had [MEDICAL CONDITION] all of her life, and she asked to be placed on hospice services. She stated she no longer wanted to be sent to the hospital. An observation on 09/04/15 at 8:30 a.m. of Resident #5 revealed the resident in bed with her eyes closed. The resident was breathing regularly, but she was not responsive. Hospice RN B, who was in the room with the resident, stated Resident #5 was given the wrong medications the night before, which included: [MEDICATION NAME] (hypnotic), [MEDICATION NAME] (supplement used to treat [MEDICAL CONDITION]), [MEDICATION NAME] (antipsychotic), Cranberry (supplement used for UTIs), [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (anticonvulsant), and Klonopin (anticonvulsant). Hospice RN B stated Resident #5's vital signs were stable, but the resident was non-responsive to stimuli at this time. Hospice RN B stated she requested [MEDICATION NAME] sulfate 1% solution (an antiarrhythmic drug) to help keep the resident's blood pressure up, but the drug had not been delivered yet. When asked why the resident did not have the standard hospice comfort kit which included [MEDICATION NAME], Hospice Nurse B stated the resident had refused any interventions to include oxygen administration or pain medications of any kind when she elected hospice. An Incident Investigation Worksheet, signed and dated by LVN D and LVN C on 09/03/15, reflected on 09/03/15 at 8:45 p.m. patient (Resident #5) was given wrong medications at bedtime, medication error form complete. Patient refused to have family notified . The Incident Investigation Worksheet reflected Resident #5 was given the following eight medications which were not prescribed for her: [MEDICATION NAME] 3 mg, [MEDICATION NAME] 3 mg, [MEDICATION NAME] 400 mg, Cranberry 450 mg, [MEDICATION NAME] 1000 mg, [MEDICATION NAME] 150 mg, Klonopin 1 mg, and [MEDICATION NAME] 200 mg. The resident's vital signs were as follows: 97.9 temperature, 62 pulse, 14 respiration, and 114/53 blood pressure. Physician G was notified of the medication error. A Telephone Order, dated 09/03/15 at 9:15 p.m., reflected Physician G ordered nursing staff to monitor Resident #5 closely for 24-hours, to check the resident's neurological signs every 30 minutes for 24-hours, and to call him if there were any changes following the medication error. A review of the Neurological Assessment form used to monitor Resident #5 on 09/03/15 and 09/04/15 reflected neurological checks were completed and documented every 30 minutes. The assessment consisted of checking the resident's vital signs, pupils, extremities, and using the Glascow Coma Scale. A Telephone Order, dated 09/04/15, reflected an order to elevate the foot of Resident #5's bed until the resident's blood pressure was within normal limits. There also was an order for [REDACTED]. A second Telephone Order, dated 09/04/15 at 9:05 a.m., reflected continuous hospice care services were effective since 5:00 a.m. for patient and family support, [MEDICAL CONDITION], Brachycardia, low respiratory rate, and non-responsiveness. An interview on 09/04/15 at 11:17 a.m. with LVN D, who worked the 3:00 p.m. to 11:00 p.m. shift, revealed she recently graduated from nursing school on 08/08/15 and was hired by the facility on 08/17/15. LVN D stated she was in-serviced by LVN E on conducting a medication pass, and she had been passing medications by herself for a week. She explained that on 09/03/15 she prepared medications for Resident #12 by placing them in a cup. However, when she went to administer the medications, the resident had to go to the bathroom so she put the medications in the cup in the top drawer of her medication cart. She stated she did not label the cup. LVN D stated she then prepared Resident #5's medications and took them into Resident #5's room. LVN D stated Resident #5 informed her she did not want to take [MEDICATION NAME] so LVN D stated she took the medications back to her cart to identify the [MEDICATION NAME] so could remove the medication. LVN D explained she inadvertently picked up the cup with Resident #12 medications when she went back into Resident #5's room, and she administered Resident #12's medication to Resident #5. LVN D stated she realized the mistake immediately, and she reported it to LVN C. LVN C then called the physician, the DON, and the Administrator to report the occurrence. LVN D stated she and LVN C went to Resident #5's room, and they woke the resident to inform her of the medication error. Resident #5 told them she did not want anyone called or notified. LVN D stated she monitored Resident #5's vital signs every 15 minutes until she left the facility at 11:00 p.m. An interview on 09/03/15 at 9:15 a.m. with LVN C, who worked the 3:00 p.m. to 11:00 p.m. shift, revealed LVN D, who was passing medications on Resident #5's hall, approached her on 09/03/15 at 9:00 p.m. and informed her she had given Resident #5 the medications for another resident (Resident #12) at 8:45 p.m. LVN C stated she and LVN D then aroused Resident #5 at 9:20 p.m. and told the resident she had been given the wrong medications. LVN C and LVN D apologized and asked Resident #5 if she wanted any family or friends called, and the resident did not want anyone called. The nurses informed the resident they were calling her physician. LVN C stated she then called Physician G, who was also the resident's Hospice Physician, and was given orders to monitor the resident closely and to perform neurological checks for 24 hours. Physician G instructed the facility to call if there were any changes. LVN C stated the DON and Administrator were also notified. LVN C stated she also attempted to notify the resident's hospice agency but was not successful. She stated the hospice agency was reached by the DON, and a Hospice Nurse arrived at the facility at 5:00 a.m. LVN C stated the hospice nurses took over monitoring vital signs from the staff. An observation on 09/04/15 at 10:20 a.m. of Resident #5 revealed the resident was still non-responsive, but her vital signs were stable. The Hospice Nurses were continuing to monitor the resident every 15 minutes. An observation on 09/04/15 at 12:00 p.m. (noon) of Resident #5 revealed the resident was still non-responsive, but her vital signs were stable. The Hospice Nurses continued to monitor the resident every 15 minutes. An observations on 09/04/15 at 3:00 p.m. of Resident #5 revealed the resident was still non-responsive, but her vital signs were stable. The Hospice Nurses continued to monitor the resident every 15 minutes. An interview on 09/04/15 at 11:44 a.m. with LVN F, who worked the 11:00 p.m. to 7:00 a.m. shift, revealed on 09/03/15 she received report of the medication error for Resident #5 when she came on duty. LVN F stated there was an order to monitor Resident #5's vital signs every 30 minutes, and the nursing staff had been monitoring every 15 minutes. She stated Resident #5's physician, the Administrator, and the DON had been notified of the medication error. LVN F explained that she continued to make attempts to contact the hospice nurses when she came on duty because LVN C had been unable to reach them. LVN F stated Resident #5's physician, Physician G, was also the resident's Hospice Physician. LVN F was asked why Resident #5 was not sent to the hospital, and she stated it was the resident's wish not to go to the hospital anymore. She stated the resident made her wishes known to staff and her physician, and the facility was following the resident's wishes. An interview on 09/04/15 at 12:00 p.m. with Physician G revealed he was contacted about the medication error involving Resident #5 at 9:00 p.m. on 09/03/15. Physician G stated he instructed the nurses to investigate the medication error and to monitor Resident #5's vital signs overnight. When asked why Resident #5 was not transferred to the hospital, Physician G stated he had cared for Resident #5 for [AGE] years, and he knew she was on hospice and did not want to go to the hospital. Physician G stated the medication error was concerning, but he felt confident the sedation would wear off, and the resident would come out of this. He stated when staff was administering sedating medications, they should be aware of whom they were administering to. An interview on 09/04/15 at 1:00 p.m. with the DON revealed she thought the medication error occurred because LVN D did not label Resident #12's medications when she was unable to give them to Resident #12. She stated LVN D had been in-serviced on medication administration by LVN H, who worked at the facility and was an instructor at the nursing school. The DON stated LVN D had a skills check-off completed by the ADON, and the medication administration skills check was completed on 08/23/15. She stated LVN D started on 08/17/15, and she was monitored by another LVN for five days without issue. The DON stated LVN D began passing medication by herself on 08/24/15. The DON stated LVN D would not pass any medications until she had been re-evaluated, re-trained and was followed by another LVN for a much longer period of time. The DON provided an in-service sheet, which reflected the nurses were instructed to label the cup and cover it with resident's full name secured by tape and put it back in the med cart if a resident was not available during the medication pass. The DON stated this information was not part of LVN D's in-services when she started her employment at the facility. The DON stated going forward she was going to address this issue in policies and procedures, and she was revising the packet given to new LVNs to address this issue. The DON stated nurses should take the MAR, which had each resident's picture, into the room and tell the resident which medications they were receiving. The DON stated all staff, who administered medications, would be in-serviced immediately, and staff would not be allowed to administer medications until they completed the in-service. She also stated the Quality Assurance Committee would address medication administration in the monthly meetings until the issue was resolved. A review of the undated in-service sheet, which was provided by the DON, revealed the following were covered in the in-service: .5. If resident unavailable at the time to give medication(s) (for example, resident in restroom) and you have medication cup with meds in it; what do you do with the meds? *Label the cup and cover it with residents full name secured with tape and put back in the med cart until the resident is available to take meds .and name all meds with resident when giving medication with the MAR (Medication Administration Sheet) An interview on 09/04/15 at 2:01 p.m. with the Administrator revealed she thought the medication error occurred because the nurse involved was inexperienced. She stated LVN D would not be passing medications until she was re-educated on medication administration, followed by another nurse, and the facility administration was satisfied with her skills. The Administrator stated LVN D would also have to complete another skills check-off. The Administrator stated nurses, who were hired immediately after completing school, needed more training and would be followed by an experienced nurse for a longer period of time. She stated the Quality Assurance Committee would address this as a problem monthly. An interview on 09/08/15 at 10:30 a.m. with Hospice LVN E revealed Resident #5 began waking up on 09/05/15. She stated by 09/06/15 the resident was fully awake, and the resident resumed her daily routines on 09/07/15. Hospice LVN E stated Resident #5 did not show any signs of side effects from the medication error that occurred on 09/03/15. A Licensed Nurse Medication Pass Checklist for LVN D, dated 08/21/15, which was signed by the ADON, reflected: .5. Resident is identified .prior to med administration The facility's current Administering Oral Medications policy and procedure, revised October 2010, reflected: Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. . 6. Check the label on the medication and confirm the medication name and dose with the MAR. .8. Check the medication dose. Re-check to confirm the proper dose. .10. Confirm the identity of the resident. 11. Explain the procedure to the resident A Resident List Report, dated 09/02/15 reflected 16 residents resided on the facility's Back Hall and received medications from LVN D.

Based on observation, interview, and record review, it was determined the facility failed to provide pharmaceutical services that assured the accurate acquiring, dispensing, and administration of drugs to meet the needs of one (Resident #11) of 14 residents, who were reviewed for medication administration. The facility failed to ensure: - the correct dosage of Hydrocodone/Acetaminophen was acquired from the pharmacy for Resident #11 when the dosage was increased on 07/26/15; and - Resident #11 received the correct dosage of Hydrocodone/Acetaminophen from 07/27/15 through 09/02/15. The failures had the potential to result in uncontrolled pain symptoms and decrease therapeutic drug benefits. The failures could affect all 16 residents, who were on a pain management program. Findings included: Resident #11's MDS assessment, dated 07/15/15, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident was cognitively intact and was independent with his ADLs. Within the last five days of the assessment, the resident reported having pain that occurred rarely at an intensity of four on a scale from zero to ten. The resident received routine and PRN pain medications. Resident #11's Care Plan, dated 04/12/15, reflected a care plan was developed to address the resident's pain both acute and chronic related to arthritis and a right hip fracture. An observation on 09/02/15 at 9:30 a.m. revealed Resident #11 ambulating in the hall independently and in no apparent distress. An observation on 09/03/15 at 9:09 a.m. revealed Resident #11 resting in bed and in no distress. An observation on 09/03/15 at 9:09 a.m. revealed LVN A dispensed one tablet of Hydrocodone 5 mg/Acetaminophen 325 mg for Resident #11 as reflected by the pharmacy label on the medication package. Resident #11's MAR indicated [REDACTED]. Resident #11 stated, Just give me two tablets. LVN A informed Resident #11 that two tablets would not be the correct dose of pain medication. Resident #11's Medication Review Report, signed and dated by the Physician on 09/01/15, reflected the resident had an order to receive Norco Tablet 10-325 mg (Hydrocodone 10 mg/Acetaminophen 325 mg) one tablet by mouth three times daily related to the healing of a traumatic hip fracture. The start date for this order was 07/26/15. The Order Summary Report for July 2015 for Resident #11 reflected the previous order was for Hydrocodone 5 mg/Acetaminophen 325 mg two tablets by mouth three times daily with a start date of 04/21/15. Resident #11's Narcotic Sheets for July, August and September 2015 reflected LVN A, LVN C, LVN D, LVN I, LVN J, LVN K, LVN L, LVN M, LVN N, and LVN O gave Resident #11 half the amount of Hydrocodone ordered by Resident #11's physician for one of his routine doses from 07/27/15 through 09/02/15. Resident #11's Narcotic Sheets for July, August and September 2015 further reflected LVN C, LVN D, LVN I, LVN K, and LVN M gave Resident #11 two tablets of Hydrocodone 5 mg/Acetaminophen 325 mg for one of his routine doses on the following days: 07/25/15, 08/01/15, 08/08/15, 08/20/15, 08/21/15, 08/22/15, 08/23/15, 08/24/15, 08/25/15, 08/26/15, 08/29/15, 09/01/15, and 09/02/15. On these dates, Resident #11 received twice the amount of Acetaminophen ordered by his physician. An interview on 09/03/15 at 10:38 a.m. with Resident #11 revealed he had good pain control throughout his stay. He stated in addition to the pain medication he also received muscle relaxants and arthritis medications which helped with pain control. An interview on 09/03/15 at 12:10 p.m. with the DON and LVN A revealed on 07/26/15, when a triplicate prescription was requested from Resident #11's physician, it was written for the previous dosage ordered, which was Hydrocodone 5 mg/Acetaminophen 325 mg. They explained that the prescription was delivered to the pharmacy, and the pharmacy sent out medications for that dosage. Resident #11 was then given this dosage one or two tablets three times daily until 09/03/15 when LVN A recognized the error. The DON stated the nurses giving the medication should have checked the medication against the order on the MAR. A new Telephone Order, dated 09/03/15, reflected the dosage was changed back to Hydrocodone 5 mg/Acetaminophen 325mg three times daily. An interview on 09/03/15 at 9:00 a.m. with the DON revealed all staff was being in-serviced on medication administration. She stated no nurse would administer medications until he or she had been in-serviced. The facility's current Administering Oral Medications policy and procedure, revised October 2010, reflected: .6. Check the label on the medication and confirm the medication name and dose with the MAR (Medication Administration Record). .8. Check the Medication dose. Re-check to confirm the proper dose. .10. Confirm the identity of the resident. 11. Explain the procedure to the resident. .16. Allow the resident to swallow oral tablets or capsules at his or her comfortable pace. .21. Remain with the resident until all medications have been taken The Resident Census and Conditions of Residents, Form CMS-672, signed and dated by the ADON on 09/02/15, reflected 16 residents were on a pain management program.