Every finding on record at Sugar Land Health Care Center

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 5 (Residents #8, #19, #79, #91 and #09) of 22 residents reviewed for infection control. The facility failed to ensure:- CNA F wore a gown while dressing and transferring Resident #8 on 7/28/26- A contact isolation order not active with a sign in place for Resident #8 as of 7/28/26 that was no longer needed - The facility failed to ensure LVN C cleaned the medication tray in between administering medications to Resident #79 and Resident #19 on 7/29/26 - CNA A and CNA B had on complete PPE while providing peri care to Resident #91 who was on EBP on 7/29/26.- Housekeeper A wore gloves when handling a dirty mop head on 7/29/26.- WCN did not cross contaminate wound care supplies with dirty iodoform gauze while providing care to Resident #09's wound on 7/30/26. This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases.Resident #8 Record review of Resident #8's face sheet dated 7/28/26, revealed the resident was a [AGE] year-old female admitted on [DATE]. Resident #8 had diagnoses which included other chronic osteomyelitis (bone infection) and encounter for fitting and adjustment of a urinary device. Record review of Resident #8's quarterly MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 15 that indicated cognition was intact. Section H (Bladder and Bowel) revealed an indwelling catheter. Section M (Skin Conditions) revealed two stage 4 pressure ulcers. Section O (Special Treatments, Procedures, and Programs) revealed IV access while a resident. Record review of Resident #8's Care Plan dated 7/28/26 revealed focus for enhanced barrier precautions with intervention that enhanced barrier precautions were necessary during high-contact care that included dressing and transferring. Record review of Resident #8's Order Summary Report with active orders as of 7/28/26 revealed physician's order for contact isolation for diagnosis of extended-spectrum beta-lactamase (an enzyme produced by certain bacteria that make them resistant to antibiotics) in urine with order date of 6/16/26 and enhanced barrier precautions due to peripherally inserted central catheter (tube inserted into a vein to deliver medication, fluids or nutrition) with start date of 6/17/26. Record review of Resident #8's Order Summary Report with active orders as of 7/29/26 revealed physician's order for enhanced barrier precautions due to PICC catheter with start date of 6/17/26. Resident #19 Record review of Resident #19's face sheet dated 7/29/26, revealed the resident was a [AGE] year-old male admitted on [DATE]. Resident #19 had diagnoses which included unspecified dementia (group of symptoms affecting memory, thinking and social abilities) and hypertensive heart disease with heart failure (condition where long-term high blood pressure causes structural and functional damage to the heart, leading to impaired pumping ability and heart failure). Record review of Resident #19's admission MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 12 that indicated moderate cognitive impairment. Resident #79 Record review of Resident #79's face sheet dated 7/29/26, revealed the resident was an [AGE] year-old female admitted on [DATE]. Resident #79 had diagnoses which included infection and inflammatory reaction due to indwelling urethral catheter (tube inserted into the bladder to drain urine). Record review of Resident #79's quarterly MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 10 that indicated moderate cognitive impairment.Resident #91Record review of Resident #91's face sheet dated 08/18/2025 revealed he was originally admitted into the facility on [DATE]. He was a [AGE] year-old male with the following diagnoses: cirrhosis of the liver, kidney disease, dysfunction of the bladder, and colostomy status.Record review of Resident's #91's MDS dated [DATE] revealed a BIMS score of 04-severe cognitive impairment. Functional abilities revealed Resident #91 requires supervision or touching during personal hygiene, lying or sitting and transfers. Bladder and bowel revealed he had an indwelling catheter (a tube and a bag used to drain urine from the bladder) and ostomy (a surgical opening created to route waste out of the body).Record review of Resident #91's care plan dated 08/18/2025 revealed: Has a potential for COVID-19 infection related to multiple co-morbidities. Goal: Assist with ADLs and re-educate/remind resident of infection control practices, hand hygiene and transmission prevention. Has a Foley catheter and requires standard nursing catheter care. Goal: The resident will be free from catheter-related trauma. Intervention: Catheter care every shift, change catheter based on clinical indications such as infection and obstruction. Resident pulls at colostomy bag causing it to detach from skin. Goal: Redirect. Intervention: Anticipate and meet the resident's needs. Resident has a rash of the bilateral buttocks related to fungal rash yeast. Goal: The resident will have no sign or symptoms of the rash infection. Intervention: Monitor skin rashes for increased spread or signs for increased spread or signs of infection.Resident #09Record review of Resident #09's face sheet dated 06/30/2026 revealed he was originally admitted on [DATE]. He was a [AGE] year-old male admitted with the following diagnoses: Infection of the sacral region, left ankle and foot, pressure ulcer stage 4, pressure ulcer of the left buttock unstageable, pressure of the right hi unstageable, urinary tract infection.Record review of Resident #09 MDS dated [DATE] revealed BIMS was 06-severe problems with thinking and memory. Total dependence on staff for all activities of daily living. Record review of Resident #09's care plan dated 06/30/2026 revealed: Resident has pressure ulcers (Left buttocks, left lateral foot/planter, right ischium, sacrum and left medial foot). Goal: Pressure ulcers will show signs of healing and remain free from infection. Intervention: Assess/record/monitor wound healing.Observation on 7/28/26 at 10:38 a.m. at the doorway to Resident #8's room revealed an enhanced barrier precautions sign that providers and staff must wear gloves and a gown for the following high-contact resident care activities that included dressing and transferring. There was also a sign for contact precautions that providers and staff must put on gloves and gown before room entry. During observation and interviews on 7/28/2026 at 10:41 a.m., CNA F was observed in Resident #8's room not wearing a gown. CNA F said she was assisting Resident #8 with putting her clothes on and transferring her to the wheelchair and had not worn a gown while assisting Resident #8. CNA F said she was told she only had to wear a gown when changing the Resident #8's brief. Resident #8 said that staff were only to wear a gown when they change her brief and staff always wore a gown when they change her brief. During an interview on 7/28/26 at 3:03 p.m., the DON said Resident #8 used to be on isolation when she was on skilled and the order was supposed to be fixed this morning when they were reviewing information during the morning meeting. The DON said Resident #8 was on enhanced barrier precautions. The DON said Resident #8 had a wound and urinary catheter and staff should wear a gown and gloves when caring for residents with a wound and urinary catheter (tube inserted into the bladder to drain urine) when dressing or transferring them.During observation on 7/29/2026 starting at 8:37 a.m., LVN C used the same small metal tray to place medication cups and a water cup for administration of Resident #79's medications at 8:37 a.m. and administration of Resident #19's medications at 9:15 a.m. and did not clean or sanitize the tray in between the residents. Two medications cups with tablet medications, a medication packet, fluticasone nasal spray bottle, cyclosporine single use eye drop dose, albuterol dose and a small water cup were placed on the tray and were brought into Resident #79's room for administration at 8:37 a.m. The two medication cups, water cup and fluticasone nasal spray bottle were placed back on the tray after the medications were administered and Resident #79 had touched the medication cup and water cup and were brought back to the medication cart and the medication cup and water cups were disposed of and the fluticasone nasal spray bottle was returned to the medication cart. A medication cup with tablet medications and a bottle of polymyxin sulfate and trimethoprim ophthalmic solution were placed on the tray and brought into Resident #19's room and then placed back on the tray and brought to the medication cart where the medication cup was disposed of and the polymyxin sulfate and trimethoprim ophthalmic solution was returned to the medication cart. During an interview on 7/29/2026 at 10:23 a.m., LVN C said they usually cleaned the tray they use to transport resident's medications into the room in between residents. LVN C said she probably forgot to clean the tray in between administering medications to Resident #79 and Resident #19.In an observation of Housekeeper A who is the Housekeeping Supervisor, on 07/29/2026 at 10:54 a.m., cleaning a resident's room. She mopped the room and picked up the dirty mop head with her bare hands. Right after that she reached out for her keys in her scrub pocket.In an interview with Housekeeper A on 07/29/2026 at 10:56 a.m., she said Housekeepers were supposed to use gloves each time they mopped and swept the floor. She said, The fact that I did not use gloves and picked up a wet and dirty mop head and did not sanitize after that I could transmit bacteria from the floor to my hands and later to other surfaces. She said mop heads usually held dirty water and bacteria from the floor. She said the infection prevention failure might cause everyone in the building to be infected.In an observation of room cleaning on 07/29/2026 at 2:48 p.m., Housekeeper B was observed picking up the dirty mop head without wearing gloves and did not sanitize after. In an interview with Housekeeper B on 07/29/2026 at 2:50 p.m., she said she was a laundry staff and housekeeper. She said wearing gloves during room cleaning was if the housekeeper wanted to. She said she knew she had to wear gloves. She said she had facilitated cross-contamination because she would leave the room and go to other rooms touching surfaces. She said it would continue to the laundry room where she would clean residents' clothes with her contaminated hands. She said the failure of not wearing gloves could make people sick. In observation of peri care on 07/29/2026 at 3:04 p.m., CNA A and CNA B were observed performing care to Resident #91 without using the complete PPE-had gloves but did not wear a yellow contamination prevention gown that was available and accessible in Resident #91's room.Observation of Resident #91's door on 07/29/2026 at 3:04 p.m., there was a colored poster with the following instructions: STOP. EBP. Everyone must: clean their hands, including before entering and when leaving. Providers and staff must also: wear gloves and gowns for the following: Dressing, bathing/showering, transferring, changing linen, providing hygiene, device care or use: central line, urinary catheter, feeding tube and tracheostomy.In an interview with CNA A on 07/29/2026 at 3:43 p.m., she said the sign on the door meant- provide protection. She said she was supposed to wear the yellow protective gown to care for Resident #91 because he had a foley catheter bag (a collection device used to drain urine from the bladder) and a colostomy bag (a waterproof bag used to collect body waste from a surgical site on the stomach). She said the fact that she did not wear the yellow protective gown meant she violated infection control. CNA A said the risk to her as a staff was that she could carry bacteria from Resident #91 to her family at home. She said she could pick up bacteria on her scrubs and transmit it to other residents as she went from room to room providing care. In an interview with CNA B on 07/29/2026 at 4: 50 p.m., she said the EBP sign on Resident # 91's door meant the resident had a wound or something else that staff needed to protect themselves and the resident. She said the sign required staff to wear the yellow protective gown for all residents with wounds, foley catheter, colostomy and g-tube (a surgical opening in the stomach to deliver food, fluid and medication). She said Resident # 91 had a colostomy and foley which meant she CNA A and CNA B were supposed to have worn a yellow protective gown and gloves. She said the fact that they did not wear the protective gown meant they violated infection control policy. CNA B said because she failed to wear the protective gown, she could take bacteria from Resident #91 to her loved ones at home and spread the bacteria to other residents in the facility.In an observation of wound care on 07/30/2026 at 9:51 a.m., by the WCN for Resident #09 with multiple wounds revealed the WCN picked an iodoform (a slip oily long gauze used to pack a wound) packing container from the table with clean supplies, placed it on the dirty brief and bedsheets and later returned it to the clean table where there were clean supplies.In an interview with WCN on 07/30/2026 at 10:50 a.m., she said cross-contamination was reaching over the clean table with something dirty. She said if one took something from a dirty surface and placed it on the clean surface it was considered cross-contamination. She said if a contaminated object was placed on the clean table, everything on the clean table was considered contaminated. She said when she placed the iodoform container from the bed on the clean table she was supposed to discard everything on the clean table and start over.In an interview with LVN A on 07/30/2026 at 12:13 p.m., she said EBP meant the staff should wear protective gowns and gloves during care for residents with foley, any form of drainage, dialysis residents, wound and colostomy. LVN A said the risk of not wearing the protective gown was cross-contamination to other residents in the facility. She said CNA A and CNA B would transmit infection if they went out of the facility to their family members. She said if the WCN took the iodoform container from the clean surface to the dirty surface and back to the clean surface she did cross-contaminated the clean surface.During an interview on 7/30/2026 at 12:20 p.m. the DON said she observed medication administration and said it depended on the situation and she did them randomly. The DON said the pharmacy consultant also observed medication administration either monthly or every other month. The DON said if the medication trays were not cleaned in between residents, then the effect could be cross-contamination, was nursing 101 and was best practice to wipe down the trays in between residents. In an interview with RN A on 07/30/2026 at 12:25 p.m., she said the table with the clean supplies was considered clean. RN A said if the WCN took an iodoform container from the clean surface to a dirty surface and back to the clean table, she did contaminate every supply on that table.In an interview with RN A on 07/30/2026 at 12:35 p.m., she said EBP meant the resident had an open wound that might have been infected, dialysis site, peg-tube (a tube that allows you to get feeding through a surgical opening in the stomach), and a colostomy. She said expected CNA A and CNA B to have performed hand hygiene and wore gloves and a protective gown. RN A said if the aides did not wear the gown, it meant they violated infection control. She said the aides exposed themselves and Resident # 91 to infection.In an interview with LVN B on 07/30/2026 at 1:04 p.m., she said the EBP sign meant Resident #91 had a weak immune system or something that required infection prevention. She said the sign could mean a resident had open wounds, ongoing chemotherapy, dialysis, antibiotic treatment, colostomy and foley catheter. She said she expected the aides to have a gown, gloves and hand sanitizer. She said if the aides did not have the protective gown on when they cared for Resident #91, they could be infected. LVN B said other residents would be infected because the aides went into all the rooms to care for residents. She said cross-contamination was when a staff took care of one resident and used the same gloves to care for another resident or touch another staff. She said the clean table with the wound care supplies was considered clean. LVN B said dirty or used supplies should not be placed on the table with clean supplies; if you did, you had to discard every supply on the clean table because they were considered contaminated.During an interview on 7/30/26 at 1:28 p.m., the Unit Manager said when residents were on enhanced barrier precautions staff should wear a gown and gloves. The Unit Manager said staff should wear gowns and gloves for the enhanced barrier precautions when they were doing activities of daily living like a shower or bed bath. The Unit Manager said the staff did not need to wear the gown and gloves when dressing or transferring a resident. The Unit Manager said they did an in-service and training every other month of donning and doffing and showed the staff who were on enhanced barrier precautions and the enhanced barrier sign. The Unit Manager said the infection nurse was who monitored that staff was wearing PPE for enhanced barrier precautions. In an interview with the ADON on 07/30/22026 at 1:32 p.m., she said cross-contamination was taking something from a dirty area to a clean area. She said the iodoform that was placed on the bed by the WCN was considered cross-contamination. She said she expected the WCN to trash the leftover of the iodoform pack and not to return it on the clean surface. She said she expected the Housekeepers to have worn gloves when they picked up the wet dirty mop head. She said if they did not that was a mode of infection transmission. She said the facility had enough supplies for the housekeeping staff. She said it was the responsibility of the Housekeeping Supervisor to train housekeepers on how to clean and what supplies to use.In an interview with the DON on 07/30/2026 at 1:59 p.m., she said the EBP sign was to let the staff know the residents had an open wound and staff had to protect themselves and the residents who might have, a foley, trach, peg-tube and intravenous access. Resident # 91 had a foley and colostomy, so she expected the aides to have worn the protective gown and gloves. She said because they did not wear the gown meant they refused to follow best practice. She said it was the responsibility of the DON and the Infection Preventionist to train the aides on the proper PPE to use in EBP rooms. She said cross-contamination was when you bring infection from one place to another. She said the WCN cross-contaminated the clean table when she took the iodoform container from the bed that was dirty to the clean table. She said she expected the housekeepers to always use gloves. She said if they did not, they might have facilitated cross-contamination from resident to resident.During an interview on 7/30/2026 at 2:05 p.m., the ADON said anyone who had any type of opening in the skin or a tube like a wound that required an actual dressing, intravenous line (tube inserted in the body to administer medication), urinary catheter (tube inserted into the bladder to drain urine), nephrostomy (tube placed into the kidney to drain urine) or g-tube (tube placed into the stomach to administer food and medications) should be on enhanced barrier precautions. The ADON said staff should be gowning and gloving if they were providing any care and the resident was on enhanced barrier precautions. The ADON said if a resident had a urinary catheter and staff was changing their clothes and transferring the resident the staff member should be wearing a gown. The ADON said the effect it could have on the resident if the staff member did not wear a gown when the resident was on enhanced barrier precautions was that because of the opening the resident had they could get an infection from us. The ADON said if the medication trays were not cleaned in between residents that cross contamination could occur and if there were any spores they could be transferred. The ADON said she walked around the facility daily to monitor general infection control and would do teaching when she saw something.In an interview with the ADM on 07/30/2026 at 2:30 p.m., she said EBP are rooms with residents who had foleys, g-tube and open wounds. She said she expected the aides who cared for Resident #91 to have worn the protective gown and gloves because the staff could be a carrier for infection. The risk is staff could increase transmission to staff and other residents. She said cross-contamination was clean should stay clean and dirty should stay dirty. She said you do not go across both surfaces. The ADM said if the WCN removed a supply from a supply from the clean table took it to a dirty surface and returned it on to the clean table that was cross-contamination. She said the Housekeepers were considered carriers of infection if they did not wear gloves. She said that might lead to cross-contamination.During an interview on 7/30/2026 at 3:22 p.m., the Consultant Pharmacist said she came to the facility once a month. The Consultant Pharmacist said she would monitor for infection control when doing medication administration observations, but she had not seen staff using a medication tray and usually they just brought the medication cups and water cup into the room and then disposed of the medication and water cup after administrating the medications. Record review of facility's policy Enhanced Barrier Precautions with copyright date of 2025 revealed PPE for enhanced barrier precautions was only necessary when performing high-contact care activities which included dressing and transferring. Record review of facility's policy Standard Precautions Infection Control with copyright date 2023 revealed all staff should adhere to standard precautions defined as the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. This includes hand hygiene, selection and use of PPE (e.g., gloves, gowns, facemasks, respirators, eye protection), respiratory hygiene and cough etiquette, safe injection practices, environmental cleaning and disinfection and reprocessing of reusable resident medical equipment. Record review of facility policy Infection Survellance retrieved from -Centers for Medicare and Medicaid Services. Infection Prevention, Control and Immunization Critical Element. CMS-20054. May 2023; stated; Its purpose is to identify infections and to monitor and adherence to recommended infection prevention and control practices to reduce infections and prevent the spread of infection.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 20% based on 5 errors out of 25 opportunities, which involved 2 of 4 residents (Residents #19 and #79) and 1 of 3 staff (LVN C) reviewed for medication error. The facility failed to ensure:1. Resident #19 received Lopressor (Metoprolol Tartrate) oral tablet 12.5 mg as ordered on 7/29/262. Resident #79 received cranberry oral tablet 300 mg as ordered on 7/29/263. Resident #79 received cyanocobalamin (vitamin B-12) oral capsule 5000 mcg as ordered on 7/29/264. Resident #79 received fluticasone propionate nasal suspension 50 mcg as ordered on 7/29/265. Resident #79 did not receive vitamin C 500 mg that was not ordered on 7/29/26 The failure could place residents at risk of not receiving therapeutic dosages and/or effects of medications. Findings included: Resident #19 Record review of Resident #19's face sheet dated 7/29/26, revealed the resident was a [AGE] year-old male admitted on [DATE]. Resident #19 had diagnoses which included unspecified dementia (group of symptoms affecting memory, thinking and social abilities) and hypertensive heart disease with heart failure (condition where long-term high blood pressure causes structural and functional damage to the heart, leading to impaired pumping ability and heart failure). Record review of Resident #19's admission MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 12 that indicated moderate cognitive impairment. Record review of Resident #19's Order Summary Report dated 7/29/26 with active orders as of 7/29/26 revealed a physician's order for Lopressor oral tablet 12.5 mg (Metoprolol Tartrate) with instructions to give 1 tablet by mouth two times a day with start date of 6/27/26. Record review of Resident #19's Order Summary Report dated 7/29/26 for order category for pharmacy revealed a physician's order for Metoprolol Succinate extended release oral tablet extended release 24 hour 25 mg (Metoprolol Succinate) with instructions to give 12.5 mg by mouth two times a day with start date of 6/26/26 and order status of discontinued. Record review of Resident #19's July 2026 MAR revealed administration of Lopressor oral tablet 12.5 mg (Metoprolol Tartrate) with instructions to give 1 tablet by mouth two times a day on 7/29/26 at 9 a.m.Resident #79 Record review of Resident #79's face sheet dated 7/29/26, revealed the resident was an [AGE] year-old female admitted on [DATE]. Resident #79 had diagnoses which included infection and inflammatory reaction due to indwelling urethral catheter (tube inserted into the bladder to drain urine). Record review of Resident #79's quarterly MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 10 that indicated moderate cognitive impairment.Record review of Resident #79's Order Summary Report dated 7/29/26 revealed physician orders for cranberry oral tablet 300 mg with instructions to give 1 tablet by mouth in the morning with start date of 7/28/26, cyanocobalamin oral capsule 5000 mcg with instructions to give 1 capsule by mouth in the morning with start date of 7/28/26, and fluticasone propionate nasal suspension 50 mcg with instructions to give 2 sprays in both nostrils one time a day with start date of 7/28/26 and no order for vitamin C 500 mg. Record review of Resident #79's July 2026 MAR documentation on 7/29/26 at 9:00 a.m. that the following medications were administered: cranberry oral tablet 300 mg with instructions to give 1 tablet by mouth in the morning, cyanocobalamin oral capsule 5000 mcg with instructions to give 1 capsule in the morning, fluticasone propionate with instructions for 2 sprays in both nostrils and documentation regarding Vitamin C. Observation 7/29/26 at 8:37 a.m. revealed LVN C administered 1 spray in each nostril of fluticasone propionate nasal spray, five tablets of vitamin B-12 (cyanocobalamin) 1000 mcg, vitamin C 500 mg and cranberry 450 mg to Resident #79. Observation on 7/29/26 at 9:15 a.m. revealed LVN C administered one half of a Metoprolol Succinate 25 mg oral tablet [VT30.1][CD30.2]to Resident #19. During an interview on 7/29/2026 at 11:21 a.m. LVN C said regarding the cranberry tablet for Resident #79 the cranberry was over the counter it was usually whatever dosage that the facility had. LVN C said she had let the nurse practitioner know this morning when she did her rounds regarding the cranberry dosage and she was supposed to update the order. LVN C said she gave five tablets of the vitamin B-12 1000 mcg instead of one 5000 mcg tablet because the 5000 mcg tablet was not available. LVN C said she knew the five tablets was a lot for Resident #79. LVN C said regarding the fluticasone propionate nasal spray that Resident #79 used to only take one spray. LVN C checked Resident #79's electronic medical record and the current order for two sprays for the fluticasone propionate nasal spray was dated 7/28/26. LVN C said if medications were not given as ordered the effect it would have on the resident would depend on the medication and regarding the fluticasone it would lower the effect of the medication because Resident#79 would not receive the full dose regarding only one spray being given instead of two sprays. During observation and interview on 7/29/2026 at 11:31 a.m., the metoprolol succinate ER medication card for Resident #19 viewed on D hallway nurse medication cart date had delivery date of 6/26/2026. LVN C said that if they updated the metoprolol that maybe that was why regarding the metoprolol having SUCC on the medication card and she did not know that the SUCC meant. During an interview on 7/29/2026 at 12:46 p.m., LVN C said the only vitamin C she remembered administering was to Resident #19 and did not remember administering vitamin C to Resident #79. During an interview on 7/30/2026 at 12:20 p.m., the DON said Resident #19 had gone to the hospital on 6/20/26 and came back on the 6/26/26 and the hospital clinicals from 6/25/26 showed an order for Metoprolol Tartrate. The DON said the effect it could have on the resident if they were getting the Metoprolol Succinate instead of the Metoprolol Tartrate was the effectiveness of the drug. The DON said she spoke with LVN C and LVN C said she did not give Vitamin C to Resident #79 as Resident #79 did not have Vitamin C ordered. The DON said Resident #79 had gone to the hospital and the discharge paperwork dated 7/27/26 showed both the 300 mg and 450 mg cranberry on the medication list. The DON said she observed medication administration randomly. The DON said the pharmacy consultant also observed medication administration either monthly or every other month. During an interview on 7/30/26 at 1:28 p.m., the Unit Manager said upon hiring staff they did a medication pass observation and the pharmacy also did a medication pass observation when she was here monthly at the facility. The Unit Manager said she and the nurse who was orientating the new nurse did the medication pass observations. During an interview on 7/30/2026 at 3:22 p.m., the Consultant Pharmacist said she came to the facility once a month. The Consultant Pharmacist said metoprolol succinate was long acting so the resident would still receive the same metoprolol, but succinate would have a longer effect, and the tartrate would only last 12 hours where the succinate would last 24 hours. The Consultant Pharmacist said, regarding the resident being administered five vitamin B-12 pills instead of the one equivalent pill that it was the equivalent dose but was not designated dose but would have the same effect but was more pills. The Consultant Pharmacist said the cranberry tablets were concentrated cranberry so the manufactures' dosages would all be about the same effect. The Consultant Pharmacist said if fluticasone 1 spray was given instead of 2 sprays that 2 sprays would probably not be that much more effective if the resident was already receiving 1 spray compared to receiving acutely or for the first time. The Consultant Pharmacist said there would not be any adverse effect for administration of vitamin C without an order and vitamin C hardly had any side effects. The Consultant Pharmacist denied any problems in the past with medication observations.Record review of facility's policy Medication Administration with copyright date 2026 revealed Ensure that the six rights of medication admiration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time and f. Right documentation.

Based on interview and record review, the facility failed to ensure each resident in a nursing facility was screened for a mental disorder and individuals with mental health disorders were evaluated and received care and services for 2 of 22 residents (Residents #7 and #10) reviewed for resident assessments.-The facility did not correctly identify Resident #7 as having a mental disorder on their PASRR Level 1 Screening.-The facility failed to ensure that Resident #10's PASRR screening was updated accurately as evidenced by Form 1012 Mental Illness/Dementia Resident Review not being completed and submitted in a timely manner. These failures could place residents with mental disorders at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being, and quality of lifeResident #7Record review of Resident #7's admission Record generated on 7/29/26 revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction (the paralysis or weakness on one side of the body caused by an interrupted blood supply to the brain) and bipolar disorder. She was [AGE] years old. Record review of Resident #7's acute rehabilitation physician progress note dated 5/1/2025 revealed Resident #7 had a diagnosis of bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels). Record review of Resident #7's PASRR Level 1 Screening dated 5/14/25 indicated that Resident #7 did not have evidence of a mental illness. The document was completed by a representative for the local acute rehabilitation hospital. Record review of Resident #7's Psychosocial Evaluation dated 5/20/25 indicated she had a previously documented diagnosis of mental disorder and psychosocial adjustment difficulty. The diagnosis was listed as bipolar disorder. Record review of Resident #7's admission MDS assessment dated [DATE] revealed she had a BIMS score of 13, indicating she had no cognitive impairment. PHQ-2 (a brief, two-question mental health screening tool used to identify potential depression) was 1, indicating she had low risk for depression. Active psychiatric/mood diagnoses included anxiety disorder and bipolar disorder. Record review of Resident #7's Care Plan dated 5/11/26 read, [Resident #7] is PASRR Positive MI related to bipolar disorder. resident will receive any PASRR specialized services as recommended .Resident #10Record review of Resident #10's face sheet dated 7/30/26, revealed the resident was an [AGE] year-old male admitted on [DATE]. Resident #10 had diagnoses which included unspecified dementia (group of symptoms affecting memory, thinking and social abilities) and schizoaffective disorder (mental health condition characterized by a combination of schizophrenia symptoms and mood disorder symptoms) with onset date of 5/14/26. Record review of Resident #10's PASRR Level 1 Screening dated 10/14/2025 revealed no evidence or an indicator of mental illness. Record review of Resident #10's significant change MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 6 that indicated severe cognitive impairment. Section I (Active Diagnoses) revealed non-Alzheimer's dementia and schizophrenia (schizoaffective and schizophreniform disorders). Record review of Resident #10's electronic medical record on 7/28/26 at 3:49 p.m. revealed PASRR Level 1 Screening dated 10/14/25 and did not reveal an additional PASRR Level 1 Screening forms or Form 1012 Mental Illness/Dementia Resident Reviews. Record review on 7/29/2026 at 4:40 p.m. of Resident #10's Form 1012 Mental Illness/Dementia Resident Review revealed date signed 5/3/26 by the MDS Coordinator - Skilled but not signed by the MD A. Record review on 7/30/2026 at 12:17 p.m. of Resident #10's Form 1012 Mental Illness/Dementia Resident Review revealed it was signed by MD A on 7/30/26. Record review of Resident #10's care plan dated 7/30/26 revealed focus for mood problem related to diagnoses of schizoaffective disorder, depression and anxiety disorder with other focuses related to dementia. In an interview on 7/29/2026 at 4:27 p.m., the MDS Coordinator-Skilled said the MDS Coordinator was responsible for entering PASRR Level 1 into the portal. She said they needed to ensure it was accurate before it was submitted to the portal. She said bipolar disorder would be considered a mental illness. When asked about Resident #7's PASRR, she said it was incorrectly entered into the portal when she was admitted to the facility by a previous MDS Coordinator. She said they completed an audit of the residents' PASRR assessments in April 2026 and stated she believed Resident #7's incorrect PASRR assessment was caught during the audit. The MDS Coordinator - Skilled said she had entered the diagnosis for schizoaffective for Resident #10 in the diagnosis tab in the electronic medical records after reviewing the clinicals from the hospital dated 5/14/26. The MDS Coordinator - Skilled said she did not have to complete a new PASRR Level 1 form because Resident #10 had a primary diagnosis of dementia and that canceled out the mental illness. The MDS Coordinator - Skilled said she had some Form 1012 Mental Illness/Dementia Resident Reviews on her desk that she was waiting for MD A to sign as the nurse practitioner could not sign the 1012 form. In an interview on 7/29/2026 at 4:49 p.m. the MDS Coordinator - Skilled provided a Form 1012 Mental Illness/Dementia Resident Review for Resident #10 that was completed except for the MD A's signature and that Resident #10 had primary diagnosis of dementia. The MDS Coordinator - Skilled said when she completed an audit for PASRR in May 2026 she completed the Form 1012 Mental Illness/Dementia Resident Review and had been waiting for MD A to sign the form. In an interview on 7/30/26 at 1:15pm, the DON stated Resident #7 had some symptoms of a mental illness like crying or wanting to be pampered. She said was aware Resident #7 had a history of a mental illness. She said she was not sure if Resident #7 should have been referred for PASRR services. She said the benefits of PASRR are the interventions like specialized services.In an interview on 7/30/2026 at 1:21 p.m. the MDS Coordinator - Skilled said the Form 1012 Mental Illness/Dementia Resident Review for Resident #10 had not been signed because MD A had not been at the facility and she had alerted the nurse practitioner that the Form 1012 Mental Illness/Dementia Resident Review needed to be signed by the physician. The MDS Coordinator - Skilled said she had notified the nurse practitioner that the 1021 form needed to be signed in May 2026. The MDS Coordinator - Skilled said it was her responsibility to make sure the Form 1012 Mental Illness/Dementia Resident Review was signed. The MDS Coordinator - Skilled said the doctor may come on the weekends when she was not in the building so she would have been unable to get the form signed. The MDS Coordinator - Skilled said there would be no effect on Resident #10 regarding not having the Form 1012 Mental Illness/Dementia Resident Review completed as his PASRR status would not have changed. In an interview on 7/30/2026 at 2:00 p.m., MD A said he was notified about the Form 1012 Mental Illness/Dementia Resident Review for Resident #10 needing to be signed and was probably signed. MD A said Resident #10 had been in and out of the hospital and maybe in passing the form got missed but usually did not happen because the staff hunt him down for everything. MD A said he usually rounded every other Tuesday. MD A said so it would be either himself or the nurse practitioner that the facility staff would have been notified regarding needing the Form 1012 Mental Illness/Dementia Resident Review signed. MD A said notification from the facility was pretty good because they like to stay in compliance. Record review of the facility's policy regarding Resident Assessment-Coordination with PASRR Program dated 2023 read, This facility coordinates assessments with the PASRR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screed for serious mental disorders or intellectual disabilities and related conditions. PASRR Level I- initial pre-screening that is completed prior to admission. i. Negative Level I Screen- permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later. Policy also revealed Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review but did not have any information regarding the 1012 form specifically.

Based on observation, interview and record review, the facility failed to ensure that all drugs and biologicals used in the facility must include the expiration date when applicable for one (Medication Cart #2) of three medications carts and two (Residents #53 and #84) of eleven residents reviewed for labeling of drugs.The facility failed to ensure that Latanoprost eye drops were labeled with an open date on all medication carts. This failure could place residents at risk of not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications. Findings included: Resident #53 Record review of Resident #53's face sheet dated 7/29/26, revealed the resident was an [AGE] year-old female admitted on [DATE]. Resident #53 had diagnoses which included Cerebral Infarction (stroke) and legal blindness. Record review of Resident #53's quarterly MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 6 that indicated severe cognitive impairment. Record review of Resident #53's Order Summary Report dated 7/29/26 revealed a physician's order for Latanoprost Solution 0.005% with instructions to instill 1 drop in the left eye at bedtime with start date of 2/2/26. Record review of Resident #53's care plan dated 7/29/26 revealed focus of impaired visual function related to blindness with intervention of Latanoprost solution 0.005% one drop in left eye at bedtime. Record review of Resident #53's July 2026 MAR revealed documentation of administration of Latanoprost Solution 0.005% with instructions to instill 1 drop in the left eye at bedtime from 7/1/26 to 7/29/26. Resident #84 Record review of Resident #84's face sheet dated 7/29/26, revealed the resident was an [AGE] year-old male admitted on [DATE]. Resident #84 had diagnoses which included unspecified dementia (group of symptoms affecting memory, thinking and social abilities.)Record review of Resident #84's quarterly MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 9 that indicated moderate cognitive impairment. Record review of Resident #84's Order Summary Report dated 7/29/26 revealed physician's order for Latanoprost Ophthalmic Solution 0.005% with instructions to instill 1 drop in both eyes in the evening with start date of 1/16/26. Record review of Resident #84's July 2026 MAR revealed documentation of administration of Latanoprost Ophthalmic Solution 0.005% with instructions to instill 1 drop in both eyes in the evening from 7/9/26 to 7/28/26. Record review of Resident #84's care plan dated 7/29/26 revealed focus of impaired visual function. During observation and an interview on 7/29/2026 at 11:07 a.m. Latanoprost 0.005% eye drops were found on Medication Cart #2 with no open dates documented for Resident #53 and Resident #84. LVN B said the Latanoprost eyes drops for Resident #84 were not supposed to be in the medication cart because it was finished and she removed the bottle from the medication cart. LVN B said the pharmacy had come two days ago and checked the dates of the medications on the medication cart. LVN B said it was the nurse and anyone's responsibility to check that the open dates were on the medications. LVN B said if there was not an open date on a medication, she would discard the medication because you cannot tell when it was first opened and she would call the pharmacy for a refill. During an interview on 7/30/2026 at 12:20 p.m., the DON said the Consultant Pharmacist also checked the medication cart either monthly or every other month. The DON said it was the nurse who opened the eye drops responsibility to write the open date on the eye drops. The DON said if the open date was not written on the eye drops it might not be effective and they would need to trash it and get a new one. During an interview on 7/30/26 at 1:28 p.m., the Unit Manager said she had last checked the medication carts about a month ago and the pharmacist had also checked the medication carts when she was here this last month. The Unit Manager said she and another nurse who was helping her was checking the medication carts every Friday up until about a month ago when they got busy. During an interview on 7/30/26 at 2:05 p.m., the ADON said she checked the medication carts for the expiration dates on the over the counter medications and medications for open dates but did not have a set schedule regarding this and had last checked two weeks ago. The ADON said the Unit Manager was checking the medication carts weekly on Fridays and the pharmacist comes to the facility once or twice a month and also checked the medication carts. During an interview on 7/30/2026 at 3:22 p.m. the Consultant Pharmacist said the staff member that opened the Latanoprost first should be the one to date the bottle. The Consultant Pharmacist said if the Latanoprost was opened longer than the use by time that the Latanoprost might not have been as effective. The Consultant Pharmacist said that she checked open dates when reviewing the medication carts at the facility. The Consultant Pharmacist said she came to the facility once a month and she checked all the medication carts. The Consultant Pharmacist said the facility was usually pretty good about dating the eye drops. Record review of facility's policy Medication Storage with copyright date 2026 revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on record review and interview the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 22 residents reviewed for physician notification. The facility failed to immediately notify Resident #106's physician after she complained of right lower extremity pain and reported that her PRN pain medication was ineffective on 11/29/2025. The physician was not notified until 12/1/2025, after the resident developed right lower extremity swelling and continued pain. An x-ray was ordered which revealed a fracture of the right lower extremity. This failure placed the resident at risk for delayed diagnosis and treatment, uncontrolled pain, worsening injury, and a decline in functional status.Finding included: Record review of Resident #106's face sheet dated 7/30/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 5/21/2026. Her diagnoses included: Dementia (a progressive condition caused by physical changes and damage in the brain, rather than a normal part of aging), congestive heart failure (a condition where the heart muscle cannot pump blood efficiently), low back pain, Disorders of Bone Density and Structure (added 12/2/2025). Record review of Resident #106's quarterly MDS dated [DATE] revealed her preferred language was Arabic and a BIMS score of 00 indicating severe cognitive impairment. Further review of the MDS revealed she received scheduled pain medication regimen but had not received any PRN pain medication. According to the MDS pain assessment interview she frequently experienced pain over the last 5 days, it rarely affected her sleep, and it rarely interfered with her therapy activities. Resident #106 rated her worse pain over the last 5 days on a scale from 0 - 10 at a 3. Record review of Resident #106's care plan initiated on 12/09/2021 revealed a focus area for right spiral fracture of the leg related to disease of the bone and osteopenia (a condition of lower-than-normal bone mineral density that serves as a warning sign for osteoporosis). She has a behavior of bumping and moving her legs on the wheelchair. The interventions included to: Follow MD order for weight bearing status. non weight bearing to right lower extremity related to right tibia fracture; monitor limb for swelling and skin changes. Take pedal pulses as ordered; Monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain; resident is wearing right knee immobilizer at all times related to spiral fracture; splint care fiberglass to the right leg and ankle. Record review of Resident #106's care plan initiated on 7/24/2022 revealed a focus area for chronic pain related to disease process. The interventions included: Administer analgesia (relief or absence of pain without causing you to lose consciousness) as per orders; notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; The resident is able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain. Record review of Resident #106's physician orders revealed an order started on 10/14/2025 and discontinued on 12/4/2025 for tramadol HCl Oral Tablet 50 MG, Give 1 tablet by mouth at bedtime for pain. Record review of Resident #106's physician orders revealed an order started on 3/18/2025 and discontinued on 2/2/2026 for Tylenol Extra Strength Oral Tablet 500 MG, Give 1 tablet by mouth one time a day for pain, Maximum 3grams Tylenol daily. Record review of Resident #106's physician orders revealed an order started on 5/5/2024 and discontinued on 2/2/2026 for PainMonitoring. Assess & document on the pain numeric scale (0-10) or using the PAINAD every day and night shift. If pain present document interventions attempted: 1. diversion, 2. Re-positioning, 3. touch, 4. calming environment, 5. relaxation/deep breathing, 6. music/art, 7. PT/OT, 8. prayer, worship, 9. hot/ice packs as ordered, 10. No Pain Record review of Resident #106's physician orders revealed an order started on 10/14/2025 and discontinued on 12/4/2025 for tramadol HCl Oral Tablet 50 MG, give 0.5 tablet by mouth every 12 hours as needed for pain. Record review of Resident #106's physician orders revealed an order started on 2/13/2023 and discontinued on 2/2/2026 for Tylenol Oral Tablet 325 MG, Give 1 tablet by mouth every 4 hours as needed for Pain related to low back pain. Record review of Resident #106's November 2025 MAR revealed:Tramadol HCl Oral Tablet 50 MG, Give 1 tablet by mouth at bedtime for pain was administered from 11/1/2025 - 11/30/2025 with pain level listed as 0 from 11/1/2025 - 11/15/2025, 11/17/2025-11/21/2025, 11/25/2025, 11/28/2025, and 11/30/2025; pain level listed as a 1 on 11/27/2025; and pain level listed as a 2 on 11/16/2025, 11/22/2025 - 11/24/2025, 11/26/2025, and 11/29/2025.Tylenol Extra Strength Oral Tablet 500 MG, give 1 tablet by mouth one time a day for pain was administered from 11/1/2025 - 11/30/2025, except on 11/3/2026, 11/12/2025, 11/15/2025, and 11/28/2025 where the medication was noted to be refused.Pain Monitoring on the day and night shift from 11/1/2025 - 11/26/2025, 11/28/2025 and 11/30/2025 indicated a pain level of 0, while on night shift 11/27/2025 and day shift 11/29/2025 pain level was listed as a 1.PRN tramadol HCl Oral Tablet 50 MG, give 0.5 tablet by mouth every 12 hours as needed for pain was not administered for the month of November 2025.PRN Tylenol Oral Tablet 325 MG, give 1 tablet by mouth every 4 hours as needed for pain related to low back pain was only administered on 11/29/2025 at 1:36am with a pain level of 4 and was marked ineffective by LVN E Record review of Resident #106's progress note dated 11/29/2025 at 1:36am revealed an administration note by LVN E, Patient is complaining of pain in Right lower extremity. Writer notes there are no open areas, no bruising, redness or swelling. Record review of Resident #106's progress note dated 11/29/2025 at 3:01am revealed an administration note by LVN E, Follow-up Pain Scale was: 4, Patient reports that medication was not effective. PRN Administration was: Ineffective. Record review of Resident #106's progress notes dated 11/29/2025 - 11/30/2025 revealed no documentation regarding physician notification of ineffective pain relief, administration of another PRN Tylenol or administration of PRN Tramadol. Record review of Resident #106's progress notes dated 12/1/2025 at 3:15pm revealed, Patient noted to have a yellow edematous (swollen or puffy due to an abnormal buildup of excess fluid trapped in body tissues) area to right ankle area, sensitive to touch at this time, Physical Therapist reports to this nurse that patent is refusing therapy due to inability to bear weight to this site. NP notified and orders received for X-ray to right ankle area. Record review of Resident #106's right ankle x-ray results with study date of 12/2/2025 at 12:00am and time read on 12/2/2025 at 4:27pm revealed an impression of:1. Mildly displaced comminuted fracture of distal shaft of tibia (a lower shinbone break featuring multiple bone pieces out of normal alignment by a small margin near the ankle).2. Incomplete fracture of lateral cortex of distal fibular shaft (a partial crack or hairline break on the outer edge of the lower calf bone near the ankle).3. Mild osteopenia. Record review of Resident #106's progress notes dated 12/3/2025 at 7:20am revealed, .7:20am resident transported via stretcher to hospital for fracture to right lower extremity. Record review of Resident #106 hospital Discharge summary dated [DATE] revealed in part, .Reason for visit: ankle pain. Diagnosis: Closed non-displaced spiral fracture of shaft of right tibia (a broken right shinbone where the crack twists around the bone like a corkscrew, the broken pieces stay properly lined up, the skin is not broken open, and the injury is along the long middle part of the bone). Done today: Knee immobilizer (a straight leg brace used to stop your knee from bending after an injury or surgery). Start taking: Tylenol with Codeine #3, 1 tablet by mouth every 8 hours as needed for severe pain. Orthopedics/Sports Medicine Referral for Acute non displaced spiral fracture in the distal tibial metaphysis (a fresh twisting break in the lower shin bone near the ankle where the bone pieces remain properly aligned). Record review of Resident #106's progress notes dated 12/3/2025 at 4:13pm, .Resident returned to facility from hospital via EMS transportation. Resident alert and oriented with nonlabored breathing observed. Resident transferred from stretcher to bed with 2 person assist. Resident has knee immobilizer placed to right leg. Record review of the facility self-report investigation for Resident #106's injury of unknown origin dated 12/8/2025 revealed a statement from the DOR which noted, On December 1, 2025, Resident #106 report to this therapist that her left leg was hurting and stated it feels broken. It was noted to have some edema (swelling) and bruising around the ankle. Complaint was immediately communicated to the nurse going off shift, the nurse coming on shift and the DON. Record review of the facility self-report investigation for Resident #106's injury of unknown origin dated 12/8/2025 revealed a statement from the Administrator regarding conversation with Resident #106 RP which noted in part, .On 12/6/2025 due to language barrier Administrator did telephone interview with RP to see if resident was able to verbalize what happened to her ankle. Per RP, Resident #106 said it could of happened during transfer from bed to wheelchair. RP stated that there was no abuse and that resident is on therapy caseload for strengthening and that she has had bad history of fracture in the past and that resident also has history of some issues with her bones.[sic] Record review of the facility self-report investigation for Resident #106's injury of unknown origin dated 12/8/2025 revealed a statement from OT A which noted in part, .Attempted to see patient on 12/1/2025 for therapy. Patient reporting that she cannot get in wheelchair pointing to right lower extremity. When assisting patient with putting on shoes, patient expressed discomfort with attempting to put on right shoes. Patient right ankle appeared swollen and with bruising. Patient sat at end of bed and attempted to stand but then declined pointing at right lower extremity. Assisted patient back to bed and got DOR to assist with translation. DOR spoke with patient and patient still with complaint of pain in lower extremity. DOR then notified patients nurse of swollen ankle and bruise along with patients complaint of pain.[sic] Record review of the facility self-report investigation for Resident #106's injury of unknown origin dated 12/8/2025 revealed a statement from RN C which noted in part, .On the 1st day of December at shift change PT manager notified this nurse about Resident #106 complaint of pain to right lower extremity. Upon assessment bruise was noted to right ankle. 2:59pm, NP was notified and she came to assess patient as this nurse was leaving hallway at the end of shift. [sic] Interview on 7/30/2026 at 3:50pm, Administrator said during their investigation they found that the therapist discovered Resident #106 had ankle pain on 12/1/2025 and then notified the nurse which prompted physician notification after nurse assessment of right ankle. The Administrator said it was not found that Resident #106 had issues with ankle pain until 12/1/2025. The Administrator stated she had not spoken to LVN E regarding noted right ankle pain on 11/29/2026 and ineffective pain relief. Interview on 7/30/2026 at 4:17pm, OT A said it was hard to remember incident with Resident #106 back in November due to so much time passing but she did recall going to get her for therapy and her complaining of pain. OT A said Resident #106 spoke a different language, so it was hard for her to understand her, but she was saying pain and pointing at her ankle when she tried to get her up for therapy. OT A said she recalled getting the DOR to come and assess her because the DOR spoke the same language as Resident #106. OT A could not say if Resident #106 had usual complaints of aches or pains because she did not routinely work with her and it was so long ago. Interview on 7/30/2026 at 4:20pm, DOR said she did remember Resident #106's incident and her passing away in May 2026. The DOR said she spoke Resident #106's language and knew her family. The DOR said she recalled OT A informing her Resident #106 was complaining of pain and asked if she could speak to her since she spoke her language. The DOR recalled that Resident #106 complained of pain to her right ankle and her noticing that it did look a little swollen. She recalled not being sure if it could be arthritis (a general term for conditions that cause joint pain and swelling) because the resident was 96 and had a history of arthritis but since she was in pain and unsure of the cause she notified her nurse. The DOR said the nurse came and assessed Resident #106 and notified the NP. She recalled them learning she had a fracture to the ankle. DOR said when she spoke with the resident, she did not recall her voicing being in prolonged pain and said that maybe the pain was only noticed when the OT came because it required her to move and try and put weight on the ankle. The DOR said she could not recall Resident #106's exact therapy schedule but said she only received therapy during the week and after viewing her calendar it was noted that 11/29/2025 was a Saturday and 12/1/2025 was a Monday which would have been the first attempt at therapy since at least 11/28/2025. The DOR said she could not recall her previously having issues with acute ankle pain but said she might have had a history of gout (a painful form of inflammatory arthritis caused by high levels of uric acid, sudden joint pain, and swelling) but was not certain. Phone interview attempted on 7/30/2026 at 5:03pm with Resident #106's RP, there was no answer and voicemail was left. A second phone interview attempt was made on 8/4/2025 at 4:00pm and a recording came on that the number was no longer available. Phone interview on 7/30/2026 at 5:12pm, LVN E said she did recall Resident #106 and said in November of 2025 she was working PRN for the facility and would sometimes be on night shift and sometimes day shift. LVN E said she did recall Resident #106 having an ankle fracture and said she had just returned from leave around the time it happened. LVN E said she did recall Resident #106 complaining of lower extremity pain and providing Tylenol, however, she did not remember the medication being ineffective. LVN E said she did not notify the physician about the ankle pain because the resident often had general aches and pains and when the resident complained of the lower extremity pain, she believed it to be her usual general pains. LVN E said typically if she provides a PRN pain medication and it is ineffective she would do what she could to try and relieve the pain and notify the physician of the pain medication being ineffective. LVN E said some things she would try would be to elevate the extremity, apply ice, provide another dose of the Tylenol or depending on how severe the pain was she could try and give the PRN Tramadol. LVN E asked if the record reflected she gave another Tylenol after noting it was ineffective but was advised record did not show another administration was made. LVN E reiterated that she could not recall there being an issue with continued ankle pain and medication being ineffective but said she certainly did not notify the physician about the ankle pain and the reasoning was because the resident often had general pain. Interview on 7/30/2026 at 5:34pm, DON said she was not working at the facility yet when Resident #106 had her fracture but did get to know the resident before she passed away in the facility in May 2026. The DON said she knew there was an outstanding self-report they did for the injury of unknown origin regarding an ankle fracture for Resident #106. The DON said if a resident is complaining of pain she would expect the nursing staff to assess the resident and administer a PRN pain medication if they have one and maybe do some type of non-pharmacological pain relief interventions. The DON said she would not expect to notify the physician from initial complaint of pain. The DON said if the PRN medication is ineffective and the resident is still in pain she said she would expect the nurse to take action and first try something else to relieve the resident's pain and notify the physician about the ineffective pain management. The DON said it was difficult for her to speak on the situation with Resident #106 being in pain on 11/29/2025 and her Tylenol being marked ineffective because sometimes the residents may not give enough time for the medication to become effective before they are stating that's ineffective. The DON said if the medication was truly ineffective to relieve Resident #106's pain the doctor should have been notified and if the doctor was not notified it could cause the resident to have prolonged uncontrolled pain or the reason for their pain not being addressed. Interview on 7/30/2026 at 5:58pm, the NP said she did remember Resident #106 having an ankle fracture. The NP said the incident happened so long ago it was hard for her to recall the details. The NP said she recalled being informed Resident #106 was having ankle pain and she ordered an x-ray the same day she notified about the ankle pain. The NP said she could not say when it was that she was told about the ankle pain but knew her response was to order the x-ray of the ankle given acute ankle pain and assessment of the ankle. NP said if pain medication is not working for a resident and they're complaining about it being ineffective she would expect the staff to notify her so she could see why the medication is ineffective and then place some orders to try and address the increase in pain. NP clarified that if a resident voiced being in pain she would expect the nurse to give PRN pain medication and she would not expect to be notified if the medication was effective. Record review of the facility undated Notification of Changes policy revealed in part, .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life threatening conditions, or b. clinical complications; 3. Circumstances that require a need to alter treatment. This may include: a. new treatment.

Based on observation, interview, and record review that facility failed to ensure residents had the right to formulate an advance directive for 1 of 22 residents (Resident #73) reviewed for advanced directives. The facility failed to update Resident #73's code status to Do Not Resuscitate (DNR) after an Out-of-Hospital DNR was requested by the Responsible Party and obtained by the facility. This failure placed residents at risk for receiving care that was inconsistent with their preferences and treatment decisions. Findings included: Record review of Resident #73's face sheet dated [DATE] at 10:37am revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Dementia (a decline in mental ability severe enough to interfere with daily life), Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), Parkinson's (a progressive brain disorder that affects the nervous system and body movement), Type II Diabetes (a chronic medical condition where the body develops insulin resistance and cannot use insulin properly, causing sugar to build up in the blood), and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Further review of the face sheet revealed resident's code status was Full Code (medical staff must use every available life-saving tool to revive a patient if their heart stops or they stop breathing). Record review of Resident #73's admission MDS dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment. Record review of Resident #73's Care Plan initiated on [DATE] and last revised on [DATE] revealed a focus area of [Resident #73] is Full Code and interventions included, in part: FULL CODE: Should resident be found with no pulse, respirations, or blood pressure, start CPR & call 911 immediately and to honor code status preference. Record review of Resident #73's physician orders revealed an active order dated [DATE] with no end date for FULL CODE. Record review of Resident #73's Physician note dated [DATE] at 7:57pm revealed in part, .Patient was seen resting in bed, nonverbal, appears comfortable. Family requested DNR . Further review of the physician note revealed, .Family requested DNR form, signed. Record review of Resident #73's Out-Of-Hospital Do-Not-Resuscitate Order (a legal medical document that instructs emergency medical services and other healthcare providers not to initiate specific life-sustaining measures such as CPR, defibrillation, or artificial breathing when a patient is in a non-hospital setting) revealed it was signed by his responsible party and two witnesses on [DATE] and signed by the physician on [DATE]. Record Review of Resident #73's electronic record on [DATE] at 10:38am revealed his profile screen listed his code status as full code. Further review of the electronic record revealed Resident #73's signed OOH-DNR dated [DATE] was uploaded in his chart under miscellaneous records. Observation and interview on [DATE] at 3:15pm, Resident #73 was lying in his bed on his left side. Attempted to greet residents but the resident appeared to be resting and did not respond. Resident #73's roommate had a visitor in the room who stated Resident #73's RP had just left and would return later during dinner time. Interview and observation on [DATE] at 3:42pm, LVN D said she was the nurse assigned to Resident #73 for the day shift. LVN D said if a resident was to code or experience cardiac arrest they should check the resident's electronic medical record profile and it would show the code status. LVN D said if a resident is listed as full code, they would perform life saving measures such as CPR (an emergency life-saving procedure performed when someone's heart or breathing stops) but if a resident was a DNR they would not perform resuscitation methods. LVN D pulled up Resident #73's electronic record profile on her computer and pointed at her screen saying he was a Full Code. After being advised there was a signed DNR in Resident #73's record, she stated she would have to check with the Social Worker to see if it is valid because sometimes a resident may have a DNR and then family or the resident may later change their minds. LVN D said typically the Social Worker obtains DNR's for residents that wish to have one and then nurse management will update the residents record to reflect the change in code status. Interview on [DATE] at 4:38pm, the Unit Manager said she reviewed Resident #73's record and saw the family had requested a DNR when he admitted and saw the signed OOH-DNR on the chart. The Unit Manager said she recalled the original OHH-DNR the RP provided was not filled out correctly and she was not aware of them receiving the correctly completed form that was currently in the chart. The Unit Manager said she contacted the RP and was awaiting response to confirm the DNR should be in place before updating the resident profile to reflect DNR for code status. The Unit Manager said the procedure in a code situation was for the nursing staff to check the resident profile in the electronic record to determine code status. The Unit Manager said the Social Worker is responsible for ensuring DNR forms are completed if that is the resident's or RP wishes and then the Social Worker would notify them in the morning meeting about any new DNR's as well as send it in a group chat they have for management staff. The Unit Manager said after the Social Worker informs them of their there being a signed DNR completed the nursing staff will update the chart. The Unit Manager said the chart could be updated by herself, the ADON, or DON. The Unit Manager does did not recall being informed of the completed DNR for Resident #73. Interview on [DATE] at 5:14pm, the Unit Manager said she had heard back from the RP who said Resident #73 should be listed as DNR. The Unit Manager said she had already gone in the chart now and corrected the code status to reflect DNR. Interview on [DATE] at 1:15pm, the DON said the Unit Manager had updated her on what happened with Resident #73's DNR. The DON said the front page of the electronic medical record is what the nurses should check to verify code status in a code situation. The DON said the social Social worker Worker usually handles getting a DNR completed correctly if a resident or RP requests one and once one is obtained the social Social worker Worker would communicate to the nursing staff there is one completed. The Social Worker will let them know via the morning meeting and through their group chat. The DON said it usis up to nursing staff to then update the record. The DON said at the time Resident #73's DNR was filled out she was out on leave but said to her knowledge the Social Worker had communicated in the group chat the DNR was obtained. The DON said in her absence other nurse management staff can update the record but said it was her responsibility upon her return from leave to ensure everything was completed. The DON said not having Resident #73's DNR status updated in his record placed him at risk of having CPR performed when it was not his or the RP's wishes. Interview on [DATE] at 4:28pm, the Social Worker said she had obtained a completed DNR for Resident #73 and after obtaining it she communicated in their group chat that the DNR was completed. The Social Worker had the completed DNR uploaded to the resident electronic record and said after typically communicated in the group chat regarding an active DNR, the nursing staff would update the clinical record. The Social Worker said she had not realized the clinical record never got updated to reflect Resident #73 had a DNR and said going forward, though it was nursing responsibility to update the clinical record, she would complete audits to ensure code statuses are updated/correct. Record review of the facility's undated Resident Rights Regarding Treatment and Advance Directives policy revealed in part, .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.3. Upon admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff.8. Decision regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instruction and whether the resident wishes to change or continue these instructions.

Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to develop a person-centered baseline care plan for 1 of 10 residents (Resident #107) reviewed for baseline care plans in that:The facility failed to ensure MDS Coordinator B developed a baseline care plan that reflected Resident #107's COVID-19 active status. This failure could place newly admitted residents at risk of delays in implementing individualized interventions necessary to address their immediate needs.Findings included:Record review of Resident #107's face sheet dated 07/26/2026 revealed she was an [AGE] year-old female admitted with the following medical diagnoses: Personal history of COVID-19, fever, weakness and dermatitis (a condition that causes inflammation of the skin).Record review of Resident #107's MDS dated [DATE] was the entry MDS which was in progress.Record review of Resident #107's psychosocial evaluation dated 07/28/2926 revealed her BIMS was-12 indicating moderate cognitive impairment.Record review of Resident #107's Baseline Care Plan and Summary dated 07/27/2026 completed by MDS Coordinator B did not indicate COVID-19 isolation precaution. The isolation precaution read: The resident is on transmission-based precaution r/t.Record review of hospital transfer report dated 07/22/2026 revealed Resident #107 was diagnosed with COVID-19 infection.In an interview with MDS Coordinator A on 07/29/2026 at 4:16 p.m., she said COVID-19 should have been added on the baseline care plan. She said when she looked at the baseline care plan she saw: Transmission based precaution. She said that was incomplete because the precaution reason was not specified. She said she was responsible for completing the care plans for the skilled residents only. She said she could add the COVID-19 specification. In an interview with MDS Coordinator B on 07/29/2026 at 4:46 p.m., she said she indicated Resident #107 was on transmission-based precautions and that was ok. MDS Coordinator B was asked why the baseline care plan was not detailed, she said it was not necessary to code the details of COVID-19 because the baseline care plan did not have to be detailed. She said the fact that the resident had a history of COVID-19, it was not necessary to include that on the baseline care plan. MDS Coordinator B developed the baseline care plan.In an interview with LVN A on 07/30/2026 at 12:13 p.m., she said she always referred to the baseline care plan for new residents to obtain information on how to care for new residents. She said if the information on the baseline care plan is incomplete that would affect the resident's care because she would not know the required care for the new resident. LVN A said if Resident #107 had a history of COVID-19 she would expect to see that on the baseline care plan. She said if the care plan had r/t and the sentence did not continue, that would be time wasted because she would have to stop and go around to the care plan developers to find out the continuation of the sentence. She said that is time she spent caring for the residents.In an interview with RN A on 07/30/2026 at 12:35 p.m., she said she usually obtained information on how to care for a new resident from the baseline care plan, Doctors' orders and hospital report. She said if Resident #107 had a history of COVID-19 she expected to see that on the baseline care plan.In an interview with LVN B on 07/30/2026 at 1:04 p.m., she said the purpose of a care plan was to have an individualized person-centered care plan for each resident. She said if the baseline care plan for Resident #107 had transmission-based precaution r/t with no continuation, it meant the care plan was incomplete and the nurse would not know the reason for the precaution. Therefore, the nurse would have to obtain more information because the nurse should not provide the wrong care. LVN B said, if Resident #107 had a history of COVID-19 and it was currently active that should have been reflected in the baseline care plan. She said it was the responsibility of the MDS Coordinators to complete an accurate baseline and comprehensive care plan. RN A said if the baseline care plan had an incomplete sentence relating to the transmission precaution, it meant the care plan was incomplete and would not be a good working document.In an interview with the ADON on 07/30/2026 at 1:32 p.m., she said the purpose of the care plan was to enable the nurses to know the individualized plan of care for each resident. She said if Resident #107 had a history of COVID-19 she would expect that the baseline care plan reflected that information. She said if the COVID-19 information was not reflected in the baseline care plan, she would consider that baseline care plan incomplete. In an interview with the DON on 07/30/2026 at 1:59 pm, she said the purpose of a care plan was to what type of individualized care the residents required. She said if Resident #107 had a history of COVID-19, she expected that information to have been in the baseline care plan because everybody needed to know. The DON said the transmission-based precaution incomplete sentence was unacceptable. She said the care plans were completed by the MDS Coordinators and crossed checked by the DON.In an interview with the ADM on 07/30/2026 at 2:30 p.m., she said the purpose of a care plan was to discuss how the facility was going to care for the residents, their goals and discharge plans. She said the baseline care plan did not have to specify the infection transmission precaution because that was not a comprehensive care plan.Record review of the facility's policy Baseline Care Plan dated 2023 revealed: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (CR #1) of 4 residents reviewed for pharmacy services.-CR #1's hospital discharge orders were not transcribed properly to the resident's facility admission orders. CR #1 did not receive the correct dose of Divalproex Sodium.This failure could result in CR #1 not receiving the correct dose of anti-seizure medication.Findings include: Review of the admission Record for CR #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures (seizure disorder), cerebral infarction (condition where blood flow to a part of the brain is disrupted, resulting in brain-tissue death), and hypertension (high blood pressure). She was discharged from the facility on 07/04/2025.Review of CR #1's 5-day Entry MDS assessment dated [DATE] revealed the resident scored 11/15 on the BIMS, indicative of moderate cognitive impairment. The resident exhibited little or no interest or pleasure doing things, had difficulty falling or staying asleep (or sleeping too much), and felt tired or had no energy.Review of CR #1's hospital Discharge Orders dated 06/14/2025 revealed she was receiving Divalproex Sodium ER (medication to treat Epilepsy/seizures) 1000 mg, twice daily.Review of CR #1's Physician's Order dated 06/14/2025 revealed Divalproex Sodium ER oral tablet Extended Release 24 hour 250 MG. to be administered every 12 hours for seizures. The order was transcribed by LVN B.Review of CR #1's Physician's PN dated 06/17/2025 at 08:18 a.m., revealed Physician A documented he saw the resident at the facility on that date. The PN reflected the resident was receiving 50 mg of Depakote ER (generic form of Divalproex Sodium ER) twice daily, instead of 1000 mg twice daily as reflected in the hospital discharge summary or 250 mg every 12 hours, as reflected in the facility Physician Order dated 06/14/2025. The PN reflected no correction of the Physician Order dated 06/14/2025. Review of CR #1's June 2025 MAR revealed she received one 250 mg tablet of Divalproex Sodium ER every 12 hours from 06/14/2025 at 9:00 p.m. to 06/30/2025 at 9:00 p.m.Review of CR #1's July MAR revealed she received one 250 mg tablet of Divalproex Sodium ER every 12 hours from 07/01/2025 to 07/04/2025 at 9:00 a.m. (date of discharge).In an interview on 12/17/2025 at 2:44 p.m., LVN B said the procedure for new admissions was to call or text the physician or NP that the resident had arrived and ask them to review medications. If there was a change, the physician or NP was to notify the nurse via phone, text, or in person. She said the medication orders were not to be entered into the system without approval. When asked if the verification was to be documented, she responded there was no protocol, so she did not document in every case. She said she would have verified the orders with NP C. She said she could not remember if NP C changed any of the orders. In an interview via telephone on 12/17/2025 at 3:12 p.m., CR #1's family member said when the resident was discharged , he noticed the facility had been administering one 250 mg tablet of Divalproex Sodium ER twice daily, instead of 1000 mg twice daily, as reflected in the hospital discharge orders. He said after the resident was discharged from the facility she would scream 'Help me!' all day. She was admitted to a different facility and passed away on 11/22/2025.In an interview on 12/17/2025 at 3:30 p.m., the DON said there was no set way for the nurses to verify new admission orders, but the nurse could call, text, or use an app. The nurse was to contact the NP or doctor, give report, and have them reconcile the medications. He said the nurse should chart that they contacted the physician. The DON said if the medications were not verified, it could result in a medication error. He said he did not know if NP C changed CR #1's Divalproex Sodium ER order upon admission.In an interview via telephone on 12/17/2025 at 4:42 p.m., NP C said she looked through her texts and said she received CR #1's medication list from the hospital. She said she told the nurse to continue with all of the medications. She said she does not review medications but tells the nurse to continue the hospital medications. When asked what complications could arise from the resident receiving 250 mg of Divalproex Sodium ER twice daily versus 1000 mg Divalproex Sodium twice daily, she said she did not want to answer that.In an interview via telephone on 12/17/2025 at 5:15 p.m., Physician A was asked what complications could arise from the resident receiving 250 mg of Divalproex Sodium ER twice daily versus 1000 mg Divalproex Sodium twice daily. He said it would depend on what other medications the resident was on. He said the resident also had low sodium levels, which could have caused altered mental status. The facility policy admission Orders (Revised 02/01/2023) read, in part, .A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs.1. The written and/or verbal orders should include at the minimum:.b. Medication orders if indicated. Review of the package insert for Divalproex Sodium (Section 8.5) revealed discontinuation of Valproate was occasionally associated with somnolence (excessive sleeping) and tremors.

Based on interview and record review, the facility failed to ensure a nurse aide was 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 one (CR #2) of five residents reviewed for assistance with meals. -An unidentified staff supported CR #2's food dish on the staff's lap as she fed the resident. The failure placed the resident at risk for acquiring food-borne illness.Findings include: Record review of the admission Record for CR #2 revealed he was [AGE] years old, admitted to the facility on [DATE]. Diagnoses included dysphagia (difficulty swallowing), lack of coordination, and muscle weakness. He was discharged from the facility on 08/08/2025. Record review of CR #2's 5-day admission MDS assessment dated [DATE] revealed, he exhibited severely impaired cognition. He had impaired range-of-motion to both upper and lower extremities. He was dependent on staff for eating assistance.In an interview via telephone on 12/17/2025 at 1:23 p.m., CR #2's family member verbalized concern that a staff member fed CR #2's meal while having the resident's plate of food on her lap. She said she would send a video. The family member gave consent for the surveyor to show the video to the facility.Review of the video dated 08/02/2025 at 1:11 p.m., revealed an unidentified staff member in a chair, next to CR #2's bed. CR #2 was lying in bed and the unidentified staff member had the resident's food dish on her lap. After she stirred and chopped at the food with a utensil, the staff fed CR #2. The resident's over-bed table was in front of the staff member.Interview and record review on 12/17/25 at 3:30 p.m., the DON viewed the video. He said the technique exhibited by the staff feeding the resident with the resident's plate on her lap was Not OK. He said the plate should not have been in her lap. He noted that the over-bed table was in front of the staff. He said the technique was an infection control issue. He did not identify the staff member but did acknowledge CR #2 resided at the facility on that date and the room was that of the facility.Observation on 12/17/2025 at 12:19 p.m. revealed CNA G assisting Resident # 3 with her meal. The tray was on the over bed table.Observation on 12/17/2025 at 12:22 p.m. revealed Resident #4's tray was on the over bed table, in front of the resident.Observation on 12/17/2025 at 12:30 p.m. revealed an unidentified staff assisting Resident #5 with her meal. The tray was on the over bed table.The facility did not provide a policy regarding staff assistance with meals but did provide a blank copy of the CNA skills check list that included feeding residents.

Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. CR #1, who was prescribed an anticoagulant, had a fall hitting her head on [DATE] at approximately 9:00 p.m. NP A recommended CR #1 be sent to the hospital immediately. Transport was not dispatched until 11:27 p.m. and CR #1 was not transported to the hospital until 12:48 a.m. on [DATE] where she later passed away. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:27 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could place residents at risk for a delay in medical treatment, of not receiving necessary medical care, hospitalization, and death. The findings included: Record review of CR #1's admission Record, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying condition that affects metabolism), cerebral infarction (stroke) due to unspecified occlusion or stenosis of left middle cerebral artery (blockage in the brain caused by atherosclerosis, leading to disruption of blood flow to brain cells), and hypertensive heart (heart problems that occur due to long-term high blood pressure) and chronic kidney disease (gradual loss of kidney function) with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. Record review of CR #1's MDS Assessment, dated [DATE], revealed a BIMS score of 5, indicating severe cognitive impairment. Further review revealed resident required a helper to complete toileting, shower/bathe, and lower body dressing. Record review of CR #1's care plan report, undated, revealed the resident was on anticoagulant therapy r/t atrial fibrillation (irregular and often very rapid heart rhythm) and CHF (chronic condition that affects the heart's ability to pump blood efficiently). Record review of CR #1's physician orders, undated, revealed an order for warfarin sodium oral tablet 2 MG, 1 tablet by mouth at bedtime to prevent blood clot, start date: [DATE]. Record review of CR #1's progress notes, dated [DATE] at 22:16 p.m. [10:16 p.m.], Author: Nurse A, read in part .around 9pm patient on the floor with unwitness fall, she stated she don't remember what happen, initiate neuro and skin assessment patient complains no pain, with obvious bruising/swelling on her left eye, informed RP who is the [family member], DON, and NP [name], ordered to transfer patient to ER for further evaluation. Record review of CR #1's Neuro Assessment Flow Sheet, dated 03/16 and 03/17, revealed neuro checks were completed at 10:00 [p.m.], 10:15 [p.m.], 10:30 [p.m.], 10:45 [p.m.], 11:00 [p.m.], 11:30 [p.m.], 12:00 [a.m.], 00:30 [12:30 p.m.], and 01:00 [a.m.] and vital signs were normal. Record review of CR #1's eInteract Change in Condition Evaluation, dated [DATE], read in part .B6. Skin Status Evaluation .6a. Describe skin changes .Discoloration .6b. Site other, Description left eye bruising .B. Provider Notification and Feedback .2. Date and time of clinician notification: [DATE] 21:30 [9:30 p.m.] .4a. Specify other: transfer to ER . Record review of CR #1's medical transport report, dated [DATE], revealed transport was dispatched at 23:27 (11:27 p.m.) and left facility at 00:48 (12:48 a.m.). Record review of CR #1's CT Brain WO IV Contrast, dated [DATE], read in part .Exam: CT Head without contrast [DATE] 1:20 AM .Impression: 1. No acute intracranial hemorrhage, midline shift, or mass effect. 2. Left frontal scalp soft tissue swelling. 3. Subacute left parieto-occipital infarct . Record review of CR#1's death certificate, issued date [DATE], read in part .immediate cause (final condition or disease resulting in death) ----> a. Intracranial Hemorrhage [bleeding inside the skull] .sequentially list conditions, if any leading to the cause listed on line a. Enter the underlying cause (disease or injury that initiated, the events resulting in death) last .b. Atrial Fibrillation . During a telephone interview on [DATE] at 10:57 a.m., Nurse A said he remembered he was passing out medications during the night shift on [DATE] when he found CR #1 on her bedroom floor. He said CR #1 kept telling him she was okay. He said he did not note any injuries, but resident was on a blood thinner. He said he called NP A and resident was sent out to the hospital immediately. He said CR #1 did not return back to the facility. He said he did not know how many days it was after she was sent out, but she passed away at the hospital. During an interview on [DATE] at 11:15 a.m., the DON said he got a telephone call from the nurse on duty (did not recall name) letting him know CR #1 fell and was found on the floor in her room. He said fall protocols were initiated. He said if he was not mistaken, the resident hit her left eye and had bruising. He said all parties were notified and the resident was sent out to the hospital. He said the resident did not return back to the facility and expired at the hospital. He said to his understanding the resident was alert upon transfer to the hospital. In a follow-up telephone interview on [DATE] at 11:28 a.m., Nurse A said CR #1 did not remember and could not tell them how she fell. He said she was awake and alert when transport arrived and transferred her to the ER. He said the resident had no bleeding but had some puffiness to her left or right eye. During a follow-up interview on [DATE] at 12:41 p.m., the DON said when CR #1 fell, they sent her out to the hospital right away. He said he was not certain if the resident was sent out via 911 or non-emergent transport. During a follow-up telephone interview on [DATE] at 12:56 p.m., Nurse A said a man who he believed was the resident's family member came up to the facility after CR #1 fell, and waited for transport to arrive and rode with the resident to the hospital. He said he thought the family member came to the facility around 11:00 p.m. or 12:00 a.m. He said NP A said to have the resident transported to the hospital but did not remember if NP A said to use regular or 911 transport. He said he called regular transport. He said he used regular transport because the resident and her vitals were stable. During an interview on [DATE] at 1:13 p.m., the Administrator said CR #1 did not remember what happened. She said the family member went to the facility 2 to 3 days after CR #1 passed away to pick up her belongings and he told her that the resident was okay on the day of the incident, that he did not even want her to be sent out to the hospital, and that it had something to do with her heart that the doctors found. She said they did not obtain any hospital records but there were no notifications about any fractures/injuries. She said based on what the NP told them, if the patient's vitals were within normal range, and if the resident was okay, then they would send out regular transport. During a follow-up interview on [DATE] at 2:00 p.m., Nurse A said he did not remember what time he called transport, but it was as soon as he received the order from NP A. He said he spoke to NP A around 9:00 p.m., and she told him to assess the resident for bleeding, check to see if the resident was on an anticoagulant, and to send her to hospital for further evaluation. He said he did not know what time transport arrived, but that they arrived kind of late, about 1 to 2 hours or something like that, after he called. During an interview on [DATE] at 3:08 p.m., NP A said she recalled receiving a telephone call about CR #1's fall on [DATE] but did not recall what time. She said when she spoke to the nurse, she gave the order to send out the resident immediately. She said she spoke to the resident's family member who was reluctant to send her out to the hospital. She said the family member told her that the resident fell a lot at home, and he would not take her to the hospital. She said she told the family member the resident needed to be sent out for safety and because she was on an anticoagulant. She said she could not say who ultimately decides if a resident was sent out 911 or regular transport [facility or physician/NP]. NP A said she could not say if the resident should have been sent out 911 or regular transport due to it being a hypothetical question. She said she could not say what the risk was to the resident who was on anticoagulant, fell and hit her head, and was not sent out 911 due to it being a hypothetical question and a case-by-case basis. During a telephone interview on [DATE] at 9:19 a.m., the DON said according to neuro checks, CR #1's vitals were stable. He said pupils and eye checks were meant to determine if there was any type of abnormalities. He said her eyes were not constricted or dilated and were brisk. He said they could not determine if there was internal bleeding through neuro checks but could determine if there were any abnormalities but not exactly what was wrong. He said a resident on an anticoagulant that sustained a head injury could be at risk for bleeding. During an interview on [DATE] at 10:42 a.m., CR #1's family member said the facility called him on the night of [DATE] around 9:00 p.m. to let him know CR #1 fell. He said he did not tell them not to send her to the hospital. He said he got up right away, went to the facility, and arrived between 10:00 p.m. and 10:30 p.m. He said when he arrived at the facility, the resident could not tell him what happened and told him she did not want to go to the hospital. He said he told CR #1 she had to go to the hospital because it was part of the facility's protocol. He said he did not recall if he spoke to NP A, but the facility told him about their protocol for sending CR #1 to the hospital. He said CR #1 had a little discoloration to her left eye, but that she was fine and talking to him. He said when transport arrived, she walked to the stretcher, and he followed behind transport. He said all test results completed at the hospital came back negative. He said he had a copy of the resident's death certificate and the cause of death listed was intracranial hemorrhage and atrial fibrillation. Record review of the facility's Provision of Quality Care policy, date implemented [DATE], read in part .1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being . Record review of the facility's Fall Prevention Program policy, date implemented: [DATE], read in part .each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . The Administrator was notified on [DATE] at 10:27 a.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on [DATE] at 6:06 p.m.: Texas Health and Human Services Commission Regulatory Services Division [address] Re: Removal of Immediate Jeopardy/Letter of Removal [Facility Name] Facility ID/# [] [DATE]th, 2025 Dear Program Manager, Allegation of Immediate Jeopardy: -The facility failed to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. CR #1, who is prescribed anticoagulants, had a fall hitting her head on [DATE] at approximately 9:00 p.m. NP recommended CR #1 be sent to hospital. Transport was not dispatched until 23:27 (11:27 p.m.) and CR #1 was not transported to the hospital until 00:48 (12:48 a.m.) on [DATE] where she later passed away. Resident #1 who is on anticoagulant (CR #1), a [AGE] year-old female admitted to the facility on [DATE] diagnosis of metabolic encephalopathy, cerebral infarction, chronic kidney disease with heart The following measures represent the immediate action [facility name] has taken to address the alleged-deficient practice and to prevent serious harm from occurring or recurring. Immediate Actions to Address Immediate Jeopardy On [DATE] at 11:00 am, the Director of Nursing (DON) completed head to toe assessments on all residents currently prescribed anticoagulant medications to ensure no signs of injury or delayed response to change in condition. Beginning [DATE] at 12:00 pm the administrator and DON initiated a 72 hour look back review of all falls and incidents from [DATE]-[DATE] involving head injuries to ensure appropriate emergency response and physician notification were documented. With no negative findings. At 1:00 pm during QAPI Administrator/Director of Nursing/Medical Director reviewed Fall policy with no revisions to the policy. Date of Action: [DATE] Objective: Ensure that resident receiving anticoagulant with head injury must be transported to hospital via 911 for further evaluation. Ensure that all nurse must assess, notify and document notification to Responsible Party, Physician/Nurse Practitioner, Director of Nursing and Administrator residents. 1. Review Resident Records o Action: Audit all records of residents on coumadin and head injuries. Audit revealed No residents on anticoagulants at this time. o Completion Date: [DATE] o Responsible Party: DON/Designee 2. Immediate Staff Training o Action: On [DATE] at pm an emergency inservice- training was held with all licensed nurses and CNAs on appropriate response protocols for head injuries, especially in resident on anticoagulants. o Topics covered: immediate assessment, neuro checks, when to call 911, and importance of timely physician notification. o Action: Provide training to 1all nursing staff on the importance of transferring residents to hospital via 911 for residents with head injuries and are receiving anticoagulants. Training to include post test. Provide training to all nursing staff to ensure nursing assessment is completed when there is a resident incident accident. Nurse must notify the Responsible party, Physician, Nurse Practitioner, Director of Nursing and Administrator. Any communication must also be documented in the medical records. o Action: DON/Admin in-serviced by corporate on response protocols for head injuries, falls and residents on anticoagulants. o Completion Date: [DATE] o Trainer: DON attendance documented. Staff not trained are removed from floor assignments until completed. 3. Documentation of Immediate Training and Competency Checks o Action: Head injury/anticoagulant transfer test will be completed by nursing staff currently on duty and for all active employed nurses prior to the start of the next scheduled shift. o Completion Date: [DATE] o Responsible Party: DON/Designee, documentation of completion on file. Goal: To Ensure nurses receive training on transferring resident to hospital via 911 for further evaluation and treatment on residents who are receiving anticoagulant with head injury 1. Training Sessions on Incident accident accident injury with anticoagulants and transfer to hospital o Action: Schedule inservice session on nursing staff to ensure Ensure that resident receiving anticoagulants with head injury must be transported to hospital via 911 for further evaluation and treatment o Completion Dates: Initial training and post test to be completed on 5 /24/25 or prior to next scheduled shift. o Trainer: DON/Designee o Competency Verification: All staff will be required to pass a posttest 2. Resident Monitoring Logs Implementation o Action: Audit to be completed daily on all resident receiving anticoagulant with head injury to ensure proper transfer to hospital is completed o Completion Date: [DATE] o Responsible Party: ED to develop log. DON/designee to complete and monitor 3. Quality Assurance and Performance Improvement (QAPI) Meeting o Action: Conduct a QAPI meeting to review the incident, corrective actions, and policy updates. Create a recurring agenda item for monitoring compliance with the new protocols. o Date of Meeting: [DATE] o Responsible Party: Administrator and QAPI Committee 4. Ongoing Audits and Compliance Checks o Action: Schedule daily audits x30 days then weekly for 30 days to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital . Document findings and review corrective actions in monthly QAPI meetings. o Start Date:[DATE], continuing weekly until confirmed compliance o Responsible Party: Administrator 5. Progressive Action/Counseling o Nurse A, will receive 1:1 in servicing prior to next scheduled shift . They will also complete post test. o [Medical Director Name], Medical Director, was notified via telephone in regard to the IJ involving resident [initials] and attended ad-hoc QAPI via telephone. Documentation and Follow-Up -Documentation of Training and Competency Checks: All staff training records, test conducted will be filed in each employee's personnel record by [DATE] -Audit Logs and Monitoring Forms: Logs for audit on falls, head injury and anticoagulants will be maintained and reviewed weekly. Compliance will be tracked, and corrective actions will be implemented as necessary. Outcome: Through these corrective actions, the facility aims to protect resident safety, enhance monitoring and responsiveness, and achieve sustained compliance with respiratory care standards. Warm Regards, [Administrator Name] [Address] Email: [] Phone: [] Fax: []. On [DATE]-[DATE], surveyor confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Record review of head to toe assessments dated [DATE] reflected the DON assessed all residents currently prescribed anticoagulant medications. The assessments revealed 25 residents had an order(s) for anticoagulants. No negative findings were identified Record review of in-service trainings dated [DATE] reflected the Administrator and DON received training from the facility's Regional [NAME] President of Operation on emergency response to falls in residents on anticoagulants. Record review revealed on [DATE], Nurse A received 1:1 verbal warning/counseling and in-service training. Nurse A demonstrated an understanding of the information and passed the competency quiz. Record review revealed on [DATE], in-service training was initiated with licensed nurses and MAs on Falls/Injury on Residents on Anticoagulants must be Transported to ER via 911; 22 staff were in-serviced. Record review revealed on [DATE], in-service training was initiated with licensed nurses, CNAs, and MAs on All Incidents/Accidents Must be Assessed Immediately with Neuro Checks Initiated and Reported Immediately to MD, DON, RP, and ED; 50 staff were in-serviced. Record review revealed on [DATE], competency quiz was initiated with nursing staff. Nursing Staff demonstrated an understanding of responding to falls in residents on anticoagulants; 31 staff were quizzed and passed. Record review revealed on [DATE], a daily audit log was initiated to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital was initiated on all residents receiving anticoagulant with head injury. Record review revealed on [DATE] the facility conducted a 72-hour look back of all fall incidents from [DATE]-[DATE] involving head injuries to ensure appropriate emergency response and physician notification were documented. Record review revealed on [DATE] a daily audit log was initiated to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital was initiated on all residents receiving anticoagulant with head injury. Record review revealed on [DATE] a QAPI telephone conference was held, and staff members present were the Administrator, DON, and Medical Director. Interviews were conducted from [DATE] to [DATE] with staff from all shifts (6:00 a.m.to 6:00 p.m., 6:00 p.m. to 6:00 a.m., 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.). Staff interviewed included the following: Administrator, DON, Nurse A, RNs C and D, LVNs B, C, E, and F, CNAs B, C, D, E, F, G, H, I and J, and MA B. All staff interviewed verbalized an understanding of the in-service training(s) they received. They understood to notify nurses when a resident has a fall, required nurse assessment, documentation, and notifications of residents who fall that are on anticoagulants, and calling 911 for transport. During an interview on [DATE] at 10:01 a.m., the DON said he completed the head-to-toe assessments on residents who were on anticoagulants and there were no negative findings. He said he and the Administrator completed the 72-hour look back and there were no negative findings. He said they conducted an audit and found there were no residents on coumadin. He said he received in-service training from Regional [NAME] President of Operation on [DATE] on response protocols for head injuries, falls, and residents on anticoagulants and verbalized an understanding. He said daily audits are being completed for the next 30 days then weekly for 30 days to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital. During an interview on [DATE] at 4:12 p.m., the Administrator said he and the DON completed the 72-hour look back on [DATE] and no negative findings were found. She said she received in-service training from Regional [NAME] President of Operations on response protocols for head injuries, falls, and residents on anticoagulants. She said he covered the assessments of residents with head injuries that are on an anticoagulant. She said nurses complete the assessment, and notification to physician and family is completed and documented. She said a QAPI meeting was held on [DATE] via telephone and she, DON, and Medical Director were in attendance. She said daily audits were being completed for 30 days and then weekly for 30 days to ensure compliance with proper transfer of patient on anticoagulants with head injury to hospital. She said findings were going to be documented. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 5:16 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to provide services that met professional standards of quality for 2 of 15 residents (Residents #55 and #24) reviewed for services. 1. Resident #55 failed to receive nine medications he was ordered to receive on 2/2/2025. 2. Resident #24 did not receive one medication 41 times from 04/20/2025 to 05/07/2025. These failures could place residents at risk of worsening of illnesses and not receiving the therapeutic dosage. Findings included: Resident #55 Record review of Resident #55's face sheet, he was an [AGE] year-old male originally admitted on [DATE] at 4:45 p.m. and discharged [DATE] to home. His medical diagnoses included metabolic encephalopathy (brain disorder caused by the body's metabolic processes and lead to impaired brain function), hyperlipidemia (high levels of fat in the blood), chronic inflammatory demyelinating polyneuritis (a rare neurological disorder affecting the nerves and nerve roots and leading to weakness and paired motor function), fracture of the first lumbar vertebra (lower spine fracture), and muscle weakness. Record review of Resident #55's functional performance assessment dated [DATE], revealed he was dependent on a helper for activities. Record review of Resident #55's care plan dated 2/2/2025 revealed he was on anticoagulant therapy with interventions including administering anticoagulant medications as ordered by physician and monitor for side effects and effectiveness. Resident #55 was on anticonvulsant medication, with interventions including administering anticonvulsant medications as prescribed. Review of Resident #55's progress notes from admission to discharge revealed Resident #55 was admitted on [DATE] at 4:45pm and discharged [DATE] around 3pm. On 2/2/25 at 2:24pm, RN A documented that all scheduled medicines were not received from the pharmacy and that she called the pharmacy to send the medications before 4pm but the pharmacy relayed the earliest the delivery could come was 5pm. The RP said they were leaving the facility. RN A informed the NP and ADON but did not state what she told them. The notes did not state the reason why Resident #55 did not receive his medications. Record review of Resident #55's Physician Orders, he was prescribed the following with start dates of 2/2/25: *Amiodarone Hcl Oral Tablet 200 Mg 1 tablet a day for arrythmia (irregular heart beat), *Apixaban oral Tablet 1 tablet twice a day to prevent blood clots, Observation for anticoagulant/antiplatelet medication side effects such as blood in urine and coughing up blood, *Metoprolol Succinate ER oral Tablet Extended Release 24 Hour 25 MG one tablet one time a day for hypertension, *Cyanocobalamin Oral Tablet 1000MCG one tablet one time a day for vitamin supplement, *Duloxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG 3 capsules one time a day for depression, *Fludrocortisone Acetate Oral Tablet 1 MG give 1 tablet by mouth one time a day related to inflammatory demyelinating polyneuritis for pain in the nerves, *Finasteride Oral Tablet 5 MG 1 tablet one time a day for BPH (enlarged prostate gland which affects urination), *Phenazopyridine HCl 1 tablet three times a day for burning sensation in the urinary tract, *Primidone Oral Tablet 50 MG 2 tablets one time a day for convulsion, and *Thiamine HCl Oral Tablet 100 MG 1 tablet a day for supplement. Record review of Resident #55's February 2025 MAR (medication administration record) revealed the following medications were documented as not administered as ordered on 2/2/25: *Amiodarone at 9am, *Apixaban for 9am and 5pm, *Metoprolol at 9am, *Cyanocobalamin at 9am, *Duloxetine HCl Oral Tablet at 9am, *Fludrocortisone Acetate Oral Tablet at 9am, *Finasteride Oral Tablet at 9am, *Primidone at 9am, *Phenazopyridine HCl Oral Tablet at 9am and 2pm, and *Thiamine HCl Oral Tablet at 9am. On 2/2/25 at 6am, Resident #55 was observed with no side effects of anticoagulant/antiplatelet medication including coughing blood and severe bruising. His vitals including his BP, temperature, pulse and oxygen were within normal limits. Resident #55's pain level was at a 1. Record review of the facility's in-service dated 2/3/2025 on the topic of med aides reporting to charge nurses for any abnormalities regarding missing medications. CMA A and RN A. There was a blank form titled Medication Request with nurses documenting medication aide requesting medications and how many medications a resident has left. Interview on 5/7/2025 at 11:42am with CMA A, she did not remember Resident #55 or the resident not getting any medications. CMA A's job duties included administering scheduled medications and over-the-counters except antibiotics and requesting refills from the pharmacy. When medications were not available, she would tell her nurses so they could get medications from emergency kit and the nurses would also call the pharmacy for follow-up on medication status. Interview on 5/7/2025 at 11:59am with RN A on 5/7/2025 at 12:50pm, she said if a new admission was coming from hospital, she would check the medication administration list. She would verify the medications with the NP, then upload the orders into the resident record. She would ask the NP about medications to confirm which medications would be continued. The person who accepted the resident would send the medication list to the pharmacy, but the assessing nurse could send it as well. Before 5:30pm, nurses could upload the medication list and call the pharmacy. If medications have not received by 5:30pm, nurses would fax and call the pharmacy about the medications to be sent before 12:00pm. RN A stated on 2/1/25 she uploaded the medication list to the pharmacy. RN A called the ADON who told her the facility could not borrow medications from the e-kit. RN A called the pharmacy late on 2/1/25 around 5pm to send the medication list. RN A said the resident did miss his doses but that day the resident was fine. RN A said if Resident #55 missed his Apixaban that could cause him to go into shock, if he missed his Amiodarone, he could have a faster heart rate, and if he missed his Metoprolol, he could have an episode of hypertension. She called the ADON and Administrator and informed them both that Resident #55 and his family left. Interview on 5/7/2025 at 12:04 with LVN A, she said she was helping that weekend as a supervisor. LVN A recalled talking to Resident #55's RP and tried to assure her the facility could get medications from the emergency kit (a machine in which nursing staff could access medications for a resident with a code from the pharmacy), but the family refused. She said RN A was the nurse on duty. She said she did not look into the issue because RN A talked to the DON about the situation already. She said a risk to residents if they did not get Apixaban could be they go into shock. If the resident did not receive Amiodarone, it could increase their heart rate and if they missed a dose of Metoprolol, it could affect their blood pressure and the resident could go into shock. Interview on 5/7/25 at 12:50pm with RN B/previous ADON, said if she was a resident's admitting nurse she would call the NP and reconcile the medication, then send it to the pharmacy to get it in before closing time. Then she would put the medication in the orders. If medications have not arrived, she would contact the hospital or call the pharmacy, then let the DON know and go to the e-kit. She would call the pharmacy for emergency deliveries and let the DON know. The pharmacy usually came once a day at 7pm but RN B said they have delivered at other times. She was not at the facility at the time of Resident #55's discharge but heard there was a miscommunication between medication aides and nurses. The nurses said the medication aides did not tell them right away about the medications not being in there, but when the nurse found out they called the pharmacy. She found this out on 2/3/25 as she was off. The facility did in services about communicating missing medications from medication aides to nurses. The nurses were in serviced to check on new admissions and if medications were in the facility. She did not talk to the pharmacy or family. If Resident #55 missed Apixaban, Amiodarone and Metoprolol he could have had a stroke. Interview on 5/7/25 at 12:57pm with the DON, he said when a new admission comes it, their medications should be verified right away and given timely. Medications should be given following Physician Orders. The DON said narcotics could be delayed but that staff could get the medications from the emergency kit while they send in an order request to the resident's doctor. If medications were not at the facility, the nurses could contact the pharmacy. The DON remembered Resident #55 was supposed to get a narcotic medication and Resident #55's family got upset that the medications did not arrive and chose to discharge Resident #55 home. The DON said it was a miscommunication issue due to CMA A not communicating with RN B that the medication was not there. The family refused to speak to the DON afterward. The DON said if Resident #55 missed Apixaban he could have bleeding, if he missed his Amiodarone, he could have elevated heart issues or hypertension, and if Resident #55 missed his Metoprolol he would be at risk of heart issues. Interview on 5/8/2025 at 4:25pm the DON said that Atorvastatin controlled lipids, and Phenazopyridine, Thiamine, Finasteride, Ergocalciferol, Duloxetine, and Cyanocobalamin were missed medication. He said the medications treated conditions, but that Resident #55 was not at any risk from missing those medications because the medications were being delivered that day. He said nurses ensured aides provided medications. He said the NP was notified of the missing medications. Most of the residents' medications would not have been in the e-kit which usually contained steroids. Interview on 5/7/2025 at 1:22pm with the Administrator, her expectation of nurses following a resident's new admission and their medication is to follow up with the pharmacy and physician and check in with DON and Administrator. Upon admissions, if resident did not have their medication, the facility could contact the physician and get it from the e-kit or contact the pharmacy to get a stat run (prioritized delivery). The Administrator said on weekends which was when Resident #55 was admitted , the cut-off would be 3pm for orders for a 5pm delivery. Facility staff could also access an online health portal to access medications from an on-call physician. The Administrator said she spoke to the pharmacy on 2/2/25 around 1pm, and they informed her Resident #55's medication was on the way, but the family said he wanted to leave. If Resident #55 missed Apixaban, it is for clotting and the risk of not giving the medication was clotting and clots could travel to the heart and cause heart attaches or travel to the brain, and Amiodarone she said he would still be able to get a dose if it came in later 5pm it would not have affected him, but signs and symptoms should be monitored. If Resident #55 did not get the Metoprolol, it could have affected his blood pressure but his vitals for blood pressure was normal that day. It would have been preferred if the medication was given in the morning, but the facility had 24 hours to get Resident #55 his daily medications. She said medication should be given one hour before or after a scheduled dose. The Administrator said the NP was notified medications were missing. Interview with NP A on 5/7/2025 at 1:51pm, she said she did the admission process including receiving and verifying Resident #55's physician orders and medications for Resident #55 and remembered meeting with Resident #55's family on 2/1/25. NP A said the facility called her on 2/2/25 to inform her that Resident #55 was leaving. She asked to speak to the family, but they had already left, and she was told they left because his medications had not come. She said the facility nurses would have submitted medications onto the online portal for the pharmacy. NP A was not notified Resident #55 missed medications on 2/2/25. If the facility had told her, NP A would have called the pharmacy herself. Apixaban could have caused a blood clot but if he was taking it daily if he missed a 24-hour dose he would have been okay, same with Amiodarone and she does not like medications to be delayed but it's okay and not risk. If Resident #55 missed Metoprolol, the facility should have checked his blood pressure, but if they had missed it, it could affect his blood pressure. If Resident #55 had high blood pressure, and the facility informed NP A, she would have sent an order from the emergency kit. She stated if Resident #55's Fludrocortisone was delayed, he could have more pain. She said that per state law, medications can be given 1-2 hours before or after the scheduled time. Resident #24 Record review of the admission Record for Resident #24 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Stage 5 kidney disease (end stage kidney disease), anemia in chronic kidney disease, history of cancer of the kidney, acquired absence of kidney, and dependence on renal dialysis. Record review of Resident #24's Care Plan (revised 03/02/2025) revealed he required hemodialysis due to renal (kidney) failure. The hemodialysis section of the Care Plan did not address medications. Record review of Resident #24's Care Plan section initiated on 05/07/2025 reflected the resident could become hypotensive (low blood pressure). One intervention read, in part, .Give medications as ordered. Monitor for side effects and effectiveness. Record review of Resident #24's Physician's Order dated 04/01/2025 revealed he was to receive Sevelamer Carbonate 800 mg tablet (2) tablets with meals (3 times per day). Record review of Resident #24's April 2025 MAR revealed the resident's Sevelamer Carbonate 800 mg tablets (2) were not administered for two of the three opportunities on the following dates: 04/20/2025 12:00 p.m. and 5:00 p.m. doses 04/23/2025 12:30 p.m. and 9:00 p.m. doses 04/28/2025 07:30 a.m. and 12:30 p.m. doses 04/30/2025 07:30 a.m. and 12:30 p.m. doses (8 missed doses ). The Sevelamer Carbonate 800 mg tablets (2) were not administered for three of the three opportunities on the following dates: 04/21/2025 07:30 a.m., 12:30 p.m., and 9:00 p.m. 04/22/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 04/24/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 04/26/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 04/27/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 04/29/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. (18 missed doses). Record review of Resident #24's May 2025 MAR revealed the resident's Sevelamer Carbonate 800 mg tablets (2) were not administered for one of one opportunity on the following date: 05/06/2025 07:00 a.m. (1 missed dose) The resident was out of the facility for the 12:00 p.m. and 5:00 p.m. scheduled doses. Record review of Resident #24's May 2025 MAR revealed the resident's Sevelamer Carbonate 800 mg tablets (2) were not administered for two of the three opportunities on the following dates: 05/02/2025 07:30 a.m. and 12:30 p.m. 05/05/2025 07:30 a.m. and 12:30 p.m. ( 4 missed doses). The Sevelamer Carbonate 800 mg tablets (2) were not administered for three of the three opportunities on the following dates: 05/01/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 05/03/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 05/04/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 05/06/2025 (9 missed doses). Record review of Resident #24's May 2025 MAR revealed the resident's Sevelamer Carbonate 800 mg tablets (2) were not administered for one of one opportunity on the following date: 05/07/2025 07:30 a.m. (1 missed dose) In an interview on 05/07/25 at 1:23 p.m., RN H said the medication was not available this morning at 7:30 a.m. He said he called the pharmacy and was told the medication was not covered by insurance. He said the pharmacy suggested he call the dialysis center. He said he called the dialysis center but could not recall whom he spoke with. He said the person at the dialysis center said they sent the prescription to the pharmacy, and that it would take 8 to 10 days for the facility to receive it. He said he informed ADON I. RN H said he had inquired about the medication on 05/03/2025. He said he had also called the pharmacy on that day and was referred to the dialysis center. He said the dialysis center had said they would look into it. RN H did not work from 05/04/2025 until his shift on 05/07/2025. He said there was no follow-up prior to 05/07/2025. In an interview and observation on 05/07/25 at 1:40 p.m., ADON I said if a medication was not available, the nurse was to inform him. He said he would then follow up with the doctor and pharmacy. He would inquire about availability and/or a substitute. He said he was unaware that Resident #24 had not been receiving any of his medications. Observation revealed ADON I pulled up Resident #24's MAR on the computer. He said the medication was placed on hold. He was not able to tell who ordered the medication to be placed on hold. In an interview on 05/07/2025 at 2:47 p.m., the DON said he called the pharmacy and approved a 14-day supply. He said the facility would cover the cost. He said the medication would be delivered today by 5:00 p.m. He said the physician was aware of the medication not being available since the beginning of the issue. He said he called the NP this morning and she placed the medication on hold. He said he did not know if the NP was called about this situation prior to today. In an interview via telephone on 05/07/2025 at 3:00 p.m., the Clinical Nurse Manager of the dialysis facility said there were two nurses working on this date, and both said they did not receive a call about Resident #24. She said Resident #24 was going to be transferring to a different dialysis treatment center on Friday (05/09/2025). She said without the Sevelamer Carbonate, the resident's phosphorous level would go up. Complications could include itching. If the phosphorous level was high enough to go into the circulatory system it could cause cardiac issues. There was not a current phosphorous level lab available for review. She said the dialysis center would not have placed the medication on hold. An attempt to contact the Physician and/or NP was made on 05/07/25 at 3:35 p.m. A message was left, but no return call was received. In an interview via telephone on 05/27/25 at 11:12 a.m., the Physician said within two or three days after Resident #24's Sevelamer Carbonate was not available (04/20/25), he was aware the medication was not available. He said Sevelamer Carbonate was a phosphate binder (medication used to reduce the absorption of dietary phosphate). He said the medication could be held for two weeks without adverse effects. He said the medication could be stopped completely if the resident was attending dialysis. He said the 41 missed doses of Sevelamer Carbonate was not a risk to Resident #24's health. He said Resident #24's syncopal (fainting) was likely unrelated to missing the Sevelamer Carbonate. Record review of a lab report for Resident #24 draw date 05/05/25 revealed his Phosphate level was 7.3 mg/dl, with reference range of 2.6-4.5 mg/dl. The Phosphate level was not 'critical high' at that time. In an interview on 05/27/25 at 1:50 p.m., the DON said the Sevelamer Carbonate 800 mg for Resident #24 had not been available for administration at the facility since 04/21/25. He said some doses were documented as given, but those were in error. Interview with the DON and record review on 05/27/25 at 2:15 p.m. revealed a 14-day supply of the Sevelamer Carbonate 800 mg for Resident #24 was delivered on each of the following dates: 02/04/25, 02/15/25, 03/04/25, 03/15/25, 04/01/25, 05/08/25. The DON said that in April 2025 CMS changed the rule, making it the Dialysis Center responsible for ordering the medication from the Pharmacy, no longer the facility responsibility. Therefore, there was no delivery in the middle part of April 2025. He said the facility contacted the Dialysis Center more than once but the Dialysis Center did not call the Pharmacy (unverifiable). Record review of the facility's policy on Pharmacy Services copyrighted 2023, read in part, .7. The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements. Record review of the facility's policy on Unavailable Medications implemented 05/10/24, it read in part, .5. IF a resident misses a scheduled dose of the medication staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. Record review of the facility's policy on Medication Administration implemented 05/10/24, it read in part, .12b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Based on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents and pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 15 (Residents #55 and #24) reviewed for medication administration. 1. Resident #55 did not receive nine medications as ordered by the Physician on 2/2/2025. 2. Resident #24 did not receive one medication 41 times from 04/20/2025 to 05/07/2025. This failure could lead to a decline in residents' physical, mental and emotional health due to not receiving the medications and the therapeutic effects to treat their conditions as ordered by their physician. Findings included: Resident #55 Record review of Resident #55's face sheet, he was an [AGE] year-old male originally admitted on [DATE] at 4:45 p.m. and discharged [DATE] to home. His medical diagnoses included metabolic encephalopathy (brain disorder caused by the body's metabolic processes and lead to impaired brain function), hyperlipidemia (high levels of fat in the blood), chronic inflammatory demyelinating polyneuritis (a rare neurological disorder affecting the nerves and nerve roots and leading to weakness and paired motor function), fracture of the first lumbar vertebra (lower spine fracture), and muscle weakness. Record review of Resident #55's functional performance assessment dated [DATE], revealed he was dependent on a helper for activities. Record review of Resident #55's care plan dated 2/2/2025 revealed he was on anticoagulant therapy with interventions including administering anticoagulant medications as ordered by physician and monitor for side effects and effectiveness. Resident #55 was on anticonvulsant medication, with interventions including administering anticonvulsant medications as prescribed. Review of Resident #55's progress notes from admission to discharge revealed Resident #55 was admitted on [DATE] at 4:45pm and discharged [DATE] around 3pm. On 2/2/25 at 2:24pm, RN A documented that all scheduled medicines were not received from the pharmacy and that she called the pharmacy to send the medications before 4pm but the pharmacy relayed the earliest the delivery could come was 5pm. The RP said they were leaving the facility. RN A informed the NP and ADON but did not state what she told them. The notes did not state the reason why Resident #55 did not receive his medications. Record review of Resident #55's Physician Orders, he was prescribed the following with start dates of 2/2/25: *Amiodarone Hcl Oral Tablet 200 Mg 1 tablet a day for arrythmia (irregular heart beat), *Apixaban oral Tablet 1 tablet twice a day to prevent blood clots, Observation for anticoagulant/antiplatelet medication side effects such as blood in urine and coughing up blood, *Metoprolol Succinate ER oral Tablet Extended Release 24 Hour 25 MG one tablet one time a day for hypertension, *Cyanocobalamin Oral Tablet 1000MCG one tablet one time a day for vitamin supplement, *Duloxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG 3 capsules one time a day for depression, *Fludrocortisone Acetate Oral Tablet 1 MG give 1 tablet by mouth one time a day related to inflammatory demyelinating polyneuritis for pain in the nerves, *Finasteride Oral Tablet 5 MG 1 tablet one time a day for BPH (enlarged prostate gland which affects urination), *Phenazopyridine HCl 1 tablet three times a day for burning sensation in the urinary tract, *Primidone Oral Tablet 50 MG 2 tablets one time a day for convulsion, and *Thiamine HCl Oral Tablet 100 MG 1 tablet a day for supplement. Record review of Resident #55's February 2025 MAR (medication administration record) revealed the following medications were documented as not administered as ordered on 2/2/25: *Amiodarone at 9am, *Apixaban for 9am and 5pm, *Metoprolol at 9am, *Cyanocobalamin at 9am, *Duloxetine HCl Oral Tablet at 9am, *Fludrocortisone Acetate Oral Tablet at 9am, *Finasteride Oral Tablet at 9am, *Primidone at 9am, *Phenazopyridine HCl Oral Tablet at 9am and 2pm, and *Thiamine HCl Oral Tablet at 9am. On 2/2/25 at 6am, Resident #55 was observed with no side effects of anticoagulant/antiplatelet medication including coughing blood and severe bruising. His vitals including his BP, temperature, pulse and oxygen were within normal limits. Resident #55's pain level was at a 1. Record review of the facility's in-service dated 2/3/2025 on the topic of med aides reporting to charge nurses for any abnormalities regarding missing medications. CMA A and RN A. There was a blank form titled Medication Request with nurses documenting medication aide requesting medications and how many medications a resident has left. Interview on 5/7/2025 at 11:42am with CMA A, she did not remember Resident #55 or the resident not getting any medications. CMA A's job duties included administering scheduled medications and over-the-counters except antibiotics and requesting refills from the pharmacy. When medications were not available, she would tell her nurses so they could get medications from emergency kit and the nurses would also call the pharmacy for follow-up on medication status. Interview on 5/7/2025 at 11:59am with RN A on 5/7/2025 at 12:50pm, she said if a new admission was coming from hospital, she would check the medication administration list. She would verify the medications with the NP, then upload the orders into the resident record. She would ask the NP about medications to confirm which medications would be continued. The person who accepted the resident would send the medication list to the pharmacy, but the assessing nurse could send it as well. Before 5:30pm, nurses could upload the medication list and call the pharmacy. If medications have not received by 5:30pm, nurses would fax and call the pharmacy about the medications to be sent before 12:00pm. RN A stated on 2/1/25 she uploaded the medication list to the pharmacy. RN A called the ADON who told her the facility could not borrow medications from the e-kit. RN A called the pharmacy late on 2/1/25 around 5pm to send the medication list. RN A said the resident did miss his doses but that day the resident was fine. RN A said if Resident #55 missed his Apixaban that could cause him to go into shock, if he missed his Amiodarone, he could have a faster heart rate, and if he missed his Metoprolol, he could have an episode of hypertension. She called the ADON and Administrator and informed them both that Resident #55 and his family left. Interview on 5/7/2025 at 12:04 with LVN A, she said she was helping that weekend as a supervisor. LVN A recalled talking to Resident #55's RP and tried to assure her the facility could get medications from the emergency kit (a machine in which nursing staff could access medications for a resident with a code from the pharmacy), but the family refused. She said RN A was the nurse on duty. She said she did not look into the issue because RN A talked to the DON about the situation already. She said a risk to residents if they did not get Apixaban could be they go into shock. If the resident did not receive Amiodarone, it could increase their heart rate and if they missed a dose of Metoprolol, it could affect their blood pressure and the resident could go into shock. Interview on 5/7/25 at 12:50pm with RN B/previous ADON, said if she was a resident's admitting nurse she would call the NP and reconcile the medication, then send it to the pharmacy to get it in before closing time. Then she would put the medication in the orders. If medications have not arrived, she would contact the hospital or call the pharmacy, then let the DON know and go to the e-kit. She would call the pharmacy for emergency deliveries and let the DON know. The pharmacy usually came once a day at 7pm but RN B said they have delivered at other times. She was not at the facility at the time of Resident #55's discharge but heard there was a miscommunication between medication aides and nurses. The nurses said the medication aides did not tell them right away about the medications not being in there, but when the nurse found out they called the pharmacy. She found this out on 2/3/25 as she was off. The facility did in services about communicating missing medications from medication aides to nurses. The nurses were in serviced to check on new admissions and if medications were in the facility. She did not talk to the pharmacy or family. If Resident #55 missed Apixaban, Amiodarone and Metoprolol he could have had a stroke. Interview on 5/7/25 at 12:57pm with the DON, he said when a new admission comes it, their medications should be verified right away and given timely. Medications should be given following Physician Orders. The DON said narcotics could be delayed but that staff could get the medications from the emergency kit while they send in an order request to the resident's doctor. If medications were not at the facility, the nurses could contact the pharmacy. The DON remembered Resident #55 was supposed to get a narcotic medication and Resident #55's family got upset that the medications did not arrive and chose to discharge Resident #55 home. The DON said it was a miscommunication issue due to CMA A not communicating with RN B that the medication was not there. The family refused to speak to the DON afterward. The DON said if Resident #55 missed Apixaban he could have bleeding, if he missed his Amiodarone, he could have elevated heart issues or hypertension, and if Resident #55 missed his Metoprolol he would be at risk of heart issues. Interview on 5/8/2025 at 4:25pm the DON said that Atorvastatin controlled lipids, and Phenazopyridine, Thiamine, Finasteride, Ergocalciferol, Duloxetine, and Cyanocobalamin were missed medication. He said the medications treated conditions, but that Resident #55 was not at any risk from missing those medications because the medications were being delivered that day. He said nurses ensured aides provided medications. He said the NP was notified of the missing medications. Most of the residents' medications would not have been in the e-kit which usually contained steroids. Interview on 5/7/2025 at 1:22pm with the Administrator, her expectation of nurses following a resident's new admission and their medication is to follow up with the pharmacy and physician and check in with DON and Administrator. Upon admissions, if resident did not have their medication, the facility could contact the physician and get it from the e-kit or contact the pharmacy to get a stat run (prioritized delivery). The Administrator said on weekends which was when Resident #55 was admitted , the cut-off would be 3pm for orders for a 5pm delivery. Facility staff could also access an online health portal to access medications from an on-call physician. The Administrator said she spoke to the pharmacy on 2/2/25 around 1pm, and they informed her Resident #55's medication was on the way, but the family said he wanted to leave. If Resident #55 missed Apixaban, it is for clotting and the risk of not giving the medication was clotting and clots could travel to the heart and cause heart attaches or travel to the brain, and Amiodarone she said he would still be able to get a dose if it came in later 5pm it would not have affected him, but signs and symptoms should be monitored. If Resident #55 did not get the Metoprolol, it could have affected his blood pressure but his vitals for blood pressure was normal that day. It would have been preferred if the medication was given in the morning, but the facility had 24 hours to get Resident #55 his daily medications. She said medication should be given one hour before or after a scheduled dose. The Administrator said the NP was notified medications were missing. Interview with NP A on 5/7/2025 at 1:51pm, she said she did the admission process including receiving and verifying Resident #55's physician orders and medications for Resident #55 and remembered meeting with Resident #55's family on 2/1/25. NP A said the facility called her on 2/2/25 to inform her that Resident #55 was leaving. She asked to speak to the family, but they had already left, and she was told they left because his medications had not come. She said the facility nurses would have submitted medications onto the online portal for the pharmacy. NP A was not notified Resident #55 missed medications on 2/2/25. If the facility had told her, NP A would have called the pharmacy herself. Apixaban could have caused a blood clot but if he was taking it daily if he missed a 24-hour dose he would have been okay, same with Amiodarone and she does not like medications to be delayed but it's okay and not risk. If Resident #55 missed Metoprolol, the facility should have checked his blood pressure, but if they had missed it, it could affect his blood pressure. If Resident #55 had high blood pressure, and the facility informed NP A, she would have sent an order from the emergency kit. She stated if Resident #55's Fludrocortisone was delayed, he could have more pain. She said that per state law, medications can be given 1-2 hours before or after the scheduled time. Resident #24 Record review of the admission Record for Resident #24 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Stage 5 kidney disease (end stage kidney disease), anemia in chronic kidney disease, history of cancer of the kidney, acquired absence of kidney, and dependence on renal dialysis. Record review of Resident #24's Care Plan (revised 03/02/2025) revealed he required hemodialysis due to renal (kidney) failure. The hemodialysis section of the Care Plan did not address medications. Record review of Resident #24's Care Plan section initiated on 05/07/2025 reflected the resident could become hypotensive (low blood pressure). One intervention read, in part, .Give medications as ordered. Monitor for side effects and effectiveness. Record review of Resident #24's Physician's Order dated 04/01/2025 revealed he was to receive Sevelamer Carbonate 800 mg tablet (2) tablets with meals (3 times per day). Record review of Resident #24's April 2025 MAR revealed the resident's Sevelamer Carbonate 800 mg tablets (2) were not administered for two of the three opportunities on the following dates: 04/20/2025 12:00 p.m. and 5:00 p.m. doses 04/23/2025 12:30 p.m. and 9:00 p.m. doses 04/28/2025 07:30 a.m. and 12:30 p.m. doses 04/30/2025 07:30 a.m. and 12:30 p.m. doses (8 missed doses ). The Sevelamer Carbonate 800 mg tablets (2) were not administered for three of the three opportunities on the following dates: 04/21/2025 07:30 a.m., 12:30 p.m., and 9:00 p.m. 04/22/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 04/24/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 04/26/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 04/27/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 04/29/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. (18 missed doses). Record review of Resident #24's May 2025 MAR revealed the resident's Sevelamer Carbonate 800 mg tablets (2) were not administered for one of one opportunity on the following date: 05/06/2025 07:00 a.m. (1 missed dose) The resident was out of the facility for the 12:00 p.m. and 5:00 p.m. scheduled doses. Record review of Resident #24's May 2025 MAR revealed the resident's Sevelamer Carbonate 800 mg tablets (2) were not administered for two of the three opportunities on the following dates: 05/02/2025 07:30 a.m. and 12:30 p.m. 05/05/2025 07:30 a.m. and 12:30 p.m. ( 4 missed doses). The Sevelamer Carbonate 800 mg tablets (2) were not administered for three of the three opportunities on the following dates: 05/01/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 05/03/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 05/04/2025 07:00 a.m., 12:00 p.m., and 5:00 p.m. 05/06/2025 (9 missed doses). Record review of Resident #24's May 2025 MAR revealed the resident's Sevelamer Carbonate 800 mg tablets (2) were not administered for one of one opportunity on the following date: 05/07/2025 07:30 a.m. (1 missed dose) In an interview on 05/07/25 at 1:23 p.m., RN H said the medication was not available this morning at 7:30 a.m. He said he called the pharmacy and was told the medication was not covered by insurance. He said the pharmacy suggested he call the dialysis center. He said he called the dialysis center but could not recall whom he spoke with. He said the person at the dialysis center said they sent the prescription to the pharmacy, and that it would take 8 to 10 days for the facility to receive it. He said he informed ADON I. RN H said he had inquired about the medication on 05/03/2025. He said he had also called the pharmacy on that day and was referred to the dialysis center. He said the dialysis center had said they would look into it. RN H did not work from 05/04/2025 until his shift on 05/07/2025. He said there was no follow-up prior to 05/07/2025. In an interview and observation on 05/07/25 at 1:40 p.m., ADON I said if a medication was not available, the nurse was to inform him. He said he would then follow up with the doctor and pharmacy. He would inquire about availability and/or a substitute. He said he was unaware that Resident #24 had not been receiving any of his medications. Observation revealed ADON I pulled up Resident #24's MAR on the computer. He said the medication was placed on hold. He was not able to tell who ordered the medication to be placed on hold. In an interview on 05/07/2025 at 2:47 p.m., the DON said he called the pharmacy and approved a 14-day supply. He said the facility would cover the cost. He said the medication would be delivered today by 5:00 p.m. He said the physician was aware of the medication not being available since the beginning of the issue. He said he called the NP this morning and she placed the medication on hold. He said he did not know if the NP was called about this situation prior to today. In an interview via telephone on 05/07/2025 at 3:00 p.m., the Clinical Nurse Manager of the dialysis facility said there were two nurses working on this date, and both said they did not receive a call about Resident #24. She said Resident #24 was going to be transferring to a different dialysis treatment center on Friday (05/09/2025). She said without the Sevelamer Carbonate, the resident's phosphorous level would go up. Complications could include itching. If the phosphorous level was high enough to go into the circulatory system it could cause cardiac issues. There was not a current phosphorous level lab available for review. She said the dialysis center would not have placed the medication on hold. An attempt to contact the Physician and/or NP was made on 05/07/25 at 3:35 p.m. A message was left, but no return call was received. In an interview via telephone on 05/27/25 at 11:12 a.m., the Physician said within two or three days after Resident #24's Sevelamer Carbonate was not available (04/20/25), he was aware the medication was not available. He said Sevelamer Carbonate was a phosphate binder (medication used to reduce the absorption of dietary phosphate). He said the medication could be held for two weeks without adverse effects. He said the medication could be stopped completely if the resident was attending dialysis. He said the 41 missed doses of Sevelamer Carbonate was not a risk to Resident #24's health. He said Resident #24's syncopal (fainting) was likely unrelated to missing the Sevelamer Carbonate. Record review of a lab report for Resident #24 draw date 05/05/25 revealed his Phosphate level was 7.3 mg/dl, with reference range of 2.6-4.5 mg/dl. The Phosphate level was not 'critical high' at that time. In an interview on 05/27/25 at 1:50 p.m., the DON said the Sevelamer Carbonate 800 mg for Resident #24 had not been available for administration at the facility since 04/21/25. He said some doses were documented as given, but those were in error. Interview with the DON and record review on 05/27/25 at 2:15 p.m. revealed a 14-day supply of the Sevelamer Carbonate 800 mg for Resident #24 was delivered on each of the following dates: 02/04/25, 02/15/25, 03/04/25, 03/15/25, 04/01/25, 05/08/25. The DON said that in April 2025 CMS changed the rule, making it the Dialysis Center responsible for ordering the medication from the Pharmacy, no longer the facility responsibility. Therefore, there was no delivery in the middle part of April 2025. He said the facility contacted the Dialysis Center more than once but the Dialysis Center did not call the Pharmacy (unverifiable). Record review of the facility's policy on Pharmacy Services copyrighted 2023, read in part, .7. The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements. Record review of the facility's policy on Unavailable Medications implemented 05/10/24, it read in part, .5. IF a resident misses a scheduled dose of the medication staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. Record review of the facility's policy on Medication Administration implemented 05/10/24, it read in part, .12b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

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 for 2 of 19 residents (Residents #61 and #99) reviewed for infection control practices. -The facility failed to ensure CNA A followed proper infection control, cleaning and hand hygiene for Resident #61 during incontinent care. CNA A double gloved, CNA A failed to use a clean washcloth surface area and perform hand hygiene between glove changes during incontinent care. -LVN G checked Resident #99's blood glucose level with a lancet, then discarded the used lancet into the trash can in the resident's room. These failures could place residents at risk of infection or a decline in health. The findings included: Resident #61 Record review of Resident #61's admission face sheet undated revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #61's diagnoses included: dementia (general term for loss of memory, language, problem-solving that interfere with daily function), protein-calorie malnutrition (a condition caused by a lack of sufficient protein and/or calories in the diet). Record review of Resident #61's admission Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS dated [DATE] revealed Resident #61's Brief Interview for Mental Status (BIMS) (a score used to assess cognitive function) was 00 which indicated it was unable to be scored. Resident #61's cognitive skills for daily decision making was not scored. Continued review of the MDS revealed Resident #61 was frequently incontinent of her bowel and bladder. Record review of Resident # 61's care plan revision dated on 12/17/2024 revealed: Focus: Resident #61 had an ADL (basic self-care tasks) self-care performance deficit and required cues (signals or prompts that guide behavior, actions or response), set up or assistance with ADL's related to dementia. Goal: The resident would participate in ADLs to her ability. Interventions: Bathing/ Showering: The resident required assistance with bathing/showering by staff as necessary. Personal Hygiene: The resident required assistance by staff with personal hygiene. Record review of Resident #61's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61's Brief Interview for Mental Status (BIMS) (a score used to assess cognitive function) was 00 which indicated it was unable to be scored which indicated sever cognitive issues. Continued review of the MDS revealed Resident #61 was frequently incontinent of her bowel and bladder. Observation on 05/07/2025 at 8:29 AM during incontinent care revealed Resident #61 was assisted to bed and positioned on her back. CNA A donned (put on) two pairs of gloves and removed Resident #61's pants. CNA A removed the double gloves. CNA A changed her gloves with outperforming hand hygiene (hand washing or hand sanitizing with alcohol base hand gel). CNA A removed Resident #61's brief. Observation of the inside of brief revealed the area from against the skin had discolored brown stains. CNA A changed her gloves without performing any hand hygiene. CNA A wet a washcloth. CNA A separated Resident #61's labia and wiped three separate wipes without refolding or changing the surface area of the washcloth. CNA A changed her gloves without performing hand hygiene. The resident was rolled to her right side. CNA A cleaned the resident's anal area. CNA A changed her gloves without performing any hand hygiene. CNA A cleaned the resident's buttocks. CNA A placed a clean brief on the resident. In an interview on 05/07/2025 at 1:36 PM CNA A stated she did double glove. CNA A stated double gloving was not supposed to be done. CNA A stated she did it because the gloves were tight and were at risk of being torn. CNA A stated she did not take the time to get new sized gloves. CNA A stated she did not clean or sanitize between the glove changes. CNA A stated she was taught to do hand hygiene between glove changes. CNA A stated she was nervous and not thinking about what she was doing. CNA A stated she thought she did turn the washcloth between wiping. CNA A stated she was trained to turn the washcloth to another clean side. The CNA stated the risk was contamination and infections. In an interview on 05/07/2025 at 3:33 PM IC RN stated double gloving was not recommended due to it not being hygienic (preventing disease). IC RN stated hand hygiene was to be done between glove changes. The IC RN stated the residents were to be wiped three times between the labia when cleaning, but a new wipe was to be used each time. IC RN stated the incontinent care that was performed was not good, it was not aseptic (free from contamination) the risk to the resident was infection. In an interview on 05/07/2025 at 4:09 PM the DON stated double gloving was not acceptable due to infection control issues and hand hygiene was supposed to be done between every glove change. DON stated different wipes were to be used with each wipe not reusing the same washcloth. The DON stated the risk to the resident was an infection. In an interview and record review on 05/07/2025 at 4:30 PM the Administrator stated her expectation was for proper infection control technique was done with incontinent care. The Administrator stated she reviewed the record and CNA A did her peri care check off on 03/03/2025. The Administrator stated she did not know what went wrong at this time. The Administrator stated hand hygiene was to be done with each glove change. The Administrator stated she says when cleaning it was one wipe one swipe. The Administrator stated disposable wipes were available to use unless the resident preferred a washcloth, but it was to be changed with each wipe. The risk to the resident was an infection. To prevent this, she would in-service on proper incontinent care. Record review of the facility policy titled Perineal Care Implemented dated 05/10/2024 read in part . : .11. Females: c. Separate the resident's labia with one hand and cleanse the perineum with the other hand by wiping in the directions from front to back (from pubic area towards anus). d. Repeat on opposite side using separate section of washcloth or new disposable wipe . Resident #99 Resident #99 Record review of Resident #99's admission Record (copied 05/08/2025) revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertension (high blood pressure), and fracture of the right femur (hip). Record review of Resident #99's Physician's Order dated 05/05/2025 revealed he was to receive Metformin HCl (antidiabetic) 500 mg every 12 hours. Record review of Resident #99's Care Plan dated 05/05/2025 revealed the resident had an order for a hypoglycemic (antidiabetic) medication and required monitoring of blood glucose levels. Observation and interview on 05/07/2025 at 7:32 a.m. revealed LVN G was at her medication cart in the doorway of Resident #99's room. LVN G dispensed three tablets to be administered to Resident #99. One of the medications dispensed was a 500 mg tablet of Metformin HCl. LVN G said she was required to check Resident #99's blood glucose level prior to administering the Metformin. Continued observation revealed LVN G pricked Resident #99's left index finger with a lancet. LVN G used a glucometer to check the resident's blood glucose level (result was 104 mg/dl). LVN G then discarded the used lancet into the resident's trash can in the room. LVN G administered the three tablets to Resident #99. LVN G left the room and returned to her medication cart. She said she should have placed the lancet into the sharps container, and that discarding it into the trash can could be a risk for infection. In an interview on 05/07/2025 at 8:35 a.m. the DON said used lancets should be discarded into the sharps containers. He said it could be a big danger and was definitely an infection control concern. The OSHA Fact Sheet 'Protecting Yourself When Handling Contaminated Sharps (presented by the facility when asked for Policy) read, in part, .A needlestick or a cut from a contaminated sharp can result in a worker being infected with human immunodeficiency virus (HIV), hepatitis B (HBV), hepatitis C (HCV), and other bloodborne pathogens. The document also read, in part, .Employers must ensure that contaminated sharps are disposed of in sharps disposal containers immediately or as feasible after use.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #147) of five residents reviewed for oxygen therapy was provided care that was consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -Resident #147 had an oxygen humidifier that was dated 02/19/2024, 10 days prior to his admission on 03/01/2024, and possibly previously used by a different resident. Resident #147 had been recently admitted to the facility with respiratory compromise. The failure placed Residents at increased risk of infection. Findings included: Record review of the Admission Record (printed 03/05/2024) revealed Resident #147 was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, and other mental changes), pleural effusion (buildup of fluids around the lungs), and anoxic brain damage (brain damage caused by lack of oxygen). Record review revealed Resident #147 had been in the facility for less than five days and did not yet have a MDS assessment. Record review of a Physician's Order dated 03/04/2024 at 9:31 p.m. revealed, in part, .Administer O2 2L via NC if Patient desaturates below 90%. Record review of a Health Status Note dated 03/04/2024 at 10:00 p.m. revealed the Nurse Practitioner gave orders for Augmentin 875-125 mg (antibiotic) to be given orally twice daily for seven days, Ceftriaxone 2 gm (antibiotic) to be administered via intra-muscular injection daily for three days, metronidazole 500 mg (antibiotic) to be given orally every eight hours for seven days, and Guaifenesin 100mg/5 ml - 300 mg (expectorant) to be given every six hours for ten days. In addition, the resident was to receive Duoneb nebulizer treatments every six hours for seven days. The Note also reflected Resident #147 was to receive oxygen PRN (as needed) at 2L. There was a standing order to send the resident to the hospital if his oxygen saturation level was below 90%. The note reflected the MAR was updated with the orders. The Note was signed by LVN A. Record review of the Orders Administration Note dated 03/04/2024 at 10:27 p.m. revealed the diagnosis as Pneumonia. Record review of Resident #147's Care Plan on 03/05/2024 at 10:00 a.m. revealed it did not yet address the Pneumonia diagnosis from 03/04/2024 at 10:27 p.m. Observation on 03/05/2024 at 9:35 a.m. revealed Resident #147 was lying in bed, awake. He responded to a verbal greeting by nodding, but he was non-verbal. There was an oxygen concentrator with a humidifier reservoir. The concentrator was set at 3L, delivering oxygen to the resident via nasal cannula. The humidifier was a refillable type. The date scribed on the top of the humidifier was 02/19/2024. Observation and interview on 03/05/2024 at 9:37 a.m. revealed the surveyor asked Resident #147's Charge Nurse, LVN B, to check the oxygen humidifier for Resident #147. LVN B looked at the humidifier and confirmed the date was 02/19/2024. She said the resident was admitted yesterday (03/04/2024), and that the humidifier should be changed every week. Observation and interview on 03/05/2024 at 11:40 a.m. the DON said humidifiers were to be changed out weekly. The DON observed the humidifier being used for Resident #147 and confirmed the date was 02/19/24. The DON said humidifiers were available in the storage room, and the nurses had access to the storage room. Observation and interview on 03/05/2024 at 11:43 a.m. revealed a storage room on Hall E. The DON opened the door with a key. There were no oxygen concentrators or humidifiers in the room. The DON said if the nurses could not find any humidifiers in the room, they should have called her. She said the facility now uses pre-filled (non-refillable) humidifiers, but the one in Resident #147's room was the refillable type. The DON said she did not know if it was facility policy to reuse refillable humidifiers for different residents, but she would check the policy. She said the risk of reusing refillable humidifiers would be increased risk of infection. At that time the DON attempted unsuccessfully to call LVN C, the 10:00 p.m. (03/04/2024) to 6:00 a.m. (03/05/2024) charge nurse for Resident #147. In an interview on 03/05/2024 at 11:53 a.m. the DON said the facility policy was to not reuse humidifiers. Observation on 03/05/2024 at 12:02 p.m. revealed the oxygen tubing and humidifier for Resident #147 had been changed. The humidifier was the non-refillable type. The scribed date was 03/05/2024. In an interview via on 03/05/2024 at 12:03 p.m. LVN B said she had just changed the humidifier for Resident #147. She said the facility was not to reuse humidifiers because it would be a risk for infection. In an interview via telephone on 03/06/2024 at 5:00 a.m. RN C confirmed she was Resident #147's Charge Nurse for the night shift on 03/04/2024. She said the evening nurse (LVN A) had received the order and was entering them into the computer when she arrived. RN C said the oxygen concentrator was already in Resident #147's room when she initially entered the room that night. She said the refillable humidifier was on the concentrator, but it was empty. She said she had a pre-filled humidifier, but it was too big to fit on that concentrator. She said she opened the pre-filled humidifier and emptied the contents into the refillable humidifier. She said she thought the refillable humidifier was new, so she just filled it. In an interview via telephone on 03/06/2024 at 3:25 p.m. LVN A said she had received the order for the oxygen on 03/04/2024 at around 9:30 p.m. to 10:00 p.m. Change of shift was at 10:00 p.m. She said she entered the order, then got the concentrator. She said she saw that it had the old refillable humidifier on it. She said she started the concentrator and asked RN C to put on a new humidifier. LVN A said before the oxygen order, an x-ray report revealed Resident #147 had pneumonia. Record review of the facility policy entitled Oxygen Administration (revised October 2010) revealed a humidifier was to be used but did not reflect new. The policy reflected, in part, .12. Check the mask, tank, humidifying jar, etc. to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as the oxygen flows.

Based on observation, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with established food preparation practices and safety techniques in that; 1. Frozen food were thawed in a sink with no running and/or standing water. 2. Frozen food were thawed in a sink used for hand washing. This failure could cause food-borne illnesses as a result and could affect the residents who consumed food from the facility's only kitchen. Findings included: Observation of the kitchen on 03-05-24 at 08:47 a.m., revealed 2 of 2 sinks used for hand washing. Observation of the kitchen on 03-05-24 at 11:52 a.m. 3-10 pound loafs of sealed frozen ground beef in 1 of 2 sinks used for hand washing without being submerged in standing water or under running cold water. Observation of the lunch meal tray on 03-06-24 at 12:55 p.m., revealed a regular textured meal consisting of meat loaf, green beans, dinner roll, mashed potatoes and gravy, and pudding. The meal was visually presentable and was tasted and found palatable. Interview on 03-05-24 at 08:47 a.m., Cook A stated that there were 2 of 2 sinks used for hand washing. She stated one near the stove and one near the dish machine and either could be used by Surveyor A to wash hands. Interview on 03-05-24 at 11:52 a.m., Cook A stated the ground beef loafs in the sink near the stove were being thawed for tomorrow's lunch. Interview on 03-06-24 at 08:40 a.m., Cook A when asked was that meat she was seasoning had been the same meat observed in the sink thawing 03-05-24, Cook A stated, The meat was thawed and stored in the refrigerator overnight. Interview on 03-06-24 at 1:10 p.m., Cook B stated that she used the handwashing station located near the dish machine. She stated on 03-05-24 the frozen ground beef loafs were placed in the sink near the stove by who she believe to be Cook A on the first shift to thaw. She stated later that afternoon, she placed the meat loafs in a pan and placed them into the refrigerator until the next day when they would be cooked for lunch. She stated the process for thawing food consisted of removing the frozen food item from the freezer, the item would be placed in a pan into the sink near the stove, and then cold water was to be ran over the item until thawed. She stated that the frozen food should be placed in a pan to avoid contaminating the sink and avoid any contamination from the sink onto the food. Interview on 03-06-24 at 01:23 p.m., Dishwasher stated that he was responsible for washing dishes, but while he does not cook any food, he did handle food items such as pudding, cereal, coffee, and bread to plate trays. He stated that he was instructed upon hire to only use the handwashing sink near the dish machine. He stated he did not know why he could not use the hand washing sink near the stove. He stated he did not defrost food items in the kitchen and was not aware who thawed the ground beef loafs in the sink on 03-05-24. Interview on 03-06-24 at 01:40 p.m., Tray Aid stated she had been responsible for assisting the cooks plate trays and making sandwiches. She stated that she was instructed to use the handwashing station near the dish machine when sanitizing her hands. She stated that the cooks were the only staff allowed to use the sink near the stove. She stated she was not responsible for defrosting frozen food items. Interview on 03-06-24 at 01:48 p.m., Dietary Aid A stated he had been responsible for assisting the cook plating trays with desserts and making sandwiches. He stated he was instructed to wash his hands near the dish machine. He stated he does not thaw foods and was not aware who thawed the ground beef on 03-05-24. Interview on 03-06-24 at 01:48 p.m., Dietary Aid B stated that she had a split role at the facility in dietary services and in laundry services. She stated her job responsibilities in the kitchen were to assist the cooks plate trays. She stated she was instructed to use the hand washing station near the dish machine. She stated that the cooks only use the handwashing station near the stove. She stated that the cooks thaw frozen food items in the sink near the stove. She stated the sinks used to thaw foods were sanitized before and after foods were thawed. She stated once the frozen food item was placed in the sink, cold water would run over the food real low. She stated that she did not thaw any food items and was not aware who thawed the ground beef loafs on 03-05-24. Interview on 03-06-24 at 02:04 p.m., Cook A stated that the kitchen had 2-handwashing stations in the kitchen. She stated that she used both handwashing stations because as the cook, she was all over the kitchen. She stated that the Floater took the ground beef loafs from the freezer and placed them in the sink near the stove in the morning of 03-05-24. She stated that the Floater had just placed the ground beef loafs in the sink just prior to Surveyor A entering the kitchen on 03-05-24 at 11:47 a.m. and was not sure why he had not turned on the water immediately after placing the loafs in the sink. She stated that the Floater had turned on the water after Surveyor A entered the kitchen. She stated that she checked the water periodically during the thawing process until it was thawed. She stated that the thawing policy stated that frozen foods were placed under running water between 2 - 3 hours or until thawed. She stated it was normally the cook's responsibility to remove items from the freezer and place them in the sink to be thawed. She stated due to her recent illness, the Floater went in and out of the freezer for her so she would avoid exposure to the cold temperature. She stated that the Floater was also helping in the kitchen stocking items from the food shipment that had been received the morning of 03-05-24. She stated depending on the size of frozen food items, it would have been placed in a pan before being placed in the sink. She stated the pan would be tilted for running water to flow over the food item and not be stopped up under the pan. She stated that the ground beef loafs were too big to fit in pans, therefore the Floater placed the meat loafs in the sink directly. She stated she did not witness the Floater disinfect the sink before or after placing the ground beef loafs in the sink, but he should have. She stated she does not know who took the ground beef loafs out of the sink once they were thawed. Interview on 03-06-24 at 02:44 p.m., the Dietary Manager (DM) stated that the kitchen had 2-handwashing sinks. She stated that the cooks used the hand washing station near the stove for easy access while preparing meals, but all other staff were to use the handwashing station near the dish machine. The DM stated that the sink near the stove had also been used to defrost food. She stated that the sink would have been disinfected before and after any foods were thawed within. She stated that the Floater placed the ground beef loafs in the sink on 03-05-24 just prior to Surveyor A entering the kitchen at 11:47 a.m. She stated that Floater then turned on the cold water to run over the ground beef loafs. She stated that the Floater sanitized the sink prior to placing the frozen items in the sink. She stated per policy defrosted items were to be submerged in and ran under cold water. The DM stated that the sink was not stopped up while the meat was thawed, and the meat was not submerged in water. She stated after viewing a picture Surveyor A took of the meat in the sink at 12:24 p.m. that the water ran over only 1 of 3 of the 10lb frozen meat loafs. She stated that frozen items were normally placed into a pan and then into the sink, but that the ground beef loafs were too long to fit the pans available to the staff in the kitchen. She stated the Floater put the frozen meat in the sink on 03-05-24, walked away just for a moment and then came back and turned on the cold water to run over the frozen ground beef. She stated that she saw the Floater sanitized the sink before placing the meat in the sink. She stated that Cook B removed the thawed meat from the sink and placed the meat on a pan and then placed it in the refrigerator overnight. She stated that the process for sanitizing the sink before and after thaw food items consisted of: wash, rise and sanitize with a sanitization solution kept under the steam table for easy access. Interview on 03-07-24 at 10:34 a.m., Dietitian stated that according to storage regulations, it was typically recommended that frozen foods be thawed under cold running water. She stated depending on the size and quantity, frozen meats would be placed in a pan in the sink under running water as long as the water would not be stagnant. She stated the sinks at the facility were small, making it difficult to meal prep and have a handwashing station. She stated after reviewing the handwashing policy on thawing foods, despite policy, it was not necessary to submerge the meat in water based on her food handling professional experience but would rather be more concerned that the water was running and under 70 degrees. Interview on 03-07-24 at 02:59 p.m., the DON stated that she was informed by the DM of the frozen ground beef in the sink. She stated that the DM was an experienced and educated DM. She stated that the DM and her would be looking at the thawing and sink sanitizing processes to ensure that the kitchen staff were educated on proper procedures. She stated that staff were not to thawed in foods in the handwashing or dishwashing stations to avoid cross contamination. She stated the Floater who placed the meat in the sink was off shift on a flight and unreachable due to his travel. Interview on 03-07-24 at 03:31 p.m., Administrator stated that the Health Department had recommended that the kitchen sink near the stove could also be used as a handwashing sink since the other sink was rather far away from where the cook's preparation station. She stated that it was her expectations that the kitchen staff follow the frozen food thawing policy: placing foods on pans and running under cold water and that the sink was to have been sanitized before and after any frozen foods were placed in it. She stated that the in-service documentation would be provided on thawing food and sanitizing sinks. Unsuccessful interview attempts to interview the Floater were made on 03-06-24 at 04:20 p.m., on 03-07-24 at 09:02 a.m., and 03-07-24 at 10:09 a.m. Record review of Food and Preparation and Service revised date November 2022 revealed that, Policy Statement. Food and nutrition service employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. General Guidelines 2. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Thawing Frozen Food 1. Foods are not thawed at room temperature. Appropriate thawing procedures included: B. completely submerging the item in cold running water (70 degrees or below) that is running fast enough to agitate and remove loose ice particles . Record review of the in-services dated 03-07-24 on Sink Sanitizing and Thawing Frozen Foods conducted by the DM. Cleaning and Sanitizing Requirements: 1. Who is responsible: If the sink is used to thaw/wash food products, it should be cleaned and sanitized first by the person (i.e. cook, dietary aid etc.) that will be placing the food item into the sink to be thawed/washed etc. 2. The practice of cleaning and sanitizing the sink is done prior to the product being placed in the sink and after the product is taken out of the sink. The person responsible for taking the product out of the sink is responsible for cleaning and sanitizing the sink when the product is removed. 3. The sink will be washed, rinsed, and sanitized (with the QA solution) prior to food products being placed into the sink and when the food product is removed from the sink. 4. If a product is placed in the sanitized sink to be thawed/washed, then cold running water should be used over the product for proper thawing. The person (i.e. cook, dietary aid etc.) that placed the product into the sink for thawing will be responsible for periodically checking the food to rotate and see if the product is thawed. Once the product is thawed it will be used to prepare the dish or stored in the cooler with a label and date. Record review of the Texas Food Service Establishment Rules Field Inspection Manual dated October 2015 recelaedd that, S228.75(C) (2) Temperature and Time Control. (C) Thawing. Except as specified in paragraph (4) of this subsection, time/temperature control for safety (TCS) food shall be thawed: (2) completely submerged under running water: .

Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 1 resident (Resident #12) reviewed for resident call system. The facility failed to ensure a call cord was in reach for Resident #12 on 03-05-24. This failure placed residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Record Review of Resident #12's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record Review of Resident #12's diagnoses revealed he had cerebral palsy (congenital disorder of movement, muscle tone, or posture), pressure ulcer of sacral region, stage 4, seizures, embolism, and thrombosis of unspecified deep veins of unspecified lower extremity (blood blots obstructing blood flow), unspecified hearing loss, contracture of muscles, left and left lower legs, profound intellectual disabilities, and parkinsonism (motor syndrome that manifests as rigidity, tremors, and bradykinesia). Observation on 03-05-24 at 12:02 p.m., revealed Resident #12 resided in a double room with no roommate. Resident #12's call light cord was hanging a crossed a 1-gallon container of drinking water sitting on resident's nightstand table beside resident's bed. Surveyor A turned on call light. Observation on 03-05-24 at 12:03 p.m., revealed Licensed Vocational Nurse (LVN) C entered room turned off call bell system on the wall, repositioned Resident #12's oxygen, and exited room. LVN C did not reposition the call bell cord in reach for resident. Observation on 03-05-24 at 02:01 p.m., revealed Resident #12's call light cord was hanging a crossed a 1-gallon container of drinking water on resident's nightstand table beside resident's bed. Interview attempt on 03-05-24 at 12:02 p.m., revealed Resident #12 did respond to any questions asked. Interview on 03-06-24 at 12:41 p.m., Certified Nursing Assistant (CNA) A stated that she started shift on 03-05-24 at 6:00 a.m. She stated that Resident #12 was total care as such, he was her first stop when beginning her shift. She stated when she entered the resident's room, she saw the call bell cord hanging on the gallon of water sitting on the resident's nightstand. She stated she changed the resident's brief and gowned and meant to attach the call bell to the resident's pillow before leaving the room but had forgotten. She stated that she had fed resident breakfast and lunch on 03-05-24. She apologized and stated that the importance of call bells in place was so that residents who needed assistance would be able to reach staff. Interview on 03-06-24 at 03:57 p.m., LVN C stated that when she entered Resident #12's room on 03-25-24 at 12:03 p.m. she had not even realized that the resident's call bell was hanging on the gallon of water sitting on his nightstand. She stated that she had not seen it hanging like that before and would be certain to notice the call lights placement in the future. She stated that the importance of resident's call light in reach was for residents' ability to call for patient care and assistance. Interview on 03-07-24 at 02:59 p.m., DON stated that Resident #12 was total care and based on the resident's diagnosis he had required frequent checks. She stated that resident call lights should be in place/and in reach at all times for residents to reach staff when needed. She stated that the facility would be replacing Resident #12's call bell with a call pad that would attach to the resident's bed and would allow him to roll on the pad to call staff rather than having to push the call bell with his hands. She stated that that nursing staff were in-serviced on call bell placement on 03-06-24. Interview on 03-07-24 at 03:31 p.m., Administrator stated that CNA A informed her of Resident #12's call bell positioning. She stated that staff need to slow down and not get too focused on the tasks that they forget to ensure that resident's call bells were in place. She stated that they would be implementing a call bell pad that would be placed on Resident #12's bed. She stated the call bell pad would allow the resident to roll his shoulder on the pad rather having had to push a call bell button to call for staff assistance. She stated the importance of the call bell system to be in reach was for residents to call for staff assistance. She stated that the nursing staff were in-serviced, and she would provide a copy. Record Review of policy Answering Call Lights revised date September 2022 revealed that, Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. The facility provided in-services on Ensuring call lights in reach for residents conducted by ADON on 03-06-24.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 4 residents reviewed for accidents in that: -Physical Therapy Assistant performed a two person transfer alone on 08/18/23. Resident #2 suffered right femur fracture that was identified via X-ray on 08/19/23. The noncompliance was identified as PNC. The IJ began on 8/18/23 and ended on 8/21/23.The facility had corrected the noncompliance before the survey began. This failure can place residents at risk of injury, pain, hospitalization and a diminished quality of life. Findings include: Record review of Resident #2's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and was re-admitted on [DATE]. Her diagnoses included Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), type 2 diabetes mellitus without complications (A chronic condition that affects the way the body processes blood sugar (glucose) and pressure ulcer of sacral region, stage 4 (skin injuries that occur in the sacral region of the body, near the lower back and spine). Record review of Resident #2's Comprehensive MDS assessment, dated 5/23/23, revealed Resident #2 had a BIMS score of 7 out of 15 which indicated severely impaired cognition. She required extensive assistance from two person physical assist for transfers. Record review of Resident #2's Care Plan dated 5/17/2022 and revised on 6/3/22 revealed the following: Focus: Resident #2 has an ADL self-care performance deficit r/t Disease Process Goal: The resident will have increased function and endurance with ADL tasks Interventions: TRANSFER: The resident requires (EXTENSIVE assistance) by (1-2) staff to move between surfaces. Record review of Resident #2's Progress notes dated 8/18/2023 at 11:52 pm revealed read in part: .Health Status Note: Xray of right leg done for c/o of pain, resident stated it happen during therapy family aware .RP request xrays be done.MD notified and xrays ordered and were done, results pending . Record review of Resident #2's facility's X-ray results dated 8/19/23 at 9:52 am revealed read in part: .Radiology Interpretation: Acute appearing fracture of the distal femoral metaphysis . Record review of Resident #2's Hospital Records dated 8/19/23 read in part: XXX[AGE] year-old woman with history of vascular dementia, hypertension, CKD, OSA, stage IV decubitus ulcer presented here with right leg pain. Patient resides in a nursing facility and was evaluated by physical therapy and transferred from wheelchair back to bed. While pivoting to her right leg Twisted and reports severe pain after was brought into the ER was noted to have x-rays done which show a minimally displaced predominantly transverse supracondylar fracture in the distal metaphysis. Orthopedic surgery has been consulted by the ER and now awaiting for further evaluation. Given fractures likely patient will be placed in a splint will defer that to orthopedic surgeon for further recommendations. Impression and Plan Diagnosis Femur fracture, right . Record review of Resident#2's PT Evaluation & Plan of Treatment dated 8/15/23 revealed read in part: .Functional Mobility Assessment: Transfers=Did Not Test (Patient at baseline of dependence for OOB with hoyer lift . In an interview on 8/22/23 at 8:14 a.m., with the Administrator, she said Resident #2 was due for quarterly MDS Part B for therapy. She said the Therapy department did an evaluation and the Patient agreed. She said the RP was not notified by the therapy department that the Pt was placed under their services. The Rehab Manager was out, and it was an oversight on their part. She said she called the hospital to confirm if the fracture was on the same knee that happened prior within this year. Hospital said it was new fracture. She said Pt was 2 person transfer but the PTA did one person transfer and had been suspended pending investigation. PTA's last working day was 8/18/23. In a telephone interview on 8/22/23 at 9:01 a.m., with Resident #2's Responsible party, she said last week, the facility started doing physical therapy with the resident. She said the family did not request therapy; the facility initiated it themselves. On Friday evening, 08/18/23, the resident reported her right leg was hurting. She said she removed the covers and noted that her right knee was swollen to the size of small basketball. The leg was also hot to the touch. The resident reported that physical therapy took her to down to therapy. Once back in her room, the therapy staff member got the resident's leg caught under the wheelchair during transfer. The physical therapy staff was transferring the resident to the bed by herself. She said the resident required two people transfer via hoyer lift. The resident's right leg did not move during the transfer and the resident felt her right leg twist around. The resident yelled out in pain. The therapy staff got some bio freeze and put it on her leg. she said she asked a nurse for a stat x-ray. she said she was notified of the x-ray results on 8/19/23. The facility reported a fracture to her right distal femur. Observation and interview on 8/22/23 at 9:21 a.m., with Resident #2 revealed she was resting in bed. She said she had returned from the hospital last night (8/21/23). She said her right leg got caught under the wheelchair while physical therapist was transferring her from wheelchair back to bed. She said she was in pain and the nurse had given her pain medication this morning. In an interview on 8/22/23 at 9:33 a.m., with LVN A, she said Resident #2 required 2 people assist with transfers from shower chair to bed using a hoyer lift. She said resident returned last night (8/21/23) from the hospital. In an interview on 8/22/23 at 9:39 a.m., with CNA CC, she said Resident #2 required 2 people transfer with a hoyer lift and sling. She said resident refused to get out of bed. Resident only got out of bed on her shower days. In an interview on 8/22/23 at 9:43 a.m., with the Rehab Director, she said Resident #2 was receiving services in the past and had gotten a custom wheelchair. She said Resident had wound and the resident laid in bed all the time that put her at risk. She said the Physical Therapist did an evaluation on Resident #2 and added her to the services sometime last week. Record review and interview on 8/22/23 at 9:45 a.m., with the Physical Therapist, she said Resident #2 was due for MDS quarterly screen. She said she found from the nursing staff that resident had not gotten out of bed. Resident only got up for showers. She said in the past resident had received physical therapy and part of the plan was for her to use the custom wheelchair so she could get out of bed. She said resident had wound which the resident laid on all day. She said she felt that resident would benefit from the therapy. She said the protocol was that the Physical Therapist completed the evaluation and created a plan of treatment and the treating Physical Therapy Assistant was to follow that plan of treatment. Physical Therapist reviewed the PT Evaluation & Plan of Treatment dated 8/15/23 with the Surveyor. Physical Therapist said under section Functional Mobility Assessment for Transfers patient was at baseline of dependence for OOB with hoyer lift. Physical Therapist said that meant the Resident was not treated for transfer because there were no goals for transfer. If Resident needed to get out of bed, then the hoyer lift was a safer way. When asked how the Physical Therapist checked to see if Physical Therapist Assistant was following the plan of treatment. Physical Therapist said she read the weekly progress notes to see what PTA had been treating. She said she looked to see if goals have been met or needed to be upgraded which required discussion with Physical Therapist. Physical Therapist said Physical Therapist Assistant was a licensed therapist, she did not need to be followed/spot checked during therapy sessions with Residents. Physical Therapist said she had her own case load and to work efficiently, the treating therapist was assigned one patient at a time and PTA were to follow the Physical Therapist's plan of treatment. She said, it was important to follow the plan of treatment, so PT and PTA were working toward the same goals. It puts them on the same page. She said PTA could have grabbed an aide to assist her with Hoyer transfer. In an interview on 8/22/23 at 10:07 a.m., with CNA DD, she said Resident #2 required a Hoyer lift to move between surfaces. She said Resident#2 always needed 2 persons to assist. She said Resident#2 did not like getting out of bed. She said Resident only got out of bed on her shower days which were Tuesday, Thursday and Saturdays. She said two staff transferred resident from bed to shower chair via hoyer lift on her shower days. In a telephone interview on 8/22/23 at 10:21 a.m., with Physical Therapist Assistant, she said Resident #2 was placed under therapy services sometime last week. She said she asked Resident#2 if she was ready to get up. Resident agreed. She said she moved her blankets, helped her sit on the edge of the bed. She said she performed lateral scoot partial stand pivot transfer with gait belt and draw sheet from edge of bed to wheelchair. When asked if she reviewed the Physical Therapist's plan of treatment dated 8/15/23 under transfer it mentioned the use of hoyer lift when out of bed. PTA said, I did look over it briefly. I scanned PT's evaluation she had sitting balance goal and wheelchair mobility goal. PTA said, I use gait belt on everyone. To increase trunk control and functional independence. PTA said hoyer lift was used when the Patient could not sit up, assist with transfer or can not hold their balance. she said she had worked with Resident#2 in the past and Resident was able to sit up. She said when resident was done eating her lunch. She asked Resident#2 if she was ready to get back in bed. Resident agreed. PTA said she did partial stand pivot with lateral scoot from wheelchair to edge of bed. Once in standing, Resident#2 reported increased pain in her right leg. She said she took her foot and slid her right foot forward to take pressure of resident's leg and assisted with positioning resident onto the edge of bed. Resident reported that right knee was still hurting. She said she tried to reposition for comfort. Placed pillows under knees. She said she asked nurse on duty, if resident could get pain medication as resident was reporting increased pain in the right side following treatment and transfer back to bed. The nurse explained that resident had pain medications prior to treatment and could not get them at that time. She said she asked resident if she would like her to get bio freeze and the resident agreed. She said she applied bio freeze to bilateral knees per request. She said she asked resident again if her pain was better or worse the resident reported that it was a little better but still hurting. In an interview on 8/22/23 at 12:08 p.m., with the DON, she said she found out on Saturday (8/19/23) from the Unit Manager that relied to her that x-ray results showed fracture. She said she was not aware of x-rays order and there was no incident report. She said she was then told about the rehab session on Friday (8/18/23). She said per the resident her legs got caught in wheelchair during transfer. she said after the incident was reported to HHSC on 8/19/23 and the facility began the investigation. She said she interviewed staff to determine the transfer status of Resident #2. She said the facility identified Resident #2 was a 2-person transfer. She said PTA should have asked for help with transfer. Record review of facility's In-service Education Program record dated 8/21/23 conducted by the Administrator on 8/21/23 to staff on Abuse Neglect protocal, Reporting/types of abuse. Record review of facility's In-service Education Program record dated 8/21/23 conducted by the DON on 8/21/23 to staff on Abuse & Neglect/ Transfer/Admssion/ POC documentation. Record review of facility's In-service Education Program record dated 8/21/23 conducted by the Administrator on 8/21/23 to Rehab department revealed read in part: .Therapist/PTA must follow the plan of care for treatment any concern regarding the plan of care must be communicated to DON/ED & MD . Record review of the facility's Safe Lifting and Movement of Residents policy (revised July 2017) read in part: .Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 2. Manual lifting of residents shall be eliminated when feasible.3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan such assessment shall include the following: b. Resident's mobility (degree of dependency): d. Weight-bearing ability: g. The resident's goals for rehabilitation, including restoring or maintain functional abilities. 8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being charged .

Based on observation, interviews, and record reviews, the facility failed to ensure a resident received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #1) of 5 residents reviewed for showers/baths. -Resident #1 did not receive showers as scheduled. This failure affected one resident and placed 88 residents requiring assistance with baths and showers at risk of not having the assistance with personal care which could cause skin breakdown and low self-esteem. Findings include: Record review of the Admission Record (printed 08/16/2023) for Resident #1 revealed she was [AGE] years old, andold and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, encephalopathy (disease that alters brain function), muscle weakness, and dementia. Record review of the quarterly MDS assessment dated [DATE] revealed no entry for Resident #1's cognitive status. The MDS reflected the resident required extensive assist of two persons for bed mobility, transfers, toilet use, and personal hygiene. She required physical help in part of the bathing activity. The resident weighed 244 pounds at the time of the assessment. Record review of the Care Plan (revised 04/05/2023) revealed Resident #1 required extensive to total assist with bathing. The Care Plan reflected the resident was to receive a sponge bath when a full bath or shower could not be tolerated. Observation on 08/16/2023 at 10:10 p.m. revealed Resident #1 to be in her room. She was lying in her bed. She was not interviewable. Observation on 08/16/2023 at 11:00 a.m. revealed CNA A and CNA B provided incontinent care for Resident #1. Observation revealed the resident required extensive assist from both staff to reposition. Interview on 08/16/2023 at 12:30 p.m. Resident #1's family member revealed the resident was not receiving showers or baths. She said one night she stayed and asked a CNA to give Resident #1 a shower. She said the CNA did not know which chair to use. She said she told the DON her concern that the resident was not receiving showers. Observation and interview on 08/16/2023 at 2:35 p.m. the DON said the shower sheets were kept in a book at the nurses' station. Review of the C-Hall shower schedule revealed Resident #1 was scheduled to have a shower every Tuesday, Thursday, and Saturday in the evening. Interview and review on 08/16/2023 at 2:40 p.m. revealed the shower sheets book at the nurses' station contained only four sheets total; none were for Resident #1. The DON said she would gather the shower sheets for Resident #1. Review on 08/16/2023 at 3:30 p.m. the August 2023 shower sheets revealed Resident #1 only received three showers during the month of August. The resident received showers on 08/01/2023, 08/09/2023, and 08/12/2023. Review of the August 2023 calendar revealed the resident should have received 7 showers during that time period. Record review of the facility policy Bath, Shower (revised February 2018) revealed the staff providing the shower or bath was to document the date and time the shower was provided, the names of the persons assisting, and if the resident refused.

Based on observation, interview, and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 (Resident #1) of 5 residents records reviewed for medication and treatment documentation. -The nurse documented Resident #1 had pain patches applied, but they were not available. -The nurse documented Resident #1 had on compression hose on both legs, but the resident did not. The failure could place residents at risk for unaddressed pain, increased swelling, and risk of blood clots. Findings include: Record review of the Admission Record (printed 08/16/2023) for Resident #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, encephalopathy (disease that alters brain function), muscle weakness, and dementia. The most recent diagnoses (06/13/2023) were acute embolism and thrombosis (blood clots) of unspecified deep veins of both lower extremities, and pulmonary embolism (blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream). Record review of the quarterly MDS assessment dated [DATE] revealed no entry for Resident #1's cognitive status. The MDS reflected the resident required extensive assist of two persons for bed mobility, transfers, toilet use, and personal hygiene. Record review of the Care Plan (revised 03/27/2023) revealed Resident #1 required extensive to total assistance with ADLs. The Care Plan reflected the resident was dependent on staff for meeting physical needs. The Care Plan did not address pain. Record review of Resident #1's Physician's Order dated 08/11/2023 at 10:05 a.m. read in part .Compression stockings Apply in the morning and remove every night. Every morning and at bedtime for prophylaxis; swelling awaiting delivery. Record review of Resident #1's August 2023 MAR revealed the resident was to have Lidocaine pain patches applied to her left knee and left thigh at 9:00 a.m. every morning. Observation on 08/16/2023 at 10:10 a.m. revealed Resident #1 in her room lying in her bed. She was not interviewable. She did not have pain patches on her left knee, and she did not have on compression stockings. Her left thigh was not visible. Observation on 08/16/2023 at 11:00 a.m. revealed CNA A and CNA B provided incontinent care for Resident #1. Observation revealed the resident required extensive assist from both staff to reposition. The resident did not have pain patches on her left knee or her left thigh, and she did not have on compression stockings. Record review of Resident #1's MAR revealed LVN C had initialed that she had applied Lidocaine pain patches to the resident's left thigh and left knee on 08/16/2023. Record review of Resident #1's MAR revealed LVN C had initialed that the compression stockings were on the resident on 08/16/2023. In an interview on 08/16/2023 at 12:30 with a family member of Resident #1 she said there were supposed to be pain patches on both knees and the left thigh. She pointed out they were not on the resident. She said the compression stockings were too small and were not being used by the facility. They were in a drawer. In an interview on 08/16/2023 at 12:45 p.m. LVN C said the Lidocaine patches were not available when she was to apply them. She said the compression stockings were removed by the CNAs when they provided incontinent care. The surveyor informed her that he was present when the CNAs provided incontinent care, and the compression stockings were not on. When asked shy she signed the two items in the MAR, LVN C said the patches and the compression stockings were not available, but she signed for them when she passed medications. In an interview on 08/16/2023 at 2:35 p.m. the DON said when the LVN noticed the patches and compression hose were not available she should have notified the Physician and documented in the NN that they were not available. Record review of the facility policy Documentation of Medication Administration (revised April 2007) read in part .Administration of medication must be documented immediately after (never before) it is given.

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or resident preferences indicated otherwise for 10 of 86 residents (Resident #56, #7, #44, #59, #18, #23, #72, #5, #14, and #45) reviewed for weight loss. 1. The facility failed to obtain accurate monthly weights for Resident #56. 2. The facility failed to ensure Resident #56 had appropriate interventions in place to prevent a severe weight loss of 39.3 % from 10/10/22 to 1/17/23. 3. The facility failed to obtain accurate monthly weights for residents from October 2022 to January 2023. The facility identified 10 (Residents #56, #7, #44, #59, #18, #23, #72, #5, #14, and #45) of 86 residents sustained significant and/or severe weight loss when an accurate weight was obtained by facility staff in January 2023. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 1/18/23 to 1/20/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of severe weight loss, delayed interventions, hospitalization , worsening health condition, and death. Findings include: Record review of Resident #56's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #56 had diagnoses which included Alzheimer's disease, unspecified severe protein-calorie malnutrition (1/21/21), vitamin B-12 deficiency anemia (11/16/21), anorexia (an eating disorder characterized by relentless drive for thinness with a fear of gaining body weight associated with self-induced behaviors towards thinness), weakness (12/2/20), vascular Parkinsonism (a disorder that affects muscle movement), and hospice care. Record review of Resident #56's quarterly MDS assessment, dated 12/8/22, revealed a BIMS score of 0 out of 15, which indicated severe cognitive impairment. She required extensive assistance of one person for eating. The assessment indicated no symptoms of poor appetite and no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #56's care plan, revised on 1/22/23, revealed she had a potential for nutritional problem related to inadequate meal intake. Interventions were to have the RD (registered dietitian) evaluate and make diet change recommendations PRN and weigh and record: monthly and PRN. Record review of Resident #56's weight summary revealed the following: 10/10/22: 107.5 pounds 11/2022: no weight recorded 12/2022: no weight recorded 1/17/23: 65.2 pounds There was a calculated weight loss of 39.3% over 3 months. Record review of Resident #56's nutritional assessment, dated 2/28/22, written by the RD revealed a weight of 115.7 pounds and a BMI of 29 (normal BMI range was 23 - 30). Resident #56 was reviewed for her annual assessment. The RD documented the resident was readmitted to hospice. There was no significant weight loss but some weight loss with overall decline was expected with hospice and diagnosis. Record review of Resident #56's hospital record, dated 9/2/22, revealed a weight of 85 pounds. Record review of Resident #56's multidisciplinary care conference, dated 12/12/22, revealed the resident's appetite was fair. Her oral intake was 25-50%. Her weight was recorded at 107.5 pounds (from October 2022). There were no issues at the time. Patient was on hospice services. Record review of the facility's nutrition recommendations from August 2022 - January 10, 2023, revealed no dietary recommendations were made for Resident #56. Record Review of Resident #56 Hospice Records dated 1/2/23 revealed Resident gargling when she drinks water and unable to tolerate but able to eat regular food. HN recommended to change thin liquid to thickened liquid and was approved. Resident appears to be weak and frail and sleeps +12 hours a day. Record review of Resident #56's nutrition/dietary note, dated 1/18/23, written by the RD read in part, .CBW (current body weight) is at 65.2 pounds, -39.3% in 90 days, -40.8% in 180 days. BMI is below favorable for age at 16.3. Noted facility recently had scale recalibrations. Resident also on hospice care at this time . weekly weights ordered to monitor and re-establish baseline. Resident is on a regular, mildly thick liquid diet and has PO intake average at less than 50% but varies with sometimes increased intake. No recent labs, noted hospice. Resident with sacral and hip wounds being followed by wound care. Weight loss with overall decline is expected with hospice. Recommend magic cup TID with meals. Recommend increase 2.0 supplement to 60 cc TID related to weight loss. Recommend snacks of preference as desired. Goal is for resident to enjoy meals and supplements for comfort care. RD will continue following this resident Record Review of Resident #56 laboratory results dated [DATE] revealed resident's pre-albumin level was 7.2 mg/dL (normal range 17.0 - 34.0) and her albumin level was 2.5 mg/dL (normal range: 3.5-5.7). (The prealbumin blood test helps determine if you ' re getting enough nutrients -- namely, protein -- in your diet. Albumin is a protein in the blood plasma.) Record review of Resident #56's arm body mass measurements summary measured by hospice revealed (upper-arm circumference roughly correlates with BMI in the average person. A measure below 23.5 centimeters indicates that the person may be underweight or borderline underweight with a BMI of 20 or lower): 01-03-23 13.5 cm 01-02-23 13.5 cm 12-27-22 13.5 cm 12-07-22 14 cm 12-05-22 14 cm 11-21-22 14 cm 11-14-22 14 cm 11-28-22 14 cm 10-24-22 14 cm 09-29-22 14.5 cm 08-29-22 15 cm In an interview on 1/22/23 at 3:21 p.m., the Administrator said the previous ADON oversaw a lot of the facility's systems and was recently let go. He said the facility noticed significant discrepancies in the weight logs and submitted a self-report to the state survey agency. He said the weight logs reflected some residents were repetitively documented as weighing the same every month. He said approximately 34 residents were identified with weight changes in January, all were reweighed, and would be weighed every Thursday for the next 4 weeks. He said the identified concern was taken to quality assurance, in-services were done, and the RD was consulted. In an interview on 1/22/23 at 3:22 p.m., the Corporate Nurse said it appeared the previous staff responsible for weights were making up weights. He said a QAPI was done, and the facility was aggressively working to turn it around. He said both persons involved were terminated. In an interview on 1/23/23 at 1:18 p.m., the RD said the DON and Administrator notified her of a weight discrepancy this month when they had someone else weigh the residents. She said she did an intervention for approximately 35 residents who had significant weight loss and said some residents needed more supplements than others. She said Resident #56's weight loss was not seen or documented (prior to the discovery). She said the resident was on hospice services but made recommendations for hospice residents the same way as non-hospice residents. She said she did not want the resident to starve to death and her meal intake flexed up and down. She said, prior to the facility becoming aware of the weight discrepancy in January 2023, she did not assess Resident #56 and said there were no dietary recommendations for the resident between August 2022 and January 2023 because the resident did not flag for weight loss. The last Nutrition assessment was completed on 2/28/22. The RD said she only assessed residents for weight or nutritional needs if there was a referral from the facility based off a trigger of significant weight gain or loss. She said skin issues and abnormal laboratory values could be a negative outcome of the untreated weight loss. She said the dietitians came to the facility three times a month and reviewed admissions, readmissions, annuals, weight loss, dialysis, pressure wounds, tube feedings, and any consults. She said residents were reviewed annually if there was no weight loss identified. She said the review consisted of interpreting the BMI, identifying weight goals, diet order, preferences, reviewing supplements, laboratory values, skin for pressure wounds, and nutritional needs. In an interview on 1/24/23 at 11:30 a.m., the Administrator said he terminated the previous ADON on 1/3/23 due to integrity issues. He said they noticed a big discrepancy with actual weights and recorded weights. He said as they reviewed the weight logs, they noticed the previous RA was the one consistently entering the weights. He said the previous staffing coordinator weighed most of the residents and asked other CNAs to give her weights. He said during their QAPI meetings prior to the discovery, there were no alarms of weight loss. The previous ADON and previous RA were responsible for accuracy of weights. He said the previous ADON was the analyzer and should have been reviewing dietitian recommendations, physician notes, and overseeing the weight system. He said Resident #56 currently weighed 65 pounds. He said the wound care nurse conducted a head-to-toe assessment of the resident and said she did not have any new pressure ulcers but did have excoriation (damage or remove part of the surface of the skin). In an interview on 1/24/23 at 1:27 p.m., the RD said it was normal for hospice resident's dietary plans to be reviewed only annually. It would be reviewed more if there were concerns noted. She said, at the time, there were no concerns noted for Resident #56. In an interview on 1/24/23 at 3:07 p.m., the DON said she began employment with the facility in September 2022. She said the previous ADON was responsible for obtaining the weight data from the floors and ensuring the data was entered into PCC. She said she became suspicious of the weights in January 2023 because there was a delay in obtaining the weights of newly admitted residents, in addition to other concerns. She assigned a new team to obtain resident weights and noticed discrepancies in previously documented weights and current weights. She said upon review of previous weights they found several resident weights did not fluctuate more than 0.1 to 0.3 pounds in a 2-year period. She said in her professional opinion those were not realistic weight fluctuations. The DON said prior to December 2022, no one identified any weight changes, and no one reported changes in condition related to skin turgor, change in overall appearance, dehydration, lethargy, decrease activity, or skin impairment to her. During the QAPI meetings no issues were reported with the weights. She said she acknowledged there was a weight loss in some residents but questioned a lot of the weights. She said on 1/18/23 it was discovered Resident #56 had severe weight loss. She said Resident #56 was on hospice care and had a progressive decline in her ADLs and ability to mobilize. She said she had a history of not eating a lot and her family brought in food from home that she liked. She said she consulted with the MD and families and did not think any of the residents were harmed due to the unidentified weight loss. She said she would need to speak with Resident #56's MD about her decline to determine if it was a progression of her illness. In an interview on 1/24/23 at 3:15 p.m., the Corporate Nurse said the MDs and families did not report any concerns regarding weight loss. He said he spoke with the previous Staffing Coordinator and was informed she weighed over half of the residents. He said he could not confirm the integrity of the weights. In an interview on 1/24/23 at 3:17 p.m., the RD said the staff reported meal intake issues to her. She said Resident #56's dietary recommendations would depend on her nutritional needs. She would recommend fortified meals if the resident was still eating and then after that supplements, ice cream, and med pass 2.0. In an interview on 1/25/23 at 10:47 a.m., the NP said she recently started seeing Resident #56. She said the resident was on hospice care due to dementia and did not want to do aggressive measures such as inserting a PEG tube. She said she expected the resident to decline with normal process. She said she referenced the monthly weight to ensure the resident was not losing too much weight. She said a significant weight loss or a drop of 40 pounds in a month would raise red flags. She said she would do a dietary consultation and if the RD made recommendations, they would get approval from hospice. She said she would also try Remeron (an appetite stimulant) if hospice approved. She said she would recommend these interventions to prevent the resident from losing too much weight but if hospice did not think it was appropriate, they would not implement it. She said with residents on hospice you want to ensure the quality of life but not prolong life. In an interview on 1/25/23 at 11:33 a.m., Resident #56's RP said the family noticed the resident was losing weight but could not tell how much. He said the resident lost more weight than he expected and said he was shocked to learn how much. He said the resident's normal weight was 115 pounds, but the facility recently informed him she weighed 75 pounds. He said the resident was put on hospice care because he and his family member were unable to see the resident during COVID-19 and the facility nurse said if the resident was put on Hospice care another nurse would come in and make her comfortable. He said he and his family member made a plan to encourage the resident to eat more because she slept so much and would gradually eat less and less. He said around the start of COVID-19, she lost a lot of weight but was still responsive and could walk around. He said the facility did not say what they would do to help with her appetite. He said when he was at the facility, he tried to assist her with meals and notified the CNAs when she would not eat well. He said they informed him they would try to get her to eat later. He said the resident got weaker and every time she walked around, she would fall and go to the hospital. He said he wanted the resident on physical therapy to walk and move around again so he removed her from hospice, but when she plateaued in therapy the facility convinced him to place her back on hospice. He said she had not been able to get out of bed very often because of unsteadiness. He said he had a care plan meeting in the past to discuss her diet preferences, such as no bones in her chicken and no spicy foods, but they did not discuss her specific dietary requirements. He said last Wednesday, 1/18/23, the facility changed her diet to a higher calorie, soft food diet which the resident took to very readily. He said she took everything on her plate on Friday, 1/20/23 but was unable to wake her to eat on Monday 1/23/23. He said she used to be able to feed herself and would eat the regular diet. He said he expressed to the facility there must be a high calorie diet that would help her eat, because the amount she was eating was small. He said he informed the facility that whatever they could do to help with her nutrition would be great. He said the hospice agency did not specifically say the resident would progressively lose weight. In an interview on 1/25/23 at 12:06 p.m., CNA A said she noticed Resident #56 lost weight and reported it to LVN A. She said the resident did not eat too much. She said last month the resident ate approximately 75% of a meal she assisted her with. She said she noticed the resident did not eat by herself but previously did not like when people fed her. In an interview on 1/25/23 at 12:29 p.m., LVN A said she noticed a few residents lost weight on her hallway not too long ago, which included Resident #56. She said she normally reported weight loss concerns to the resident's hospice nurse. She said Resident #56 was always fatigued and would refuse everything with feeding. She said her meal intake was around 25% but she liked to drink. She said her weight loss was obvious when the staff got her up to weigh her last week. She said she did not know who weighed the residents prior to January 2023. She said the RP would come to ensure she got enough food. She said the resident was on med pass 2.0 and the hospice nurse started her on Sucralfate. She said she was supposed to report weight concerns to the facility doctor and the hospice nurse, and they would schedule blood work and send it to the doctor. She said she was not sure when to notify the RD. She said she reported Resident #56's weight concerns to the previous ADON and was informed to notify hospice and the resident's doctor. She said the previous ADON did not say anything about informing the RD. She said the RD monitored the food the residents ate and monitored the weight. Based on the weights they could tell if the patient was going up or down. She said the CNAs would report Resident #56's appetite changes to her. She said she reviewed Resident #56's weight and noticed the weight was previously around 100 and now it went down to 67. She said she knew the resident was losing weight based on her intake but never questioned the weights in the system because they looked right. She questioned the amount of weight she lost because it was a lot. She said she was recently in serviced on reporting weight concerns to the RD and conducting an assessment when there was a decline. In an interview on 1/25/23 at 2:00 p.m., Resident #56's Hospice Nurse said she assessed Resident #56 for the last 2 years. She said in the last 3-4 months Resident #56 had a decline in appetite and weight loss. The Hospice Nurse said the resident declined food and had low food intake. The Hospice Nurse determined the resident had a decline in body mass based off the mid-upper arm circumference body mass checked every 2 weeks during hospice visits. She said she received weight updates from various CNAs and nurses when she visited the resident. The last weight recording the Hospice Nurse recalled was approximately 97 pounds from the resident's recent hospital visit (exact date unknown). In an interview on 1/25/23 at 4:09 p.m., the DON said she was not previously aware of any weight changes for Resident #56. She said the Hospice Nurse, previous ADON, and charge nurses did not report any information about Resident #56's weight or appetite changes to her. She said if she was aware of the weight or intake changes, she would have notified the physician and obtained appropriate referrals such as for the RD. In an interview on 1/26/23 at 9:31 a.m., the previous ADON said she never weighed residents or documented weights. She said she only followed up on any recommendations from the RD if the RD saw weight loss or weight changes and if she wanted supplements or adjustments made. She said any CNA on the hall did the weights then gave those weights to the previous Staffing Coordinator. In an interview on 1/26/23 at 10:00 a.m., the previous Staffing Coordinator said the facility told her she falsified resident weights. She said she documented weights in the system when the CNAs gave them to her. She said she did weigh some residents and a lot of their weights changed. She said she recorded weekly weights in a binder but corporate was destroying papers in her old office when she was suspended. She said the scales were not calibrated and there was always an issue with the Hoyer lift scales jumping up and down. She said the last time she weighed Resident #56 was in November because the RD said she did not have to weight hospice residents. In an interview on 1/26/23 at 11:12 a.m., the DON said because of the internal audit, weights would be obtained on admission, the day after, and weekly for 4 weeks. She said she would review the weights and look at consistency in weighing procedures (i.e. hoyer lift, wheelchair scale, and same time of day). She said the DON, Administrator, or designee would be responsible for weekly spot checks of weights on each hall. She said they would select a resident and verify their weight with another person. In an interview on 1/26/23 at 11:24 a.m., the DON said the previous Staffing Coordinator was not the only person weighing residents but was the person who made sure the weights were done and entered in the system. She said the previous Staffing Coordinator worked with different CNAs to obtain weights. She said after the facility identified the weight discrepancies, she educated the lead nurses on how to identify weight loss and when to report. She said the scales were calibrated quarterly and no one ever reported any issues with the scale. Record review of the 10 residents identified with weight loss revealed new dietary physician orders were obtained and entered and care plans updated. Record Review of Resident #7 revealed was a [AGE] year-old female admitted on [DATE] with diagnoses mobility (severe) obesity due to excess calories, moderate protein- calorie malfunction, gastrostomy status, chronic kidney disease stage 3 unspecified, and gastro-esophageal reflux disease without esophagitis. Record Review of Resident #7 weights revealed that resident had a weight loss of 37.2% weight loss from 12/05/22 to 01/18/23. Resident #7 weight 155.5 lbs. dated 01/18/23 and 247.7 lbs. dated 12/05/22. Record Review of Resident #44 revealed was a [AGE] year-old female initially admitted on [DATE] with diagnoses chronic diastolic (congestive) heart failure, morbid (severe) obesity due to excess calories, vitamin B12 deficiency anemia, unspecified, vitamin D deficiency, unspecified gastro-esophageal reflux disease without esophagitis, and muscle weakness (generalized). Record Review of Resident #44 weights revealed that resident had a weight loss of 36.9% weight loss from 10/10/22 to 01/18/23. Resident #7 weight 201 lbs. dated 01/19/23; 318.6 lbs. dated 12/12/22; 317.57 lbs. dated 11/07/22 and 318.8 lbs. dated 10/10/22. Record Review of Resident #59 revealed was a [AGE] year-old female initially admitted on [DATE] acquired absence of left leg below knee, acquired absence of right leg below knee, cerebral infarction, unspecified, essential primary hypertension, anemia in other chronic diseases classified elsewhere, slow transition constipation, pressure of artificial left leg (complete) (partial), encountered for surgical aftercare following surgery on the digestive system, iron deficiency, anemia, unspecified, abnormal posture, muscle weakness (generalized), bed confinement status, Record Review of Resident #59 weights revealed that resident had a weight loss of 17.8% weight loss from 09/08/22 to 01/17/23. Resident #59 weight 97.6 lbs. dated 01/17/23; 118.8 lbs. dated 12/12/22; 119 lbs. dated 11/09/22; and 119.8 lbs. dated 09/28/22. Record Review of Resident #18 revealed was a [AGE] year-old male initially admitted on [DATE] with diagnoses of unspecified severe protein-calorie malnutrition, chronic kidney disease, stage 3 unspecified, anemia in chronic kidney disease, and benign prostatic hyperplasia without lower urinary tract symptoms, Record Review of Resident #18 weights revealed that resident had a weight loss of 18.5% weight loss from 10/14/22 to 01/19/23. Resident #18 weight 149.4 lbs. dated 01/19/23; 183.3 lbs. dated 12/10/22; 184.0 lbs. dated 11/09/22; and 184.4 lbs. dated 10/14/22. Record Review of Resident #23 revealed was a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, single episode, unspecified, gastro-esophageal reflux disease without esophagitis. Record Review of Resident #23 weights revealed that resident had a weight loss of 10.1% weight loss from 10/10/22 to 01/17/23. Resident #23 weight 145.2 lbs. dated 01/17/23; 161.5 lbs. dated 12/10/22; 161.9 lbs. dated 11/07/22; and 161.6 lbs. dated 10/10/22. Record Review of Resident #72 revealed was a [AGE] year-old female admitted on [DATE] with diagnoses of deficiency of vitamin K, aphasia, muscle weakness generalized, cognitive communication deficit, and dysphonia, oropharyngeal phase. Record Review of Resident #72 weights revealed that resident had a weight loss of 22.1% weight loss from 10/10/22 to 01/17/23. Resident #72 weight 106.2 lbs. dated 01/17/23; 136.3 lbs. dated 12/09/22; 136.8 lbs. dated 11/09/22; and 136.3 lbs. dated 10/10/22. Record Review of Resident #5 revealed was a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications, vitamin D deficiency, unspecified, and muscle weakness (generalized). Record Review of Resident #5 weights revealed that resident had a weight loss of 22.4% weight loss from 10/10/22 to 01/17/23. Resident #43 weight 143.4 lbs. dated 01/17/23; 176.8 lbs. dated 12/09/22; 176.2 lbs. dated 11/09/22; and 176.8 lbs. dated 10/10/22. Record Review of Resident #14 revealed was an [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes,unspecified severity protein calorie value function now nutrition mode morbid severity obesity due to excess calories, anemia and other chronic diseases classified elsewhere, vitamin D deficiency, other specified disorders of bone density and structure, unspecified site, other specified disorders of bone intensity and structure, unspecified site, bed confinement status, and muscle weakness (generalized). Record Review of Resident #14 weights revealed that resident had a weight loss of 27.5% weight loss from 9/9/22 to 01/19/23. Resident #43 weight 122 lbs. dated 01/19/23; 190 lbs. dated 11/09/22; 190.6 lbs. dated 10/10/22; and 191.8 lbs. dated 9/9/22. Record Review of Resident #45 revealed was an [AGE] year-old male admitted on [DATE] with diagnoses of heart failure, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellitus with diabetic neuropathy, unspecified, Record Review of Resident #45 weights revealed that resident had a weight loss of 27.5% weight loss from 11/7/22 to 01/19/23. Resident #45 weight 97 lbs. dated 01/19/23; 134.3 lbs. dated 12/10/22; 134.3 lbs., and 134.0 lbs. dated 11/7/22. Record Review of the facility's, undated, Weight Assessment and Intervention Policy Statement revealed: Weight Assessments 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 5. The dietitian will review the unit weights record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss =(usual wight - actual weight) / (usual weight) x 100]: a. 1 month - 5% weights loss is significant; greater than 5% is severe. b. 3 month - 7.5% weights loss is significant; greater than 7.5% is severe. c. 6 month - 10% weights loss is significant; greater than 10% is severe. Record Review of the facility's, undated, Weighing and Measuring the Resident Level II. revealed Preparation 4. Weight is usually measured upon admission and monthly during the resident's stay. Documentation: The following information should be recorded in the resident's medical record. 2. The name and title of the individual(s) who performed the procedure. Record Review of the facility's, undated, Nutritional Assessment Policy Statement revealed: As part of the comprehensive assessment and nutritional assessment including current nutritional status and risk factors for impaired nutrition shall be conducted for each resident A. Nursing: (1) usual body weight (2) current height and weight (3) a description of the resident's usual intake and appetite (4) a history of reduced appetite or progressive weight loss or gain prior to admission (5) current clinical conditions and recent events that may have affected the residents nutritional status and risk factor (7) general appearance under scription of the residence overall appearance (8) the residents usual routine(s) intake (e.g. , oral, enteral, parenteral). Record Review of In-Service Education Program Record dated 1/18/23 Instructed by DON on the subject of Weight Assessment and Interventions and Review of Facility Policy and Procedures for Obtaining Resident Weights, Signs and Symptoms of Weight Loss of Resident and reporting Suspected wight Loss . Record Review of Statement of Inservice Training for Employees dated 1/20/23 Instructed by DON on the subject of Weight Assessment and Interventions and Review of Facility Policy and Procedures for Obtaining Resident Weights, Signs and Symptoms of Weight Loss of Resident and reporting Suspected wight Loss . This was determined to be a Past Noncompliance IJ that began on 1/18/23 and ended on 1/20/23. The Administrator was notified on 1/26/23 at 5:37 p.m. The Administrator was provided with IJ template on 1/26/23 at 5:37 p.m. No plan of removal was required. 44669

Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 of 3 residents (CR #1) reviewed for safe discharge . The facility failed to provide sufficient preparation to ensure safe and orderly discharge of CR#1. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings include: Record review of the admission sheet for CR #1 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of the comprehensive Minimum Data Set (MDS), dated [DATE], revealed CR #1 was assessed and had a BIMS of 04 out of 15, which indicated severely impaired cognition. She required extensive assistance from one staff physical assist with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Record review of CR #1's discharged MDS, dated [DATE], revealed section F entry\discharge reporting was coded #10 which meant (discharge return not anticipated). Further review of Section A. A2100 Discharge status was coded as 01 which meant she was discharged to community (private home/apt., board/care, assisted living, group home) on 10/25/21. Record review of CR #1's Social Worker's notes, dated 10/26/21, read in part: .SW called pts husband. He called the ombudsman to follow up on the feeding/supplies. He thought it was the correct number after getting it off the discharge paperwork. SW provided him with the contact number to [name of home health agency] . Record review of CR#1's Discharge Summary instruction dated 10/25/21 read in part: .1. Discharge Summary follow-up tests & procedure 7. Test(s) within last 5 days a. Blood. C. Functional Status: Total dependence with bed mobility, transfer, locomotion, toileting, dressing, grooming, bathing and eating. Incontinent of bladder and bowel. D. Skin condition: Fragile. 2a. site: sacrum. 2b. size: large. 2c. Stage 4. 3. Treatments: cleanse with normal saline, calcium alginate and apply dry dressing. Rehabilitation Services Physical Therapy Received: TP increase strength, ROM and provide proper positioning. Recommend further therapy: Yes. Instruction After Discharge 2. Equipment: Enteral Feeding and Supplies. Dietary needs: Special diet/liquids-[MEDICATION(S)] 1.5 American Home Patient (phone number) Home Health Referral: Texas Home Health . Further review revealed the discharge summary was not signed and dated by CR#1 or the responsible party that they have received and understood the discharge instructions provided by LVN A. Record review of CR#1's Discharge information signed by CR#1's physician dated 10/27/21 read in part: .summary of course of treatment: IV therapy, wound care, G-tube nourishment needs and medication management. Disposition: Home with husband. Condition on discharge: alert, prognosis: fair . Record review of CR #1's emergency room hospital records, dated 10/30/21, read in part: . Pt is a 68 yo female with pmh of [CONDITION(S)], hypertension, kidney stone, Foley and recent G-tube placement here with complaints of failure to thrive and weakness. Patient was recently admitted and had a G-tube placement along with treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Husband states that patient was discharged with no significant instructions or food for the patient. Patient's husband states that he had to get food and also bandages for the wound. Patient has not eaten anything and not drink anything for the past 3 days. Husband states that the patient will not take anything by mouth and is now not drinking any water either. Patient has gotten progressively worse and believes patient is getting dehydrated. Husband denies any fever, vomiting or diarrhea. Husband does note that the patient does not have any significant urine output . Record review of CR#1's hospital records, dated 10/30/21, read in part: .[CR#1] is a [AGE] years old women with a history of hypertension, [CONDITION(S)] with functional [CONDITION(S)], [CONDITION(S)] bladder requiring an indwelling foley catheter, severe protein calories malnutrition requiring PEG tube placement, stage IV sacral decubitus ulcer present on admission recently cultured positive for [CONDITION(S)] who was discharged to a skilled nursing facility 9/21 and returns today with failure to thrive, severe protein calorie malnutrition, lactic acidosis, suppurative pyelonephritis, acute renal failure, and worsening sacral [CONDITION(S)] admitted to the ICU for the these conditions. The patient was not able to communicate much with me given her severely debilitated state but she reports she was transferred from the SNF to the ED directly. She was [CONDITION(S)] to the 140s upon arrival, with borderline [CONDITION(S)] (90/50), afebrile, with a longstanding foley in place along with a worsening known stage IV sacral decubitus ulcer. Foley was removed with purulent drainage noted and replaced. CT A/P demonstrated significate sacral [CONDITION(S)]. Patient given IV Fluids, [MEDICATION(S)]/[MEDICATION(S)]/[MEDICATION(S)], and admitted to the ICU for further management. 2. Sacral [CONDITION(S)]: 3. Stage IV Sacral Decubitus Ulcer-Patient had [CONDITION(S)] positive Stage IV sacral decubitus ulcer that has progressed to more extensive [CONDITION(S)] on CT today . In a telephone interview on 11/4/21 at 9:19 a.m., with the Ombudsman, he said on 10/25/21, CR #1 was discharged to her home. CR#1's Responsible party received a notice on the way out the door and he was not sure on what kind of notice he received. CR #1's RP was [AGE] years old, and he was not understanding why the facility would discharge CR #1 in her condition. CR #1's RP informed him the facility pressured him into picking up CR #1 and taking her home. The Ombudsman stated CR #1's RP told him CR #1 was on a feeding tube as the facility did not assist him with supply of liquid food or any contractors to help him received the liquid food once she got home. CR #1's RP said the facility forced him to take his wife home with open bed sores and the facility did not arrange any post DC for CR #1 going home. On 10/29/21, CR #1's RP contacted him to state CR #1 did not have any liquid food and her health declined. Therefore, CR #1's RP called for an ambulance to take her to the emergency room . CR #1's RP said he found out about the Ombudsman Program the day he picked CR #1 up and there was no information on advocacy. CR #1's RP was unable to care for his wife. In a telephone interview on 11/4/21 at 11:07 a.m., with CR#1's Responsible party, he said CR #1 had a large wound on her bottom and the facility discharged her with no wound care supplies, medication or instructions on how to care for the wound. He said the wound had a lot of drainage and he tried his best to keep the wound clean with the badges he had at home. He said she also had a feeding tube and no food was provided from the facility and he could not get the formula without a prescription from the local drug store. CR #1 went 3 days without food and toward day 3 she could not swallow water and was not responding to him, so he brought her to the hospital. He said he tried to feed her through mouth, but she could not swallow. He said, I could not get her to drink water either having no food got her sick again and was admitted at the hospital. He said there was only 1 can of formula which sat in her room and he took it home with him. He said the discharge nurse (LVN A) told him there would be nurses going to take care of her, but nobody showed up. He said the day of discharge the nurse gave him list of numbers he needed to contact. He said he now had 5 cases of formula, but it was no use because CR #1 was admitted to the hospital. He said the facility should have assisted him and made sure the supplies were available for CR #1 when she went home. In an interview on 11/4/21 at 10:46 a.m., with the Social Worker, she said CR #1 was on a skilled stay. She was supposed to be discharge to home health. The home health agency declined the referral and did not call the facility. When the husband called them was when he found out on 10/27/21 that home health declined the referral. The Social Worker said today (11/4/21) was the first time she found out Home health did not accept the referral. She said RP considered placing her at an assistant living facility. The Social Worker said she called that assisted living but they never called her back. RP wanted her back home with assistance of his family. She said she did Discharge planning with an assisted living facility. RP changed his mind again to send her to an assisted living and she went home. CR #1 was Total assist. Home health did not say they clinically denied the resident. Social Worker said on 10/22/21 she made the referral. Today, she called home health agency because the State Surveyor was at the facility, and the facility tried to figure out what was going on. She said her role with discharge was planning to confirm a location, making sure Medicare network with her insurance, teaching resident/RP with g-tube feeding/meds by nurses, and gave a number for the medical supply company that serviced their area. She said the family needed to coordinate and call the medical supply company because a co-pay was involved. She said the RP told her he missed a call from the supply company. If he did not pay for the formula it would not be delivered. The Social worker said she felt it was a safe discharge because MS was not a new diagnosis, RP was clear about family support. He spoke very competently and confidently in the ability to care for CR #1. She said the RP was given the discharge paper upon discharge. Ombudsman information was on every discharge form. DME company information was next page at the top. The RP said the nurse (LVN A) told him the number to contact the feeding/supplies were at the bottom of the page so he called the ombudsman instead. In an interview on 11/4/21 at 11:58 a.m. with the DON, he said the Social Worker prepped and got everything ready for example if family needed assistance with home health the SW would arrange all of that. He said the nurse reviewed discharge medications, provided any education that needed to be done at the time of discharge and completed her section of the discharge form. He said routine medications were sent home with family. He said for wound care no dressing change supplies, no feeding formula were given to the family at the time of discharge. The Family should obtain that from home health which should be set up prior to discharge. The only thing the nursing home sent home with the resident was their routine medication and the family should obtain formula from home health. He said he was not aware home health was not set up. He said the Social Worker should have followed up with home health agency prior to discharge to make sure they had accepted the referral. In an interview on 11/4/21 at 12:23 p.m. with the Administrator, she said usually if home health company denied a resident they would let the facility know so the facility could contact another home health company, but home health did not notify the facility of the denial. She said going forward she would follow up on discharges. In an interview on 11/4/21 at 12:29 p.m., with the Social Worker, she said when she called the home health agency, today (11/4/21) they said they notified RP they denied the referral. SW said she was shocked. Home health should have let the referral source (SW) know. She said the home health agency said the husband called them to inquire too and they told him as well they were denied. The SW said once she made the referral, she confirmed they received the referral. Then, the family had to make the contact to complete delivery, co-payment, billing. She said the service provider needed to follow up with family. Her responsibility was to make the referral and family took care of the rest. She said she does not follow up with home health agency to confirm if the referrals were accepted. In an interview on 11/4/21 at 1:02 p.m. with LVN A, she said her role was to get the discharge order, talk with the Social Worker, Physical Therapy and Occupational Therapy to see if their portion was done on the discharge paperwork. Collect routine medications, print out discharge/medication summary, go through each section with the family, have them sign and she signed. LVA A said CR #1 could eat by mouth and the G-tube bolus feeding was to maintain calorie weight the dietician wanted. CR #1 received regular trays as well as bolus feedings at the facility. LVN A said she taught CR#1's RP to check placement prior to administering bolus feedings but he said he did not have statoscope at home. She said there were 3 different phone number listed on the discharge summary for home health, place for formula and ombudsman. LVN A said she did not teach RP how to perform wound care because she assumed home health was set up. She said she did not give RP any wound care supplies or the formula. She only gave him CR#1's routine medications. In an interview on 11/4/21 at 1:06 p.m., with the Administrator and the DON, the Administrator said they discussed with corporate and corporate said if home health denied the resident, Home Health should have found another company for the resident. The Facility did their part by making a referral. If home health denied it because of staffing or whatever reason they were responsible for finding another company for the resident. Observation and attempted interview on 11/4/21 at 2:54 p.m., with CR#1 revealed she was resting in bed. [MEDICATION(S)] 1.5 running continuously at 50ml/hr. She did not respond appropriately to the questions asked. In an interview on 11/4/21 at 3:02 p.m., with hospital RN A, she said CR#1 was NPO. She received continuous [MEDICATION(S)]. She was admitted from home to the hospital with a wound on the back that the treatment nurse treated. Her potassium was 2.7 this morning so they were replenishing potassium. In an interview on 11/16/21 at 10:15 a.m. with the Treatment nurse, she said CR #1 came with a stage 4 pressure ulcer to the facility from the hospital and nursing treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said CR #1 was discharged home from the facility but she could not care for her wound on her own. She said CR #1 returned to the facility few days ago. In an interview on 11/16/21 at 10:38 a.m. with the DON, when asked if home health was set up for CR #1 could the readmission have been prevented.The DON said not setting up proper home health could have a negative outcome if proper care was not set up. Which could mean anything especially about wound care, g-tube care and overall health of the resident. He said CR #1 returned to the facility from the hospital. He said CR #1 used to eat but now she was completely NPO now. Record review of facility's Transfer or Discharge Notice policy (revised December 2016) read in part: .our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge) . The policy did not state anything about assisting with setting up post discharge goals and services.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 did not sustain a major injury ( [CONDITION(S)]) during transfer with one staff in which a fall occurred. This failure placed facility resident at risk of harm to include neglect, diminished quality of life, and psychosocial harm. Findings Included: Record review of Resident #1's, undated, face sheet revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hypertension, [CONDITION(S)], non-Alzheimer's dementia, malnutrition, metabolic [CONDITION(S)], muscle weakness, and unspecified lack of coordination. Record review of Resident #1's Quarterly Minimum data set assessment (MDS), dated [DATE], revealed a BIMS score of 7 out of 15, which indicated severe cognitive impairment. MDS further revealed the resident required extensive assistance of two persons for transfer. Record review of Resident #1's undated care plan reflected Resident #1 required extensive assistance by 1 staff to move between surfaces as necessary. Further review shows that Resident #1 had an actual fall with serious injury (Right [CONDITION(S)]) because of Poor Balance. Interventions: Continue Interventions on the at-risk plan. Monitor/document/report PRN to Medical Doctor for signs and symptoms of pain, bruises, change in mental status, New Onset: Confusion, Sleepiness, Inability to maintain Posture, Agitation. Physical Therapy consults for Strength and Mobility. Record review of the facility undated Investigation note indicated the facility learned on 09/20/21 Resident #1 stated her hip was hurting because the nurses dropped her when she was picked up using the lift. During an observation and interview on 10/06/21 at 11:24 a.m., Resident #1 was lying on her bed and receiving therapy. She was observed screaming in pains while undergoing therapy Session. Resident #1 said she was dropped by the Nurses when being transferred from her bed to her chair. She was unable to recall the name of the Nurse and the date the incident happened . In an interview with the DON on 10/06/21 at 1:15 p.m., he stated the Incident with Resident #1 occurred over the weekend, but he found out on 9/20/2021 when making rounds. He said the resident was lying in bed, and she was not her usual self. She complained her hip was hurting and over the weekend, the nurses dropped her from a Hoyer lift. He ordered an x-ray which revealed Resident #1 fractured her hip, and she was sent to the hospital the same day. He investigated, and CNA A told him Resident #1's bed was Malfunctioning, and while was transferring her from the bed to her chair, she lost her balance, sliding down her leg but did not hit the floor. She was assessed by RN B, and the resident didn't complain of any pain. He said CNA A decided not to return to work while the investigation was ongoing and was subsequently terminated. He said that the Assistant Director of nursing conducted a video review of the A hall for that weekend shift and confirmed that the gait belt and Hoyer lift were not used in transferring resident #1 as it remained in the same position for the period the incident occurred. He said he did not report Incident to the State Survey Agency because the facility was not certain it was a fall, the only staff who witnessed it said it was not a fall as Resident #1 was assisted to the floor. He said Resident #1's roommate was interviewed but didn't know anything about the fall. She said she was outside her room when it happened. In an Interview with Administrator on 10/06/2021 at 4:36 p.m. She said CNA A was transferring Resident #1 from her bed to the chair when she slides off her leg and was assisted to the floor. She reviewed the camera footage for the Hall A where resident #1 resides and confirmed that Hoyer lift was never used. She said according to her most recent care plan Resident #1 is a one to two person assist. She said she requires two people assist only when she exhibit behavioral disturbance but for transfers, she was a one person assist. She said it is her responsibility to report falls to the State Survey Agency but upon investigation of the incident, they were unable to establish that it was a fall. CNA A who witnessed the incident said it was an Assist to the floor. In an Interview with Regional Nursing Consultant on 10/07/2021 at 8:45 a.m., she said from her understanding the resident was assisted to the ground and it was not an actual fall. She said based on the facility policy on reportable incidents, they are not required to report an assist to the ground. She said the aide was supposed to have notified the nurse on duty, and the nurse was supposed to conduct an assessment and notify the DON. She said the nurse was supposed to complete an incident report and get a physician's order if required. She said the cooperate office just found out about the incident on 10/06/2021. She said the staff who witnessed the incident said Resident #1 was assisted to the floor. The nurse on duty didn't complete an incident report and that's against the facility policy and procedure. In an interview with RN B on 10/07/21 at 10:15 a.m., she said CNA A observed Resident #1's bed was broken and tried to lift her. She was unable to transfer her properly, and she called for help; she said when she got to the room, Resident #1 was on CNA A's leg but didn't fall, Two extra CNA'S were called into the room, and they were able to lift her and place her on the chair next to her bed after which she was transferred to her bed. She complained of leg plain, and this was not new as she complained every time. She conducted an assessment on Resident #1 and didn't notice any unusual inflammation or bruises, Tylenol was administered, and she fell asleep. She said she didn't fill out an incident report since she was not in severe pain; her pain rating was less than 5, which was documented in the progress note. In an interview with CNA A on 10/07/21 at 11:35 a.m., she said the incident happened on Saturday, 09/18/21, close to lunch time. Resident #1 was seated on her bed which was misconfigured as the head of the bed was elevated and refused to come down, she tried to transfer her to her chair due to her complaining. When she realized she was unable to transfer her alone, she kept her on the side of the bed and used her leg to support her before she slides down slowly, she called RN B, CNA B and CNA C to come assist her transfer the resident to the bed. She said Resident #1 was usually a one-person transfer. She said RN B was with her when the incident happened, so she didn't see the need to fill out an incident report; she said she was not sure the nurse conducted any assessment on Resident #1. She said if a resident required more than one person for transfer, she would request assistance and wait. She said her Charge Nurse notified her Resident #1 is a one-person transfer, and she could find the information at the nursing station. In an interview with CNA B on 10/07/21 at 12:45 p.m., she said for residents who required more than one-person transfers, she could find the information on the ADL in the medical record or nursing station. She said the last time she worked the B Hall Resident #1 was mostly seated on the edge of her bed. She said she was at the nursing station on 09/18/21 at between 9 to 10 a.m., when CNA A went down the hallway to ask for help because Resident #1 had a fall, she, RN B, CNA C, and CNA A assisted in transferring Resident #1 to her bed. When she got to the room, Resident #1 was leaning on the floor, her bed was in a highest position, and she asked for help to be taken off the floor. RN B was inside the room when she arrived. She said Resident #1 was transferred using a 4 person assist, and no gait belt or Hoyer lift was used. She said if she witnessed any fall, she was required to notify the nurse immediately. Record review of the facility's policy Abuse Prevention Program, revised March 2018, reflected .Reporting and Response issues: All allegations of possible abuse, neglect, exploitation, or misappropriation of Property will be immediately reported to the Texas Health and Human Services by the Administrator or designee and will be evaluated to determine the direction of the investigation .Any and all staff observing or hearing about such events must report the event immediately to the Administrator, Immediate supervisor, and one of the following: Director of Nursing, ANEM prevention Coordinator or Risk Manager, so that appropriate reporting and investigation procedures take place immediately.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as is possible for 1 of 11 residents (Resident #1) reviewed for accidents. Resident #1 ' s leg was injured during a transfer by 2 staff from her wheelchair to her bed. She received a large cut to her left lower leg with a sharp edge in the bed that was missing a cap. She had to be transferred to the emergency room where she had complex plastic surgery of her left lower leg requiring 16 sutures. This failure affected 1 resident and placed 22 residents requiring 2-staff for transfers at risk for injury and unnecessary pain. Intakes: # 5 and # 4. Findings include: Resident #1: Record Review of Resident #1 ' s clinical file indicated she was [AGE] years old admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Admission Assessment Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was totally dependent of 2 person ' s for physical assist. Record review of the Quarterly MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 person ' s physical assist for transfers. Record review of the Comprehensive Care Plans for Resident #1 dated 09/25/15 indicated: The resident has an Activities of Daily Living (ADL) self-care performance deficit due to musculoskeletal impairment, limited mobility, impaired balance, disease process (Peripheral vascular disease with edema.) Interventions: Transfer - The resident requires (EXTENSIVE assistance) by (one to two) staff to move between surfaces as necessary. Record review of the facility Admit/Discharge To/From Report dated 12/01/15 - 02/22/16 indicated Resident #1 was discharged to the hospital on [DATE]. Record review of the Provider Self-Reporting of Incidents forms indicated: - Date and time submitted: 02/22/16 at 4:48 p.m. - Date and time the facility first learned of the incident: 02/20/16 at 8:30 p.m. - Allegation: Neglect. - Client/Resident: Resident #1. Alleged Perpetrators: CNA A and CNA B. Details: Resident received a skin tear to her left lower leg during transfer from chair to bed per 2 CNA ' s A and B. Charge nurse was unable to control the bleeding and resident was transferred to the hospital. In an interview on 02/24/16 at 10:38 a.m. the Director of Nursing (DON) said she was notified of the incident with Resident #1 by LVN A at approximately 8:30 p.m. on 02/20/16. LVN A told her Resident #1 had a skin tear to the left leg and she could not control the bleeding. She said it occurred during a transfer. Resident #1 was sent to the hospital. She said LVN A did not tell her the actual size of the skin tear. The DON said to her knowledge Resident #1 did not end up having surgery. During an interview on 02/24/16 at 11:00 a.m. with Resident #1 ' s family member and Resident #3 (Resident #1 ' s roommate), they said Resident #3 was in the room when Resident #1 was injured. Resident #3 said she was in the B-bed and she saw 2 CNA ' s were transferring Resident #1 from the wheelchair to her bed in the A-bed side of the room. She said she heard Resident #1 holler Oh my leg . She said she looked over and saw a lot of blood on the resident and on the bed. The EMS took her to the hospital that night. Resident #3 said the facility removed the bed Resident #1 was in that night, moved it out, and brought a new bed into the room. Resident #3 said there was a sharp edge on the other bed when she got hurt. It was missing a cap. Interview and observation on 02/24/16 at 11:51 a.m. with the Housekeeping Supervisor he said he had moved Resident #1 ' s bed out of her room before she had returned from the hospital on [DATE]. He said he traded it with a different type of bed that was in resident room #D-9A. Observation of the bed at the time revealed that was unoccupied and had 2 areas on the bottom of the ¼ side rail that were now taped over. During an interview on 02/24/16 at 4:15 p.m. CNA A said she and CNA B were transferring Resident #1 from her wheelchair to her bed on Saturday night at around 8:00 pm, 02/20/16. She said they often transferred her with a sling, but they used a gait belt that night. They said that Resident #1 received an injury. CNA A said she did not see how the injury was caused, she just saw blood. She said she did not see the cut, so she could not say the size of it. When the surveyor pointed at the bed in Resident #1 ' s room, she said that was not the bed she had when she was injured. In further interview the bed in room D-9A was showed to CNA A . She said that was the bed Resident #1 was in previously and the 2 areas covered with tape were not covered that way before the injury. During an interview on 02/24/16 at 4:20 p.m. CNA B said she was working with Resident #1 the night of her injury. She said and CNA A were transferring her from the wheelchair to the bed. She said they lowered the bed and put the ¼ side rail down. She said she did not see what happened to Resident #1 ' s leg, she just saw a lot of blood on the bed and coming from the resident ' s leg. She said she saw the cut on her leg and described it as not small, but hard to say the size, there was a lot of blood . During an interview and observation on 02/24/16 at 4:32 p.m. with Wound Care Nurse she said Resident #1 had returned from the hospital on [DATE]. She said she had re-wrapped her wound in the morning and it measured 35 cm. Resident #1 was sitting in a Geri-chair. The Wound Care Nurse unwrapped the wound. The wound on Resident #1 ' s lower left leg was a very large flap of skin (4 inches long on two sides by 3 inches wide) with sutures on 3 sides. The sutures on the bottom 3 inch area had come loose and a 3 inch wide by 1 inch area was bright pink/red in color, with no skin covering it. Wound Care LVN C said the sutures had pulled away due to edema or infection. Record review of the Weekly Skin Observation Tool dated 02/24/16 indicated Resident #1 had a trauma wound to her left lower leg that measured 35 length by 4 width by 0.2 depth. The nursing notes indicated: Re-Admit to facility 02/23/16. Has a trauma wound with 15 sutures, to the left lower leg, some of the sutures have dehiscence that is 4 cm wide. The suture site measures 35 cm. Record review of the Hospital Emergency Department Physician documentation record for Resident #1 indicated: - Arrival date: 02/20/16 Time: 21:15 (9:15 p.m.). - Chief Complaint: skin Tear(s), with complaints of Laceration. - Onset: The symptoms/episode began/occurred today. Associated signs and symptoms: wound heavy bleeding. - [AGE] year old female presents to the Emergency Department via Emergency Medical Service due to laceration to Left Lower Extremity sustained while Resident #1 was being moved out of wheelchair. - Exam: 21:36 (9:36 p.m.) Skin: Large flap laceration noted to left lower extremity around posterior calf region. Each of three sides measure about 10 centimeters and the laceration is deep down to the fascia, with primarily subcutaneous tissue exposure .Active bleeding noted . Record review of the Hospital History and Physical dated 02/21/16 for Resident #1 indicated: - Assessment and Plan: This is a [AGE] year-old female who came here with: 1. Fall with left lower extremity wound. The patient will receive plastic surgery this afternoon. Record review of the Hospital History and Physical/Discharge Summary dated 02/21/16 for Resident #1 indicated: - Assessment, Plan and Recommendations: Take the patient to the operating room and perform complex closure of the left lower extremity under local anesthesia. Observation on 02/25/16 from 10:25 - 10:45 a.m. of the resident beds indicated the following resident rooms had areas on the side rails that were sharp/uncovered and could cause a potential risk to residents: Resident room # ' s: Occupied by residents: A-4B, A-10B, B-3B, B-5A, B-5B, B-9B, B-10A, C-2B, D-1B, D-15B, E-12A and E15A. Beds not occupied by residents: B-10B,C-3B, C-6A, C-7B, E-6B. During an interview on 02/25/16 at 9:45 a.m. the Administrator said part of the investigation into the incident that involved Resident #1 showed that it may have been caused by her bed. He said they changed out her bed on 02/23/16 and they started padding and replacing side-rails on beds throughout the facility hall by hall and were almost finished. He said the Maintenance supervisor was in charge of checking the facility equipment regularly. The Administrator also said staff was supposed to place any issues with equipment on the maintenance book located at the nurses ' station. During an interview on 02/25/16 at 10:20 a.m. the Maintenance Supervisor demonstrated how he was padding and taping the resident side rails with uncovered areas that had sharp edges throughout the facility. He said he started in Hall D and he was going from hall to hall until they were all completed. Record review of the In-Services indicated: - 02/23/16 Environmental Hazards - Safety prevention, sharp items . check equipment/broken furniture. - 02/25/16 Report incidents and damaged equipment immediately to DON/Administrator and maintenance. Also add equipment to maintenance log to be corrected. -02/25/16 DON demonstrated equipment for beds. DON showed staff faulty equipment - vs. - correct equipment. DON showed staff how to make sure equipment is working correctly, how to remove resident from damaged equipment and who to report faulty equipment to. Put equipment information in the maintenance log book. Record review of the Accident/Incident Reporting policy, undated, indicated: All accidents or incidents involving residents . occurring on our premises must be investigated and reported to the administration .Review of Accident/Incident Reports: The risk manager, and/or DON and the Administrator will review all Accident/Incident Reports and follow up as is appropriate and necessary. Record review of the Job Description - Maintenance Supervisor, undated, indicated: This position organizes, directs and supervises the maintenance and repair program involving buildings and grounds. Duties and responsibilities: 7. Inspects all equipment and systems regularly for proper functioning and safety. Record review of the Equipment policy indicated: The facility shall provide routine equipment for the general use of the residents. The facility census listed 88 residents with 23 residents requiring assistance with transfers by 2-staff.

Based on observation, interview and record review the facility failed to ensure that patient care equipment was in safe operating condition for 1 of 11 residents reviewed for safety. (Resident #1) Resident #1 ' s leg was injured during a transfer by 2 staff from her wheelchair to her bed. She received a large cut to her left lower leg with a sharp edge in the bed that was missing a cap. She had to be transferred to the emergency room where she had complex plastic surgery of her left lower leg requiring 16 sutures. This failure affected 1 resident and placed 22 residents requiring 2-staff for transfers at risk for injury and unnecessary pain. Intakes: # 5 and # 4. Findings include: Resident #1: Record Review of Resident #1 ' s clinical file indicated she was [AGE] years old admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Admission Assessment Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was totally dependent of 2 person ' s for physical assist. Record review of the Quarterly MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 person ' s physical assist for transfers. Record review of the Comprehensive Care Plans for Resident #1 dated 09/25/15 indicated: The resident has an Activities of Daily Living (ADL) self-care performance deficit due to musculoskeletal impairment, limited mobility, impaired balance, disease process ([MEDICAL CONDITION] with [MEDICAL CONDITION].) Interventions: Transfer - The resident requires (EXTENSIVE assistance) by (one to two) staff to move between surfaces as necessary. Record review of the facility Admit/Discharge To/From Report dated 12/01/15 - 02/22/16 indicated Resident #1 was discharged to the hospital on [DATE]. Record review of the Provider Self-Reporting of Incidents forms indicated: - Date and time submitted: 02/22/16 at 4:48 p.m. - Date and time the facility first learned of the incident: 02/20/16 at 8:30 p.m. - Allegation: Neglect. - Client/Resident: Resident #1. Alleged Perpetrators: CNA A and CNA B. Details: Resident received a skin tear to her left lower leg during transfer from chair to bed per 2 CNA ' s A and B. Charge nurse was unable to control the bleeding and resident was transferred to the hospital. In an interview on 02/24/16 at 10:38 a.m. the Director of Nursing (DON) said she was notified of the incident with Resident #1 by LVN A at approximately 8:30 p.m. on 02/20/16. LVN A told her Resident #1 had a skin tear to the left leg and she could not control the bleeding. She said it occurred during a transfer. Resident #1 was sent to the hospital. She said LVN A did not tell her the actual size of the skin tear. The DON said to her knowledge Resident #1 did not end up having surgery. During an interview on 02/24/16 at 11:00 a.m. with Resident #1 ' s family member and Resident #3 (Resident #1 ' s roommate), they said Resident #3 was in the room when Resident #1 was injured. Resident #3 said she was in the B-bed and she saw 2 CNA ' s were transferring Resident #1 from the wheelchair to her bed in the A-bed side of the room. She said she heard Resident #1 holler Oh my leg . She said she looked over and saw a lot of blood on the resident and on the bed. The EMS took her to the hospital that night. Resident #3 said the facility removed the bed Resident #1 was in that night, moved it out, and brought a new bed into the room. Resident #3 said there was a sharp edge on the other bed when she got hurt. It was missing a cap. Interview and observation on 02/24/16 at 11:51 a.m. with the Housekeeping Supervisor he said he had moved Resident #1 ' s bed out of her room before she had returned from the hospital on [DATE]. He said he traded it with a different type of bed that was in resident room #D-9A. Observation of the bed at the time revealed that was unoccupied and had 2 areas on the bottom of the ¼ side rail that were now taped over. During an interview on 02/24/16 at 4:15 p.m. CNA A said she and CNA B were transferring Resident #1 from her wheelchair to her bed on Saturday night at around 8:00 pm, 02/20/16. She said they often transferred her with a sling, but they used a gait belt that night. They said that Resident #1 received an injury. CNA A said she did not see how the injury was caused, she just saw blood. She said she did not see the cut, so she could not say the size of it. When the surveyor pointed at the bed in Resident #1 ' s room, she said that was not the bed she had when she was injured. In further interview the bed in room D-9A was showed to CNA A . She said that was the bed Resident #1 was in previously and the 2 areas covered with tape were not covered that way before the injury. During an interview on 02/24/16 at 4:20 p.m. CNA B said she was working with Resident #1 the night of her injury. She said and CNA A were transferring her from the wheelchair to the bed. She said they lowered the bed and put the ¼ side rail down. She said she did not see what happened to Resident #1 ' s leg, she just saw a lot of blood on the bed and coming from the resident ' s leg. She said she saw the cut on her leg and described it as not small, but hard to say the size, there was a lot of blood . During an interview and observation on 02/24/16 at 4:32 p.m. with Wound Care Nurse she said Resident #1 had returned from the hospital on [DATE]. She said she had re-wrapped her wound in the morning and it measured 35 cm. Resident #1 was sitting in a Geri-chair. The Wound Care Nurse unwrapped the wound. The wound on Resident #1 ' s lower left leg was a very large flap of skin (4 inches long on two sides by 3 inches wide) with sutures on 3 sides. The sutures on the bottom 3 inch area had come loose and a 3 inch wide by 1 inch area was bright pink/red in color, with no skin covering it. Wound Care LVN C said the sutures had pulled away due to [MEDICAL CONDITION] or infection. Record review of the Weekly Skin Observation Tool dated 02/24/16 indicated Resident #1 had a trauma wound to her left lower leg that measured 35 length by 4 width by 0.2 depth. The nursing notes indicated: Re-Admit to facility 02/23/16. Has a trauma wound with 15 sutures, to the left lower leg, some of the sutures have dehiscence that is 4 cm wide. The suture site measures 35 cm. Record review of the Hospital Emergency Department Physician documentation record for Resident #1 indicated: - Arrival date: 02/20/16 Time: 21:15 (9:15 p.m.). - Chief Complaint: skin Tear(s), with complaints of Laceration. - Onset: The symptoms/episode began/occurred today. Associated signs and symptoms: wound heavy bleeding. - [AGE] year old female presents to the Emergency Department via Emergency Medical Service due to laceration to Left Lower Extremity sustained while Resident #1 was being moved out of wheelchair. - Exam: 21:36 (9:36 p.m.) Skin: Large flap laceration noted to left lower extremity around posterior calf region. Each of three sides measure about 10 centimeters and the laceration is deep down to the fascia, with primarily subcutaneous tissue exposure .Active bleeding noted . Record review of the Hospital History and Physical dated 02/21/16 for Resident #1 indicated: - Assessment and Plan: This is a [AGE] year-old female who came here with: 1. Fall with left lower extremity wound. The patient will receive plastic surgery this afternoon. Record review of the Hospital History and Physical/Discharge Summary dated 02/21/16 for Resident #1 indicated: - Assessment, Plan and Recommendations: Take the patient to the operating room and perform complex closure of the left lower extremity under local anesthesia. Observation on 02/25/16 from 10:25 - 10:45 a.m. of the resident beds indicated the following resident rooms had areas on the side rails that were sharp/uncovered and could cause a potential risk to residents: Resident room # ' s: Occupied by residents: A-4B, A-10B, B-3B, B-5A, B-5B, B-9B, B-10A, C-2B, D-1B, D-15B, E-12A and E15A. Beds not occupied by residents: B-10B,C-3B, C-6A, C-7B, E-6B. During an interview on 02/25/16 at 9:45 a.m. the Administrator said part of the investigation into the incident that involved Resident #1 showed that it may have been caused by her bed. He said they changed out her bed on 02/23/16 and they started padding and replacing side-rails on beds throughout the facility hall by hall and were almost finished. He said the Maintenance supervisor was in charge of checking the facility equipment regularly. The Administrator also said staff was supposed to place any issues with equipment on the maintenance book located at the nurses ' station. During an interview on 02/25/16 at 10:20 a.m. the Maintenance Supervisor demonstrated how he was padding and taping the resident side rails with uncovered areas that had sharp edges throughout the facility. He said he started in Hall D and he was going from hall to hall until they were all completed. Record review of the In-Services indicated: - 02/23/16 Environmental Hazards - Safety prevention, sharp items . check equipment/broken furniture. - 02/25/16 Report incidents and damaged equipment immediately to DON/Administrator and maintenance. Also add equipment to maintenance log to be corrected. -02/25/16 DON demonstrated equipment for beds. DON showed staff faulty equipment - vs. - correct equipment. DON showed staff how to make sure equipment is working correctly, how to remove resident from damaged equipment and who to report faulty equipment to. Put equipment information in the maintenance log book. Record review of the Accident/Incident Reporting policy, undated, indicated: All accidents or incidents involving residents . occurring on our premises must be investigated and reported to the administration .Review of Accident/Incident Reports: The risk manager, and/or DON and the Administrator will review all Accident/Incident Reports and follow up as is appropriate and necessary. Record review of the Job Description - Maintenance Supervisor, undated, indicated: This position organizes, directs and supervises the maintenance and repair program involving buildings and grounds. Duties and responsibilities: 7. Inspects all equipment and systems regularly for proper functioning and safety. Record review of the Equipment policy indicated: The facility shall provide routine equipment for the general use of the residents. The facility census listed 88 residents with 23 residents requiring assistance with transfers by 2-staff.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent the development of pressure ulcers and that residents with pressure sores received necessary treatments to promote healing for 1 of 22 residents (Resident # 10) who were reviewed for pressure sores. -Resident #1 developed a pressure sore on the left sacral area that worsened. - Resident #10 was not repositioned per his care plan, did not have skin assessments completed and did not have timely incontinent care to avoid further skin breakdown. These failures affected 1 resident and placed 10 other residents with pressure sores at risk of worsening of the sores and placed 66 residents receiving preventative skin care at risk of developing pressure ulcers. Findings: Record review of Resident #10 ' s face sheet revealed an admitted 12/4/13 with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #10 ' s initial MDS assessment dated [DATE] revealed that her BIMS score (Brief Interview for Mental Status) was 3 which suggested that her cognitive skills was severely impaired. Under Section G, she required extensive assistance with one person assist in areas of transfer, bed mobility, toilet use and personal hygiene. Under Section M: Skin Condition, Resident #10 was identified as a risk for developing pressure ulcers. She was assessed as not having any unhealed pressure ulcer or any ulcers, wounds and skin problems on admission. Record review of Resident #10 ' s Braden Scale dated 12/5/13 and 04/29/14 (used for Predicting Pressure Sore Risk), she scored 12 which indicated that Resident #10 was a high risk for development of pressure ulcer. Record review of Resident #10 ' s skin assessment revealed that she developed a Stage III pressure ulcer on the right heel on 3/11/14. The pressure ulcer on the right heel healed on 5/6/14. Record review of Resident #10 ' s clinical records revealed that there was no skin assessment done from 5/7/14 to 5/31/14. Record review of Resident #10 ' s care plan dated 5/31/14 revealed a care plan for a Stage III pressure ulcer on the left sacral gluteal that measured 2.5 cm x 1 cm. Interventions included: 1. Keep affected area clean and dry at all times. 2. Administer treatment ordered by MD. 3. Turn and reposition resident often to avoid further progression of affected area. 4. Provide incontinent care when incontinent to avoid further breakdown. 5. Weekly skin audits by licensed nurse. 6. Turn and reposition, off load. Observation of Resident #10 on 6/3/14 at 11:09 am during initial tour revealed that she was lying in bed with disheveled hair and long nails with a brown substance under the tips. She mumbled words that were not clearly understandable when asked. She was not interviewable. Observation of Resident #10 on 6/4/14 at 10:00 am revealed that she was lying in bed with eyes closed. Observation of Resident #10 on 6/4/14 revealed the following: 7:15 am - sitting in wheelchair next to her bed inside her room. 10:00 am - Resident #10 was observed for wound care and incontinent care and she was transferred to bed. After the incontinent care the resident was transferred back to wheelchair. 11:30 am- up in wheelchair inside her room. 12:30 pm - sitting in wheelchair in her room next to her bed. 12:45 pm- sitting in wheelchair in the dining room. 1:56 pm - sitting in wheelchair, asleep next to her bed. 2:45 pm - sitting in wheelchair, asleep next to her bed. 3:30 pm- sitting in wheelchair, asleep next to her bed. 4:00 pm - sitting in wheelchair, asleep next to her bed. 4:15 pm - sitting in wheelchair, asleep next to her bed. Resident #10 had a pommel cushion (rounded pommel designed to help prevent from sliding forward) on her wheelchair. Observation of Resident #10 on 6/4/14 at 10:48 am revealed that LVN B was doing wound care on Resident #10 ' s Stage III pressure ulcer on her left sacral gluteal. The pressure ulcer measured 3.5 cm x 1.5 cm. The wound bed had yellow slough. In an interview with LVN B, the treatment nurse, on 6/4/14 at 10:48 am stated she found out about the pressure ulcer on the sacral area last week. She said that since the pressure ulcer on the right heel had healed on 5/6/14, she was not in charge of doing the skin assessment. LVN B said that if a resident had no pressure ulcer, the charge nurses were the ones responsible for doing skin assessment. She said that she only did the skin assessments of residents with pressure ulcers. She said that skin assessments should be done weekly. In an interview with CNA EE on 6/4/14 at 10:52 am revealed that the nurse aides should report any skin breakdown to the nurse. In an interview with LVN L on 6/4/14 at 11:36 am revealed that there was no skin assessment on Resident #10 from 5/7/14 because she did not know that Resident #10 ' s pressure ulcer on the right heel was healed and that she should be the one doing the skin assessment. She said that she thought that the treatment nurse, LVN B was doing the skin assessment on Resident #10. Observation of Resident #10 on 6/5/14 revealed the following: 8:30 am - sitting in wheelchair in the dining room 9:30 am - sitting in wheelchair in her room next to her bed. 10:10 am - sitting in wheelchair in her room next to her bed. 10:30 am - sitting in wheelchair in her room next to her bed. 11:00 am - sitting in wheelchair in her room next to her bed. 11:40 am - sitting in wheelchair in her room next to her bed. 12:15 pm - sitting in wheelchair in her room next to her bed. 12:57 pm - sitting in wheelchair in the dining room. 2:00 pm - sitting in wheelchair next to her bed asleep. 2:45 pm - sitting in wheelchair next to her bed asleep. 3:30 pm - sitting in wheelchair next to her bed asleep. Observation of Resident #10 on 6/5/14 at 3:50 pm revealed that Resident #10 was transferred to bed. During transfer, Resident #10 grimacing. She said that she was hurting. Resident #10 was provided with incontinent care. Her brief was soaked with urine. The wound bed of the pressure ulcer on the left sacral gluteal was bright red with slough in the middle. In an interview at the time, the treatment nurse, LVN B, said that the pressure ulcer looked " worse than yesterday " . In an interview with the DON on 6/5/14 at 3:38 pm revealed that Resident #10 should not be up in the wheelchair for such a long amount of time because of the sacral pressure ulcer. She said that the nurse's aides should be checking on Resident #10 every 2 hours. The DON said that she would ask the nurse ' s aides to put Resident #10 to bed. Resident #10 had been observed to be in a wheelchair on 6/5/2014since 8:30 am. In an interview with Unit Manager II on 6/5/14 at 3:40 pm revealed that Resident #10 should not be up in the wheelchair for that long amount of time because it put pressure on the pressure ulcer. Record review of the facility ' s policy and procedures on Pressure Ulcers dated 10/18/14 revealed, read in parts, " ...Any new pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers ... " Record review of the facility ' s policy and procedures on Prevention of Pressure Ulcers dated 3/5/08 revealed, read in parts, " Interventions and Preventive Measures ...Place a minimum of a every 2 hour turning and reposition program, Positioning devices (e.g. pommel cushion) must be monitored to assure pressure is not being placed on the labia/scrotum, for chair-fast residents - postural alignment, weight distribution, sitting balance and stability should be elevated. Change position at least every 1-2 hours, Change position at least every hour and use foam, gel, or air cushion as indicated to relieve pressure; check resident for incontinence at least every 2 hours and clean skin when soiled, assess and treat urine leaks. Documention: the condition of the resident ' s skin will be documented weekly. Review of the facility's CMS form 672 revealed that there were 11 residents with pressure ulcers and 66 residents receiving preventive skin care.