Every finding on record at Texhoma Christian Care Center Inc

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, by failing to ensure: A. floors were swept and free from dirt and food crumbs. B. bottom shelves were clean. C. staff were wearing beard restraints. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: On 08/26/24 at 9:14 AM, during the initial tour of kitchen, the walk-in refrigerator #1 had spilled, dry milk on the floor in multiple areas, and underneath the shelves. In the corners and against the wall, there were dust and food crumbs. In the walk-in refrigerator #2, there were dirt and food crumbs underneath the shelves and along the walls. In the walk-in freezer in the kitchen area, the floor was dirty with dirt and food crumbs and trash underneath the shelves and along the walls. In the main kitchen, the bottom shelves were dirty with dirt and food crumbs. The cleaning schedule posted and initialed by the assigned staff as task completed. There was 1 male cook observed with facial hair not completely covered by the beard restraint, and his moustache and side and neck area were not covered. In a follow-up interview and observation of the kitchen on 08/29/24 at 9:00 AM, there was no change in the soiled floors. In the walk-in refrigerator #1, there was dry spilled milk in multiple areas and dust and food crumbs underneath the shelves and along the walls. [NAME] A stated the refrigerator was usually cleaned every Sunday, but she ran out of time, and it did not get done. She said there was a cleaning schedule that was followed and should be signed when completed. In the walk-in refrigerator #2, there was dirt and food crumbs underneath the shelves and along the walls. In the walk-in freezer, there were dirt, trash, and food crumbs underneath the shelves and around the walls. In the main kitchen, there was dirt and food crumbs underneath the shelves and along the wall. [NAME] B was observed preparing food at the stove. His beard restraint was crooked on his face failing to cover his facial hair. [NAME] B stated the beard restraint should cover his beard; he said he did not realize it was crooked on his face. He fixed his beard restraint but failed to cover his moustache and upper lip. He stated he did not know that his moustache and upper lip were supposed to be covered. [NAME] B stated there was a cleaning schedule and should be signed when completed. [NAME] C was observed having a short beard. He did not have on a beard restraint. [NAME] C stated he was normally clean shaven and didn't wear beard restraints. [NAME] C stated there was a cleaning schedule and should be signed when completed. In an interview with the Dietary Manager on 08/29/24 at 3:15 PM, he said the refrigerators and freezer should be cleaned weekly. He said if staff spills food, it was his expectation it was cleaned up at the time. He said the kitchen was cleaned daily, including sweeping the floors and cleaning the bottom shelves. There was a cleaning schedule that was posted daily, and staff should initial when completed. He said beard restraints should cover all facial hair including the upper lip and moustache. He said failure to do so posed a risk for infection and pests. In an interview with the Administrator on 08/29/24 at 3:35 PM, he said it was his expectation for the kitchen to be cleaned daily. If food was spilled, it should be cleaned up at that time. He said staff should wear hair restraints that cover all facial hair. Failure to do so had the potential for infection and pests. A record review of the facility policy Cleaning and Disinfection of Environmental Surfaces, dated as revised August 2019, revealed the following [in part]: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. A record review of the facility policy Professional Appearance in the Workplace, dated May 2022, revealed the following [in part]: Hair - Dietary employees shall wear, in kitchens and any foodservice area, hair restraints such as hats, hair covering or nets, beard restraints, and clothing that covers body hair, which are designed and worn effectively to keep hair from contacting food. Review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 7 residents (Residents #59 and #126) reviewed for comprehensive care plans. 1. Resident #59 developed cellulitis in her left forearm and a skin rash which covered her body. Physician ordered creams were applied to treat her skin. Resident #59's care plan was not revised and updated to address the development of skin conditions and the treatment of them. 2. Resident #126 was noted to have developed a skin rash during March 2024. Physician orders were obtained for creams to be applied to the affected areas. Resident #126's care plan was not revised and updated to address the development of skin conditions and the treatment of them. These failures placed the residents at risk for not receiving necessary care and services to meet their individual needs and to promote a feeling of wellbeing during daily life within their living environment. The findings included: 1. Review of Resident #59's Face Sheet, not dated, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: dementia; pruritis (itchy skin); contact dermatitis (an itchy rash caused by direct contact with a substance or an allergic reaction to it); and cellulitis of the left upper limb (bacterial skin infection characterized by swelling and redness). Review of Resident #59's Annual MDS Assessment, dated 7/30/24, revealed in Section M - skin treatments - the application of ointment other than feet was selected. Review of Resident #59's comprehensive care plan, dated as initiated 7/24/2023 and reviewed and revised on 8/05/2024, revealed it addressed the resident's risk for skin breakdown related to urinary incontinence. The care had not been revised and updated to address Resident #59's cellulitis or development of a rash/contact dermatitis. Review of Resident #59's physician orders revealed the following: - 5/02/24 triamcinolone acetonide cream 0.1%; apply a thin layer topical twice a day, continue until resolved. - 6/19/24 clotrimazole cream 1%; apply a thin amount topical twice a day, administer with triamcinolone cream to hand until healed. Review of Resident #59's Skin Integrity Event, dated 6/15/24, revealed the resident's left forearm had redness and was warm to touch and the skin to the palm of the hand was cracked and flaky with slight redness noted. Review of Resident #59's Physician Progress Note, dated 6/20/24, revealed documentation that the resident had a diffuse rash on trunk and arms, itching and scratching. The note documented the resident was on Bactrim DS BID for one week for cellulitis. The note documented possible dermatology consult. Review of Resident #59's Nursing Progress Notes revealed the following documentation: - 6/29/24 In room at this time. Applied triamcinolone cream to chest, back, and bilateral upper extremities. Clotrimazole cream applied to palms of hands. Note rash fading. Skin palm of hands improving. Redness to left forearm is resolving. - 7/01/24 Continue to monitor resolving rash to skin to abdomen, back, thighs, flanks. Resident denies pain or active itching, no redness to skin under breast or abdominal folds at this time, continues to receive triamcinolone cream to areas of affected skin. Clotrimazole cream to hands. - 7/16/24 Continue to monitor extensive rash to bilateral upper extremities, chest, bilateral lower extremities, and torso. Scabs to scalp noted. - 7/21/24 Refused shower, states I will later, not now. Compliant with triamcinolone cream treatment. Continue to note rash with picked scabs to upper bilateral extremities and shins. Red bumps to back of neck at hairline, torso, and chest. Scabs also noted to posterior scalp. - 7/25/24 Continue to note rash to skin, picked areas with scabbing to abdomen, buttocks, flanks, bilateral upper extremities and bilateral lower extremities. Triamcinolone cream administered, tolerated well. Rash to hands resolved, no peeling or scaly skin. Scab to left forearm, no sign of infection. During an interview and record review on 8/30/24 at 3:56 PM, the MDS Coordinator reviewed Resident #59's electronic health record documents and physician progress notes and stated she did not see a dermatology consult note. She reviewed Resident #59's care plan and stated she did not see a care plan addressing the resident's skin rash. 2. Review of Resident #126's Face Sheet, not dated, revealed a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: dementia; tinea corporis (fungal infection of the skin); and pruritis (itchy skin). Review of Resident #126's Annual MDS Assessment, dated 2/25/2024, revealed in Section M - skin treatments - the application of ointment other than feet was selected. Review of Resident #126's Quarterly MDS Assessment, dated 8/04/2024, revealed it documented a BIMS score of 3 out of 15 (severe cognitive impairment) and in Section M - skin treatments - the application of ointment other than feet was selected. Review of Resident #126's comprehensive care plan, dated as initiated 3/08/2023, revealed a care plan dated 2/28/2024 that addressed risk for skin break down related to urinary incontinence. The care plan was dated as reviewed and revised 8/05/2024 and had not been updated to address the resident's skin rash and physician ordered topical treatment. Review of Resident #126's Physician Visit progress note, dated 1/09/2024, revealed documentation of a chief complaint of the resident picking the skin on his forearms causing bleeding and itching. The physician's assessment and plan documented pruritis on upper extremities and self-inflicted skin excoriations. An order was documented to start Hydroxyzine 25 mg every 6 hours PRN for 6 weeks and to redirect the patient to abstain from picking the skin on his upper extremities. Review of Resident #126's physician orders revealed an order dated 4/23/2024 for miconazole nitrate cream 2% topical to all rash areas. Special Instructions: APPLY BID ON RASH AREAS TO (R) BILATERAL THIGHS. Twice A Day. Review of Resident #126's Nursing Progress Notes revealed the following documentation [in part]: - 3/06/24 SKIN: Redness noted to coccyx, red bumps noted to bilateral thighs. No other skin issues noted at this time. - 3/21/24 SKIN: Red bumps noted to bilateral thighs. No other skin issues noted at this time. - 8/16/24 Continue to note symptoms of rash to right thigh, Hydrocortisone cream applied, tolerated well. Diagnosis: pruritis. - 08/25/24 Resident noted to have rash to right lower extremity, cream applied and small scab to right upper extremity with no signs or symptoms of infection. During an interview and record review on 8/30/24 at 3:45 PM, the MDS Coordinator reviewed Resident #126's care plan. She stated she thought she had done a care plan for the resident's rash and stated she could not locate a care plan addressing the resident's rash. Review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered, dated as revised March 2022, revealed the following [in part]: Policy Statement A comprehensive care plan is developed and implemented for each resident. Policy Interpretation and Implementation 6. The comprehensive care plan: g. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 10. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes .

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 3 (Treatment Cart 1, Treatment Cart 2, and Medication Cart 1300) of 8 carts observed for medication storage. The facility failed to ensure Treatment Cart 1, Treatment Cart 2 and Medication Cart 1300 were locked and secure. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: In an observation on 8/28/24 at 4:19 PM revealed Treatment Cart 1 and Treatment Cart 2 on east side nurses' station of the new building were unlocked and unattended. The following medications were noted to be in the drawers of both Treatment Cart 1 and Treatment Cart 2: insulin, hypodermic needles, resident private health information, medicated ointments. In an interview on 8/28/24 at 4:21 PM LVN A stated, I was on other cart, so I forgot to lock it. In an interview on 8/28/29 at 4:24 PM the ADON stated the carts are supposed to be locked and I don't know why its unlocked. In an interview on 8/28/24 at 4:35 PM with the Administrator regarding treatment cart unlocked, the Administrator stated that it was his expectation for carts with medication to be locked. In an observation on 8/29/24 at 10:45 AM revealed medication cart 1300 unlocked and unattended. Observation of medications that were in unlocked cart included: over the counter medications, prescription cards with medications for residents, narcotic box (box was locked within open drawer). In an interview on 8/29/24 at 10:47 AM with RN B regarding unlocked medication cart, RN B stated, it's the med aids cart but she ran on a break, I have her keys, but I didn't know she didn't lock it. In an interview on 8/29/24 at 10:49 AM MA C stated, I am supposed to lock my medication cart any time I walk away, I could have sworn I locked it. When asked about adverse outcome, MA C stated, someone could get into it, it could be a bad thing. In an interview on 8/29/24 at 12:17 PM the ADON stated the expectation was medication and treatment carts must be locked at all times if not in view of staff assigned to carts. The ADON further stated failure to secure carts could result in residents' allergic reaction or drug diversion. In an interview on 8/29/24 at 3:08 PM the DON stated that it was her expectation for the carts (medication and treatment carts) to be locked when not in use or in direct view of nurse. The DON stated that failure to do so could result in resident getting into medication cart and result in a drug diversion. Record review of the policy and procedure titled Security of Medication dated April 2007 revealed the following: Policy statement: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation: 1) The nurse shall secure the medication cart during the medication pass to prevent unauthorized entry. 2) The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3) Medication carts must be securely locked at all times when out of the nurse's view. 4) When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of 2 residents reviewed for infection control practices in that: RN A failed to perform hand hygiene, wash hands, change gloves and prevent cross contamination while providing wound care for Resident #1. These failures could affect the residents by placing them at risk for the spread of infection. Finding included: Review of Resident #1's Face Sheet dated 02/08/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of non-pressure ulcers, urinary tract infection, exposure to covid-19, and candidiasis. Review of Resident #1's Minimum Data Set (MDS) Assessment undated revealed Resident #1 required total assistance with most activities of daily living (ADLs) and was always incontinent of bowel and bladder. Review of Resident #1's care plan dated 08/03/22 revealed he was at risk pressure ulcers and skin breakdown related poor intake, abnormal labs, incontinence, and impaired mobility. Observation of wound care on Resident #1 on 02/08/24 at 11:30 a.m. revealed RN A did not wash hands but donned gloves before the start of care. She prepared a clean field on a paper spreader. RN A communicated and positioned Resident #1. She removed old dressing revealing a thin reddish clear dry wound on the left heel. RN A cleansed the wound with normal saline and patted dry. She did not wash hands, change gloves, or perform hand hygiene before retrieving the clean kerlix gauze bandage roll. As RN A was covering the wound with the kerlix gauze, it fell on the floor. She picked it up and continued to use it to cover the wound. RN A did not change or replace the dressing. In an interview on 02/08/24 at 11:46 a.m. with RN A, she said he had been employed in the facility for one year. She noted she received infection control training in November 2023. RN A stated she should have washed her hands, performed hand hygiene before retrieving the clean kerlix gauze. She said cross contamination was mixing clean with dirty and the resident could get sick if good infection practice was not followed. During an interview with the ADON on 02/08/24 at 4:23 p.m. she acknowledged he was aware of some of the concerns raised about infection control practices. The DON stated she expected the nurses to wash hands and change gloves at appropriate times while providing wound care. Review of the facility's hand washing/hand hygiene policy revised August 2019 reflected, The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and implementation: 1) All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2) All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors . 3) Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a) When hands are visibly soiled and b) After contact with a resident with infectious diarrhea including, but not limited to infections caused norovirus, salmonella, shigella and C. difficile.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for kitchen sanitation, where male staff with beards and mustaches (FSS. FSM, FSW A, FSW B and FSW C) were not wearing beard restraints. The facility failed to ensure staff (FSS, FSM and FSW A, FSW B and FSW C) wore appropriate hair restraints while working in the kitchen. This failure could place residents at risk of food borne illness, and contaminated food. Findings include: Observation on 07/03/2023 at 09:05 AM, in the main dining kitchen revealed, the FSS walked around inside the kitchen without covering his beard and mustache. The FSS' whole face was covered by his beard and the length was longer than a stubble (1/4 to 1/2 inch in length) and his mustache covered his upper lip and blended into his beard. Observation on 07/03/2023 at 09:05 AM, in the main dining kitchen, revealed FSW A prepared lunch and did not wear a beard and mustache restraint. The length of FSW A's beard was between 1/4 to 1/2 inch in length, and his mustache covered his upper lip. Observation on 07/03/2023 at 09:13 AM, in the main dining kitchen, revealed the FSM worked in the kitchen and did not wear a beard or mustache restraint. Observation on 07/03/2023 at 09:20 AM, in the main dining kitchen, revealed FSW C worked in the kitchen during meal preparation and did not wear a beard restraint to cover his beard. Observation on 07/03/2023 at 11:58 AM, in the ancillary kitchen (used only to keep food hot while waiting to serve residents, no cooking was done here) FSW B plated food for residents and did not have a restraint or mask to cover his goatee/mustache. Observation on 07/04/2023 at 09:30 AM, in the main dining kitchen Revealed FSW A wore beard restraint, however it did not cover his mustache and left his upper lip exposed. FSW C's wore a beard restraint and did not contain/cover his beard on the lower part of his neck. In an interview on 07/03/2023 at 09:22 AM with FSW A, the FSW A said the facility allowed them to wear short beards as long as it did not exceed a certain length which he did not identify. In an interview with the ADM on 07/30/2023 at 2:33 PM, the ADM said all the training for the kitchen was what he learned from his administrator courses, and he thought beard restraints were not required. The ADM said he relied on the FSS for that information and the FSS told him beards were acceptable if, they were no longer than one-half inch in length. In an interview on 07/04/2023 at 09:30 AM, the FSS said he thought beards not exceeding 1/2 inch in length were acceptable and did not need to be covered. The FSS said a negative resident outcome on finding hair in the resident's food might be a loss of trust in the kitchen and a dislike of the food the hair was found in. In an interview on 07/05/2023 at 11:50 AM with the ADM, the ADM said his facility's policy would allow male staff to have beards up to 1/2 inch in length without wearing a beard restraint but decided to have his male staff cover their beards while he waited for the local health department to tell him their expectations. He then admitted he found the regulation that applied to hair coverings and had the facility policy revised on 07/05/2023. Record review of the 2022 Food Code of the U.S. Food and Drug Administration, January 18, 2023, Version revealed in part: Section 2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Record review of a facility document titled Professional Appearance in the Workplace, from the Employee Handbook, dated May 2022, revealed in part: Facial Hair - all facial hair shall be groomed and not to exceed 1/2 inch in length without the use of a beard guard when in any food service area throughout the facility.

Based on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 or 3 Residents (Resident #18, Resident #94, and Resident #125) reviewed for accommodation of needs. The facility failed to provide dining tables with the appropriate height to accommodate residents' needs and preferences for Resident #18, Resident #94, and Resident #125. This failure could place residents at risk of decreased nutritional intake and weight loss. Findings include: 1. Record review of Resident #18's, undated, face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included senile degeneration of brain (dementia - a group of symptoms that affects memory, thinking and interferes with daily life) and idiopathic scoliosis (an abnormal curvature of the spine). Record review of Resident #18's Quarterly MDS, dated [DATE], revealed a BIMS score of score of 1, which indicated (severe impairment). Section G revealed Resident #18 required extensive assistance with transfers and used a wheelchair for mobility . 2. Record review of Resident #94's, undated, face sheet, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included unspecific dementia (a group of symptoms that affects memory, thinking and interferes with daily life), repeated falls, dizziness and giddiness, fracture of unspecified part of neck and right femur - right hip pinning (broken right hip). Record review of Resident #94's Quarterly MDS, dated [DATE] revealed a BIMS score of score of 3, which indicated (severe impairment). Section G revealed Resident #94 required total dependence with transfers and used a wheelchair for mobility. 3. Record review of Resident #125's, undated, face sheet, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anterior dislocation of right hip, osteoporosis of right hip (a skeletal disorder characterized by low bone mass leading to bone fragility and increase in bone fracture), generalized muscle weakness, and abnormal posture. Record review of Resident #125's Admission Assessment MDS, dated [DATE], revealed a BIMS score of score of 2, which indicated (severe impairment). Section G revealed Resident #94 required extensive assistance with transfers and used a wheelchair for mobility. In an observation on the 800-hallway dining room, on 07/03/23 at 12:20 PM revealed, Resident #18 was sitting at a table eating her lunch in a low wheelchair. The height of the table was to the resident's upper chest. The resident's plate of food was sitting on the table which required the resident to reach up her arms above her shoulders to get the food off her plate. The resident was eating unassisted. The resident was not interviewable and failed to answer if the table was too high for her . Resident #94 was observed sitting at a table eating her lunch in a low wheelchair. The height of the table was to the resident's neck. The resident's plate of food sat in her lap. The resident was eating unassisted. The resident was not interviewable and failed to answer if the table was too high for her. In an observation in the 800-hallway dining room, on 07/06/23 at 11:47 AM revealed, Resident #18 was sitting in a low wheelchair with the height of the table to the resident's chin. The resident's plate of food was on the table, which required the resident to reach up to eat her food. The resident was not interviewable and failed to state if the table was too high. At that time, a CNA came and raised up her wheelchair which changed the height of the table to the resident's upper chest. The resident still had to lift her arms to eat her food. The resident was eating unassisted. Resident #94 was observed sitting at a table eating her lunch in a low wheelchair. The height of the table was to the resident's chin. The resident had her plate of food sitting in her lap. The resident was eating unassisted. The resident was not interviewable and failed to answer if the table was too high for her. In an interview on 07/06/23 at 11:48 AM, LVN E said Resident #18's wheelchair could be raised up which helped. Resident #94 always ate with her plate of food in her lap. She was unsure if the height of the tables could be lowered. In an observation and interview in the dining room in the north building, on 07/06/23 at 11:55 AM, Resident #125 was observed sitting in a low wheelchair. The height of the table went up to her neck. The resident's plate of food was sitting on the table, which required the resident to reach up to eat her food. The resident was eating unassisted. The State Surveyor asked Resident #125 if the table was too high, she stated probably . In an interview on 07/06/23 at 1:37 PM, the DON said the tables were adjustable in the dining rooms. She said it was her expectation that the tables would be placed at the appropriate height as not to be an obstruction to the resident's ability to feed themselves. She said a possible negative outcome would be a dignity issue as the resident's would not be able to feed themselves which could result in a possible decline in functioning and health. A facility policy was requested but the DON stated there was no policy regarding this situation . A policy was requested but not provided by the time of exit. The Administrator said there was not a policy that addressed table height of residents.

Based on observations, 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 (Resident #55 and Resident #28) of 2 residents (Residents #55 and #28) reviewed for infection control. techniques in that: 1. The facility failed to ensure the 400 hall Hospitality Aide washed or sanitized her hands in between rooms. 2. The facility failed to ensure the 400 hall Hospitality Aide closed the ice chest lid in the hallway while passing ice to Resident #55 and Resident #28 . These failures could place residents at risk of infections. The findings were: 1. Record review of Resident #55's face sheet, dated 07/05/2023, revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Hypertension (high blood pressure) and Obesity (excessive body weight). Record review of Resident #55's Quarterly MDS assessment, dated 05/17/2023, revealed the following: Section C revealed a staff assessment of the BIMS score of 14, which indicated (cognitively intact cognition). Section G revealed the resident required set up help only with eating. 2. Record review of Resident #28's face sheet, dated 07/05/2023, revealed Resident #28 was an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis ofdiagnoses which included Cerebrovascular Accident (stroke) and Bronchitis (inflammation of the mucous membrane in the bronchial tubes). Record review of Resident #28's Quarterly MDS Admission assessment, dated 03/25/2023, revealed the following: Section C revealed a staff assessment of the BIMS score of 9, which indicated (moderately impaired cognition). Section G revealed the resident required set up help only with eating. Observation and interview on 07/05/2023 at 3:30 PM revealed the Hospitality Aide passing passed ice and water to Resident #55 and Resident #28. During this observation the Hospitality Aide was observed bringing Resident #55's ice cup out into the hallway to an ice chest filling it with ice using an ice scoop and pouring water into the cup from a water pitcher and taking taking it back into the residents' room leaving the ice chest lid open in the hallway, then returning returned to the ice chest and proceeding proceeded to Resident #28's room and retrieving retrieved her ice cup and filling filled it with ice and water. The Hospitality Aide left the ice chest lid open and did not perform hand hygiene between residents after touching the residents bedside table. Interview on 07/05/23 at 3:40 PM the Hospitality Aide stated, When asked why she had not performed hand hygiene in between resident's , she stated, she knew she was supposed to wash or sanitize her hands between resident to resident care and she further stated and I'm supposed to close the ice chest lid when I get ice from it , but I I didn't do it. She stated, and not washing my her hands in between residents could spread germs and disease . Interview on 07/05/2023 at 3:45 PM, the ADON revealed, all of the CNA's and Hospitality aides were trained to perform hand hygiene before and after resident care. Interview on 07/05/2023 at 3:55 PM, the DON revealed, hand hygiene is was to be performed before during and after all resident care and not doing so would promote the spread of disease. The DON stated the facility did not have a policy for passing ice, but all of the staff was were trained on hand hygiene . Interview on 07/05/2023 at 4:15 PM, the Administrator stated, the facility did not have a particular policy on passing ice, however, the Administrator I expected everyone staff to use best practice , which was to wash or sanitize his or her hands before and after providing any type of resident care and not doing so could cause the spread of disease. The facility did not provide surveyor a policy on hand hygiene.

41871 45437 Based on interview and record review the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment prepared by an interdisciplinary team for 6 of 12 residents (Resident #30, Resident #47, Resident #84, Resident #90, Resident #110, and Resident #119) reviewed for care plan timing and revision. The facility failed to ensure Resident #30, Resident #47, Resident #84, Resident #90, Resident #110, and Resident #119 had a comprehensive care plan developed and updated within 7 days following the completion of the admission comprehensive assessment. This failure could place residents at risk of not having their care plans completed, accurately and timely. Findings include: 1. Record review of Resident #30's face sheet, dated 07/05/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30's primary diagnosis included senile degeneration of the brain (a decline in cognitive abilities that impacts a person's ability to do everyday activities - dementia). Record review of Resident #30's Annual MDS Assessment, dated 05/28/2023, revealed the resident had a BIMS score which was blank, which indicated the resident was not able to complete the assessment. Record review of Resident #30's care plans revealed the facility developed a care plan on 04/27/2023 and conducted an IDT Care Conference on 04/27/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS dated [DATE]. 2. Record review of Resident #47's face sheet, dated 07/06/2023, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47's primary diagnosis included senile degeneration of the brain (a decline in cognitive abilities that impacts a person's ability to do everyday activities - dementia). Record review of Resident's #47's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 3 which indicated severe impairment. Record review of Resident #47's care plans revealed the facility developed a care plan on 02/15/2023 and conducted an IDT Care Conference on 02/15/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS, dated [DATE]. 3. Record review of Resident #84'sface sheet, dated 07/05/2023, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #84's primary diagnoses included unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), psychoactive disturbance (changes in mood, awareness, thoughts, feelings and behaviors), and anxiety (state of anxiousness). Record review of Resident's #84's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 3, which indicated severe impairment. Record review of Resident #84's care plans revealed the facility developed a care plan on 02/15/2023 and conducted an IDT Care Conference on 02/23/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS, dated [DATE]. 4. Record review of Resident #90's face sheet, dated 07/05/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #90's primary diagnoses included Pneumonia (an inflammation of the lungs) and seizure Disorder (a sudden uncontrolled burst of electrical activity in the brain). Record review of Resident #90's Significant Change MDS Assessment, dated 05/01/2023, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #90's care plans revealed the facility developed a care plan on 05/16/2023 and conducted an IDT Care Conference on 05/16/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Significant change MDS, dated [DATE]. 5. Record review of Resident #110's face sheet, dated 07/06/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #110's primary diagnosis included senile degeneration of the brain (a decline in cognitive abilities that impacts a person's ability to do everyday activities - dementia). Record review of Resident's #110's Annual MDS, dated [DATE] revealed the resident had a BIMS score of 3, which indicated severe impairment. Record review of Resident #110's care plans revealed the facility developed a care plan on 06/30/2023 and conducted an IDT Care Conference on 06/08/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS, dated [DATE]. 6. Record review of Resident #118's face sheet, dated 07/06/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #118's had diagnoses which included vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), psychotic disturbance (a condition of the mind that results in difficulties determining what is real and what is not real), mood disturbance (a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature), and anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events). Record review of Resident's #118's Significant Change in Condition MDS, dated [DATE], revealed the resident had a BIMS score of 1, which indicated severe impairment. Record review of Resident #118's care plans revealed the facility developed a care plan on 06/29/2023 and conducted an IDT Care Conference on 06/29/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Significant Change in Condition MDS, dated [DATE]. In an interview on 07/05/2023 at 2:55 PM, the MDS Coordinator revealed the care plan schedule and care plans did not go along with the MDS schedule. She said they always conducted the care plans before the MDS was completed and she did not realize their policy stated to complete it after the comprehensive MDS was completed. She said she could see how the failure would place the residents at risk of not having the care plan reflect what the MDS assessment showed, which would result in an inadequate care plan. Record review of the facility's care planning policy, dated 2001, and revised in December 2016, titled Care Plans, Comprehensive Person- Centered revealed: The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

Based on interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #30) reviewed for unnecessary psychotropic medications. Resident #30 had an order and administered Depakote (an anticonvulsant medication) and Risperdal (antipsychotic) for a diagnosis of unspecified psychosis not due to a substance or known physiological condition, which was not an appropriate indication for use. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms. The findings include: Record review of Resident #30's face sheet, dated 07/05/2023, revealed a [AGE] year-old female who's most recent admission to the facility was 10/22/2020. The resident had a diagnosis which included unspecified dementia with behavioral disturbance (a group of symptoms that affects memory, thinking and interferes with daily life with behavioral and psychological symptoms such as agitation, anxiety, and psychosis). Record review of Resident #30's Physician Order Report, for 06/07/2023 to 07/06/2023, revealed an order for Depakote (divalproex), 500 mg, twice a day, for unspecified psychosis not due to a substance or known physiological condition, with a start date of 05/14/2023. Risperdal (risperidone) 1 mg at bedtime, for unspecified psychosis not due to a substance or known physiological condition, with a start date of 05/14/2023 . Record review of Resident #30's Care Plan, last reviewed/revised 06/02/2023, revealed a care plan for Psychotropic Drug Use - Risk for adverse psychotropic side effects., Resident #30 was treated with an antipsychotic. Record review of Resident #30's Annual MDS, dated [DATE], revealed in Section C, a Brief Interview of Mental Status was not conducted due to the resident was rarely/never understood., Section N revealed, the resident received antipsychotic medications 7 of 7 days and antipsychotics were received on a routine basis only. In an interview on 07/06/2023 at 2:21 PM, the DON said her expectation was for nursing to communicate with the doctor to ensure a medication had a correct diagnosis. She said possible negative outcomes would be a resident would receive an unnecessary medication and experience side effects to the medication . Record review of the website drugs.com, https://www.drugs.com/depakote.html, accessed on 07/07/2023, revealed Depakote therapeutic class is an anticonvulsant that can be used as an adjunctive therapy to treat manic episodes associated with bipolar disorder; and revealed, https://www.drugs.com/risperdal.html, Risperdal therapeutic class is an antipsychotic used to treat schizophrenia and bi-polar disorder. Record review of the facility's policy titled Antipsychotic Medication Use, dated as revised December 2016, revealed the following [in part]: Policy Interpretation and Implementation: 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured, stored, and labeled in accordance with currently accepted professional principles for 2 of 4 medication carts: A. Medication cart #1 had intravenous [MEDICATION(S)], intravenous tubing, air freshener spray, Lysol spray, drug destruction liquid , (a liquid to destroy medications of all routes of administration) and pudding stored together in the bottom drawer. The drawers of the cart had oral medications, nasal inhalants, and oral inhalants all stored in one compartment B. The bottom drawer of the Medication cart #1, contained a soiled package of Intravenous tubing, a soiled bottle of medication destruction liquid and loose pills. The bottom drawer was soiled and covered with a sticky, dried brown substance. C. Medication cart #2 had oral medications in individual bottles, nasal inhalant medications, and oral inhalant medication stored together in a plastic zip lock bag. A one-half gallon bottle of oral drug destruction liquid was stored in the bottom of the cart. These failure could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications, medication via an incorrect route or ineffective therapeutic dosage and possible contamination by another agent or medication. The findings include: On 06/15/22 at 9:28 AM an observation of Medication cart #1 revealed the drawers of the cart had oral medications, nasal inhalants, and oral inhalants all stored in one compartment together. Medication cart #1 also had Lysol disinfectant spray, vanilla pudding, one package of labeled, unused [MEDICATION(S)] flush syringes, and a package of soiled intravenous tubing stored in the drawer with a bottle of drug destruction liquid. There were 2 unidentified yellow pills laying loose in the bottom of the drawer. The bottom of the drawer and the label and side of the drug destruction liquid container were soiled with a dried, brown sticky substance. On 06 /15/22 at 9:35 AM an observation of Medication Cart #2 revealed bottle prescription and over the counter medications (nasal inhalants, oral inhalant, and oral medications) all belonging to one resident were stored together in a plastic bag. The half-gallon bottle of drug destruction liquid was stored in the bottom drawer with two loose, yellow pills laying there . An interview on 06/15/22 at 9:42 AM with LVN B revealed she had accepted Medication cart #1 when she came on duty. She stated she had used the drug destruction liquid during the medication pass and should have cleaned the cart when she accepted it. She stated storing pudding, disinfectant spray, loose pills, and oral inhalers of different routes of administration in the same compartment could result in the medications being given via the wrong route or result in cross contamination and the spread of infection. She stated it was each nurse's responsibility, during their shift, to see that med carts were kept clean and medications of different routes were not stored in the same compartment She stated the medications and the soiled package of tubing should not be used due to possible contamination by another substance. An interview on 06/15/22at 10:00 AM with LVN C, who was responsible for medication cart #2 revealed she knew that carts should be cleaned, and medications of different routes should not be stored in the same compartment. She stated storing medications together could result in the wrong route of administration or contamination by another substance. She stated each nurse was responsible for keeping the medication cart that they were assigned to clean and that she would not use intravenous tubing in soiled packaging, she would discard it immediately. She stated medication carts shoudlbe cleaned when they became soiled. She stated that she understood chemicals should not be stored with food and medications, and the drug destruction liquid should probably be stored in a different location. In an interview on at 10:00 AM ADON F stated under no circumstances should pudding, disinfectant spray, loose pills, and oral inhalers for different residents be in the same compartment. She stated those items should be stored separately due to the risk of cross contamination and the spread of infection. She stated it was each nurse's responsibility to see that med carts were kept clean, and medications of different routes were not stored in the same compartment during their shift. She stated the [MEDICATION(S)] injectable syringes and the loose pills and the soiled package of tubing should be discarded immediately. She stated she did not monitor the med carts for cleanliness, but she would begin to do so. In an interview on at 11:10 AM the DON revealed it was each nurse's responsibility and her expectation that medication carts be kept clean, and drugs should be stored according to the appropriate route and use. She stated storing medications of different routes and chemical agents could cause the spread of infections and unwanted medical side effects. She stated it was her expectation that nurses be responsible for cleaning their own carts and keep the medications stored according to the route they are administered. She stated ADON F trusted the LVN's to monitor themselves and keep the carts clean, but the ADON'S would be responsible for monitoring to ensure the carts were kept clean on a regular basis from this point forward. Record review of the facility policy titled Storage of Medications dated revised April 2007, revealed in part: 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from regular medications. 8. Drugs shall be stored in an orderly manner in cabinets, rooms, refrigerators, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility mixing medications of several residents. The policy did not address medications of different routes being kept separate. Review of the SDS (safety Data Sheet) for the drug destruction liquid provided by the DON revealed in part: Trade Name: Rx destroyer 2. Hazardous Identification. - Classification of the substance or mixture: The product does not need classification according to OSHA Hicom Standard 29 CFR paragraph (d) of Sec1910.122(g) and GHS (Globally Harmonized System Revision 3) NFPA Rating (National Fire Protection Association) scale (0 - 4). HMIS H Health + 1 Fire+0 Reactivity = 0 HMIS Rating (Hazardous Materials Identification) = 1 (low risk for health) First aide skin contact: generally, the product does not irritate the skin, After eye contact: rinse open eyes for several minutes under running water. If ingested and symptoms occur notify the physician. The usual precautionary measures for handling chemicals should be used. No hand protection required.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 3 residents (Residents #77 and #62) reviewed for infection control (incontinent care). CNA E failed to wash or sanitize her hands before and during incontinent care for Resident #'s 62 and 77. NA Student D failed to sanitize her hands between glove changes and when going from a dirty to a clean area during incontinent care for Resident #'s 62 and 77. These deficient practices placed residents at risk for cross contamination and/or acquiring an infection. Findings include: Resident# 62: Review of Resident 62's face sheet, not dated, revealed Resident #62 was a [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's Annual MDS, dated [DATE] revealed the resident's BIMS score was a 2, (indicating severe cognitive impairment) and Resident #62 required supervision with the support of 1 staff for toileting . During an observation on 06/14/22 at 10:30 AM CNA E and Student NA D provided incontinent care to Resident #62. CNA E and Student NA D entered Resident #62's room. CNA E donned gloves without washing or sanitizing her hands prior to assisting the resident to beginning the procedure. CNA E removed Resident #62's brief, which was soiled with urine. CNA E did not change gloves or wash or sanitize her hands. Student NA D then cleaned Resident #62's perianal area with wipes. Student NA D did not change gloves or wash or sanitize her hands before placing a clean brief on the resident and adjusting her clean clothing . Resident #77: Review of Resident #77's face sheet, not dated, revealed Resident #77 was a [AGE] year-old male originally admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #77's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was a 1, (indicating severe cognitive impairment). Resident #77 required extensive assistance with the support of one staff for toileting, personal hygiene, and was always incontinent of bowel and bladder. Review of Resident # 77's care plan revealed the resident had a self-care deficit and required extensive assistance with personal hygiene, and toileting. Interventions included: provide consistency in caregivers as much as possible and provide assistance with incontinent care as needed. During an observation on 06/14/22 at 10:54 AM CNA E and Student NA D provided incontinent care to Resident #77. CNA E did not wash her hands before applying gloves to begin the incontinent care. Student NA D loosened the brief and both Student NA D and CNA E removed the resident's pants. Student NA D cleansed the head of the penis and replaced the foreskin after cleaning. CNA E then cleaned the rectal area and obtained a clean brief. She adjusted a new brief underneath Resident #77. CNA E and Student NA D did not change gloves and perform hand hygiene after providing incontinent care ,applying a new brief and clean pants, and exiting the room. During an interview on 6/14/22 at 11:15 AM, CNA E stated she normally performed hand hygiene after completing incontinent care and after glove changes. She stated she should have changed her gloves when moving from a dirty area to the clean area. She stated the failure to perform hand hygiene could increase the risk of infections. She stated that she had been trained and checked off on incontinent care by the ADON. During an interview on 6/14/22 at 11:30 AM, LVN A stated it was her expectation that CNA's and all staff should change gloves and perform hand hygiene after resident contact and, when going from a dirty to a clean area during resident care. She stated it was her responsibility to monitor the CNA's during her shift to see that they were using good infection control practices. She stated failure to perform hand hygiene properly could cause infections. During an interview on 6/14/22 at 11:40 AM, Student NA D stated she normally performed hand hygiene before beginning a procedure and after completing a procedure. She stated she should have performed hand hygiene when moving from a dirty area to a clean area and when she changed gloves . She stated failure to perform hand hygiene could increase the risk of infections. She stated she had been trained and checked off on incontinent care by the ADON . During an interview on 06/15/22 at 11:10 AM, the DON stated she expected staff to remove their gloves and either wash or sanitize their hands after touching a dirty area prior to moving to a clean area when performing incontinent care and between glove changes. She stated all staff had been trained on that procedure. She stated she did not know why Student NA D and CNA E failed to perform hand hygiene at the appropriate times. She stated it was the responsibility of the ADON's to do competency checks on all CNA's on hire and yearly. She stated she would do additional in-service training with staff regarding infection control and incontinent care. She stated failure to perform hand hygiene during resident care placed the resident at risk for infection. Review of the facility policy titled Handwashing/Hand Hygiene dated August 2019, revealed the following elements in part: The facility considers hand hygiene the primary means to prevent the spread of infection. Use an alcohol-based hand rub containing at least 65 % alcohol, or alternatively soap and water: before going from a contaminated body site to a clean site, after contact with a resident's intact skin, after removing gloves. Hand hygiene . Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities (Third Edition 2000), Procedural Guideline #24-Perineal Care/Incontinent Care Female (with or without catheter), revealed the following elements: B 1. a. Wash hands 6. Wash hands and put on clean gloves for perineal care. 11. Closing steps b. If gloved, remove and discard gloves following facility policy at the appropriate time to avoid environmental contamination. Wash Hands.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in two of three kitchens reviewed. 1. The South Building satellite kitchen had expired, unlabeled, and undated food in the walk-in refrigerator. 2. Dietary Aide H did not demonstrate a sanitary procedure while measuring food holding temperatures and sanitary use of disposable gloves in the North Building satellite kitchen. These failures could place residents at risk for foodborne illness and a decline in health status. The findings included: 1. South Building Satellite Kitchen Observations on [DATE] at 9:00 AM, during the tour of the South Building satellite kitchen, revealed the walk-in refrigerator contained the following: - an opened package with what appeared to be meat that was wrapped in cellophane and was dated [DATE]; - an opened plastic bag containing shredded cheese was wrapped with cellophane and was not labeled and dated; - an opened bag containing shredded lettuce was undated; the lettuce was brown colored, and the bottom of the bag had collected a brown colored fluid. In an interview on [DATE] at 9:10 AM, Dietary Aide H said he was not aware the articles of food in the walk-in refrigerator were expired and he would throw them away immediately. In an interview on [DATE] at 2:30 PM, the Director of Nurses said they seldom used the South Building kitchen. She stated she suspected they had food in it and recognized the fact that food in the refrigerator should be dated and labeled regardless if the satellite kitchen was used or not. In an interview on [DATE] at 2:40 PM, the Dietary Manager stated his expectations were that all food in the refrigerator would be dated and properly stored and he as well as the dietary aides are responsible for checking dates and disposing out of date food. 2. North Building Satellite Kitchen During and observation and interview on [DATE] at 10:48 AM, while in the North Building satellite kitchen, revealed pans covered with aluminum foil were being removed from hot carts brought from main kitchen in the West Building. The pans were placed on the steam table. The Dietary Manager stated no cooking was done in the satellite kitchen. He stated all residents were being served using foam containers. He stated regular eating utensils were being used and were washed in the low temperature dish machine with chlorine sanitizer. Observation on [DATE] at 10:50 AM revealed 2 enclosed food carts from the main kitchen in the West Building arrived in the North Building satellite kitchen. The pans were covered with aluminum foil. The dietary aides placed the pans on the steam table. During an observation and interview on [DATE] at 11:00 AM, Cook I began taking the food holding temperatures for foods on the left-hand side of the steam table. She stated she worked in the main kitchen in the West Building and the food temperatures had been taken in the main kitchen prior to being sent to the satellite kitchens in the North and South Buildings. Cook I used alcohol preparation pads to sanitize a digital food thermometer. Cook I stated she had been employed in the facility for 5 years. She stated she did not work in the North Building and was told to come to the North satellite kitchen and take the steam table food holding temperatures for lunch today. She stated the menu today was salmon croquettes, oven browned potatoes, sweet/green peas, and a brownie for dessert. During an interview and observation on [DATE] at 11:02 AM, Dietary Aide H stated he had been employed in the facility for a little more than one month. He stated he worked during the breakfast and lunch meals and arrived to work about 6:20 AM. He stated the dietary aides usually checked the steam table food holding temperatures for the North Building and agreed to take over for the cook. Dietary Aide H proceeded to check the temperature of the salmon croquettes, which was measured at 151.3 degrees F. He wiped the food surface of the digital thermometer on a dry rag before measuring the cardiac diet croquettes at 154.9 degrees F. When asked how he cleaned and sanitized the digital thermometer between food items, he stated he wiped them on the rag. When asked where the dry rag came from he replied it had come from the main kitchen. When asked if he had been trained to take steam table food holding temperatures and when and who had trained him, Dietary Aide H stated another dietary employee who no longer worked here had trained him. In an interview and observation on [DATE] at 11:10 AM, Cook I stated there was a stack of clean rags in the main kitchen. The rag appeared to be a piece of a towel that had once been white and was now a dingy light brown-gray color with darker brown and gray stains. Cook I was asked if Dietary Aide H was cleaning the digital thermometer correctly, and she said no. Cook I told Dietary Aide H to use the alcohol preparation pads that she had placed on the counter and to rub the thermometer food surface for 15 seconds with an alcohol pad. During an observation and interview on [DATE] at 11:14 AM, Dietary Aide H started using the alcohol preparation pads to clean the digital food thermometer. He used his gloved hand and slid diced oven-browned potatoes, that were skewered onto the food thermometer, back into the pan. Dietary Aide H dropped meal tray diet order slips, held together with a paperclip, on the floor. He picked them up off the floor and placed them on the first tray, on the top of a stack of meal trays. Dietary Aide H said the trays were not used. He did not change his gloves until after he was asked if his gloved hand had touched the floor when he picked up the diet order slips from the floor. In an interview on [DATE] at 11:20 AM, after the Dietary Manager entered the steam table area, he was asked what would be done after the meal tray diet slips had been on the floor. He said they probably should not be used. He stated they were for the people who lived in the cottages on the grounds/campus. The Dietary Manager instructed Dietary Aide H to serve the North Building meal trays first, and he would print new meal tray diet order slips to replace the ones that had been on the floor. The Dietary Manager stated Dietary Aide I knew how to take steam table holding temperatures and he would be trained again before the end of the day. In an interview on [DATE] at 2:02 PM, the Dietary Manager stated the new dietary aides were usually trained by the experienced dietary aides, and the dietary manager followed-up with the new dietary aides later and observed them. He stated Dietary Aide H was trained by a dietary aide who worked in the facility for a couple of years, and no longer worked in the facility due to going to nursing school. The Dietary Manager stated sometimes staff did wipe the food thermometer on a paper towel to remove excess food before sanitizing with the alcohol pad, but he had never seen staff wipe it on a rag until Dietary Aide H did it at lunch the other day. He stated he had never seen Dietary Aide H do that before and had watched him take food holding temperatures. He stated Dietary Aide H knew how to do it. The Dietary Manager stated Cook I from the main kitchen in the West Building main kitchen had been sent to help Dietary Aide H with serving the lunch meal that day ([DATE]), and not to take the steam table food holding temperatures. He stated he would look for a policy and procedure for taking food holding temperatures and food thermometer use and sanitization. Review of the facility's current employee list with hire dates, provided [DATE], revealed Dietary Aide H was hired on [DATE]. [He had been measuring steam table food holding temperatures prior to serving breakfast and lunch meals for more than one month.] Review of the facility's policy for Food Storage Procedure, not dated, revealed the following [in part]: B. Cold Storage .6. All items should be rotated on shelves so that older items are towards the front. If an item reaches its expiration or use by date it should be discarded immediately. Review of the facility's policy and procedure for Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated [DATE], revealed the following [in part]: Policy Statement Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents . 9. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. 10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper hand washing [The facility did not provide a policy and procedure specifically for the sanitization and use of food thermometers as requested on [DATE] at 2:02 PM.] The U.S. Food and Drug Administration, 2017 Food Code specified: Food storage/labelling ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. ,d+[DATE].10 Food-Contact Surfaces and Utensils. EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED. Frequency ,d+[DATE].11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.

Based on observations, interviews and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of five residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 received adequate supervision to prevent the resident from ingesting a hazardous cleaning solution (harmful if swallowed per material safety data sheet) which was left unattended in a resident room in the facility. This was determined to be Immediate Jeopardy at past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the inspection. This failure could affect residents and place them at risk for poisoning, injury or harm. Findings include: Review of resident #1's face sheet, dated 12/18/21, revealed Resident #1 was an [AGE] year-old female originally admitted on [DATE] with diagnoses of dementia without behavioral disturbances, COVID acute respiratory disease, and [CONDITION(S)] heart disease. Record review of Resident #1's MDS dated [DATE] revealed Resident#1's staff interview for mental status revealed she had a short and long term memory problem, her cognitive skills for daily decision making were severely impaired, She required extensive assistance of one person for bed mobility, transfer, locomotion on or off unit, dressing, toileting, personal hygiene and bathing and she needed supervision of one for eating. Record review of Resident #1's Care Plan dated 12/14/21 revealed Resident #1 was identified as at risk for injury related to effects of impaired judgment as evidenced by history of elopement at other facilities, wandering behavior, and disrobing in public. Review of HHSC reported incident created on 12/17/21 reflected, on 12/17/21 at approximately 4:10 PM a call light came on in a resident room and CNA A immediately answered call light to find resident #1 in another resident's room. She appeared to have pink liquid around her mouth and the front of her clothes were damp. She had a bottle of disinfectant [hazardous cleaning solution] with the spray nozzle off. The aide immediately brought the resident to the nurses' stations and notified the nurse. Some contents did appear to get in resident's #1's mouth. Poison Control was notified, first aid was initiated according to the Material Safety Data Sheet. Instructions were given by poison control to monitor for one hour. The resident was taken to the shower to wash traces of disinfectant from her skin. She vomited during the shower. Poison control was again notified, and recommended resident go to ER for evaluation. Resident's MD was notified. Hospice Plus was notified and resident's family was notified. Resident left facility at approx. 5:12 PM via ambulance. Review of Emergency Department provider note dated 12/17/21 (the day of the incident) reflected, The patient is an 87- year-old female sent in from a facility after being found with a bottle of cleaning solution. It appeared the resident drank the cleaning solution and then vomited. Patient has been having respiratory difficulty since that time. Poison Control was contacted by the Nursing home and it was recommended that patient be brought to the emergency department. Resident is nonverbal which is her normal state. Past medical History provided by the Nursing home. Diagnoses: Allergic Rhinitis, Alzheimer's Disease Coronary Artery disease. Resident positive for cough and shortness of breath and positive for vomiting. Resident in no acute distress on arrival. Clinical Impression as of 12/17/21 Chemical poisoning due to ingestion of cleaning solution, shortness of breath, aspiration into airway, intermittent vomiting. Record review of facility in-services and staffing sheets reflected in-service sign in sheets on safe storage of hazardous chemicals signed by staff that were scheduled to work on 12/17/21 and 12/18/21. Record review of Chest x-ray final report dated 12/17/21 at 7:56 PM reflected ; Findings: Chronic and fibrotic type findings in the lungs. Organized infiltrate or effusion. Impression: Chronic type findings in the chest (changes that have persisted for a long time). Resident remained in the hospital at the time of the investigation but returned to the facility on [DATE]. An observation on 12/17/21 at 12:10 PM of resident rooms, housekeeping carts, and shower rooms on the secure unit revealed no hazardous chemicals left unsecured and accessible to residents. Observations on 12/17/21 at 1:30 PM. revealed the place Resident #1 obtained and ingested the harmful cleaning solution was another residents room. The room was located within a secure unit where Resident #1 resided. The resident residing in the room was not interview able. Interview with Housekeeper D on 12/17/21 at 12:10 PM revealed that she was the housekeeper assigned to clean the room where Resident #1 ingested the hazardous chemical. She stated she does not remember what time she cleaned the room. She stated that she had been in-serviced on the storage of hazardous chemicals this morning before beginning her shift and when she was hired. She stated that she did not remember leaving the cleaning solution in the room where the incident occurred. She stated she never left chemicals on top of her housekeeping cart and locked them in the secure compartment on her cart when not in use. She stated leaving chemicals out and within reach of residents could result in harm to the residents. Interview with Housekeeper E on 12/17/21 at 300 PM revealed that she had been in-serviced on 12/17/21 and on her hire date on the proper storage of chemicals and stated they should be kept in the secure compartment on her cart. She also stated that she locked her cart in the designated housekeeping storage when not in use and kept her cart in her direct view in the Resident's doorway when cleaning the room with the chemical's storage compartment facing the door. Interview with CNA A on 1217/21 at 12:35 PM revealed she was the aide responsible for Resident #1's care on the day of the incident and witnessed the resident with the harmful cleaning solution bottle in her hands and the pink substance on her mouth. CNA A explained the call light in the room was on and she entered the room to answer the call light. She stated that both residents often pulled the call light accidentally Upon entering the room, she saw Resident #1 with the harmful cleaner in her hands and a pink substance around her mouth. She stated she took the bottle containing the cleaner from the resident, removed it and resident # 1 from the room and immediately notified the charge nurse. When asked, CNA A said she did not know how the cleaner had gotten into the resident room. She said it shouldn't have been there. She stated she and the other staff on duty had been in-serviced after the incident on 12/17/21 on proper storage of chemicals. An interview with LVN B and RN C on 12/17/21 at 12:43 a.m. revealed LVN B was the charge nurse responsible for Resident #1. She stated she was notified by CNA A that the resident ingested the cleaning solution . She immediately assessed the resident and had the CNA A shower the resident while RN C located the Material Safety Data sheet. She notified poison Control and then notified doctor, family and the DON. RN B stated Resident #1 vomited while in the shower and LVN B notified the physician and received an order to transfer Resident #1 to the hospital for evaluation and treatment. LVN B explained the cleaner was not supposed to be left unsecured and in the reach of residents. She stated chemicals that can be harmful to residents needed to be stored away from the reach of residents. I Interview with the Maintenance Director (MD) on 12/17/21 at 2:30 PM., revealed he was the person that was in charge of the housekeeping staff, and it was his responsibility to monitor to see that housekeeping staff did not leave chemicals unsecured. He stated it was his responsibility to see that the staff received training. He also stated he had immediately started interviewing housekeeping staff regarding the proper storage of chemicals. He stated that he was at the facility today to conduct Inservice with all housekeeping staff that were not in serviced on 12/17/21 and that staff would not be allowed to work until the Inservice was completed. He stated that he had only been in his position for a little over a week. He explained he worked on the day of the incident but did not witness any chemicals that had been left unsecured. He stated he was informed by the DON that the substance was harmful and not properly stored. He stated he planned to be more vigilant and do spot checks and monitor frequently to check to make sure things were stored properly. Interview with the DON on 12/17/21 at 12:20PM, revealed she said she was in the facility when the incident occurred. She was notified and went to see Resident #1. They tried to give the resident some water, but she refused to open her mouth. The DON explained the facility communicated with poison control and 911 was called to transfer Resident #1 to the hospital for further evaluation and treatment. She said the resident had wandering behaviors. She provided a timeline of the resident's activity prior to the incident that she compiled from the facilities monitoring system. She stated the resident was not visible in the hallway before entering the room and the housekeeper was not visible with cleaning solution before entering or leaving the room. She stated in-service on storage of chemicals and keeping housekeeping carts in line of sight when not locked in the storage closet was started immediately after the incident and would continue until all staff were in-serviced prior to beginning their shift upon returning to work. The DON stated that under no circumstance should hazardous chemicals or medications be left unsecured and accessible by residents. Review if Resident #1's progress notes, care plan, and facility incident reports revealed no evidence of like incidents involving this resident. Reviewed in-service training records for proper storage and securing of hazardous chemicals in employee files of housekeepers D and E and CNA A. Reviewed Inservice records dated 12/17/ and 12/18/21 on Topic of storage of Hazardous chemicals. Review of the cleaning solution Clean on the go safety data sheet revised 10/21/2014 revealed the following: 1) May cause eye damage. 2) If swallowed do not induce vomiting, may burn mucosal tissue. Immediately call Poison Control. Do not induce vomiting or Gastric lavage (stomach pumping). 3) Exposure may aggravate those with preexisting eye, skin, or respiratory conditions. First aid measures after inhalation: When symptoms occur. Go into open air and ventilate suspected area. Remove to fresh air and keep at rest in a position comfortable for breathing. Obtain medical attention if breathing difficulty persists. Take off contaminated clothing and Rinse with water or shower. Immediately call poison control. Flush eyes for 15 minutes Review of the facility policy and procedure on accidents and supervision revised in July of 2017 reflected, in part: : Any bottle containing the phrase keep out of reach of children will be kept out of reach of residents.

Based on interview and record review, the facility failed to ensure intial Pre-Admission Screening and Resident Review (PASARR) Level I (PL1) Screening of residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 3 of 7 residents (Resident #s 11, 16, and 122) reviewed for a mental illness, intellectual disability or developmental disability. Resident #122 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16's initial PL1 was negative. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents with mental illness at risk for not receiving needed care and services. The findings included: Resident #122 Review of the Resident Face Sheet, printed 04/09/2021, revealed Resident # 122 was an [AGE] year-old female who admitted to facility on 10/18/2019 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Order's included [MEDICATION(S)] 10 mg every day, for depression and Trazadone 100 mg 1 hour prior to bedtime. A record review of a PASARR Level I (PL1) Screening, dated 09/27/2019, indicated Resident #122 had no indication of mental illness. No PASARR Level II (PE) Screening was found in the clinical record. A record review of the most recent annual MDS assessment, dated 03/22/2021, indicated Resident #122, under section A1500, showed no mental illness. Section E (Behavior). E0100 question B Delusions question answered Yes. Section I under Psychiatric/Mood Disorder Anxiety Disorder. Depression. A record review of the last Care Plan from a conference completed on 03/04/21, with a Problem Start Date of 10/18/2019, shows under Category Psychotic Drug Use; Risk for adverse [CONDITION(S)] side effects, AEB: Resident is treated with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview and record review on 04/08/2021 at 2:00 PM with MDS Coordinator#2 and DON accessed the LTC online portal for a history of Resident #122's PASARR screening. They stated a PL1, dated 09/27/2019, had been completed and was negative for indication of MI, ID, and DD. They stated no further screenings had been completed for Resident #122 they revealed if they had Dementia with behavioral disturbances as a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #11 A record review of the Physician orders, dated 04/04/18, indicated resident #11, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders included [MEDICATION(S)] 150 mg PO QD for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of the Resident Face Sheet, dated 04/04/18, indicated resident #11 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of a PASARR Level I (PL1) Screening, dated 04/04/18, indicated Resident #11 had no indication of mental illness. No PASARR Level II (PE) Screening was found in the clinical record. A record review of the most recent annual MDS assessment, dated 01/25/21, indicated Resident #11, under section A1500, showed no mental illness. Section I (Psychiatric/Mood Disorder) of the same MDS indicated the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section D (Mood) of the same MDS indicated the resident had answered yes to question B1. Feeling down, depressed, or hopeless - Symptom Presence. A record review of the last Care Plan from a conference completed on 03/23/21, with a Problem Start Date of 07/09/2018, shows under Category Mood State: Despondence, exhibition of sad mood; related to absence of significant purpose in life; loss of physical skills to care for self; AEB: Her saying that she has trouble staying asleep and gets restless. During an interview and record review on 04/08/21 at 9:30 AM, MDS Coordinator #1 accessed the LTC online portal to search for a second PL1 and a PE. She stated she did not see a new PL1. The only PL1 completed was one done on 04/04/18. She stated she was not sure why another PL1 was not completed. She acknowledged that a form 1012 needed to be sent to the Local Authority. She acknowledged that there should be a positive PL1, and that a PE should have been completed by the LA. She acknowledged that she is responsible for completing another PL1 and entering a form 1012 into the LTC Portal. She acknowledged she needs to follow through to make sure another PL1 is completed and a PE is completed. Resident #16 Review of the Resident Face Sheet, printed 4/09/21, revealed Resident #16 was an [AGE] year-old male who had been admitted to the facility on [DATE]. Review of Resident #16's census information revealed he had a prior stay in the facility 11/01/2107-11/17/2017, with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review Resident #16's PL1, dated 10/30/2017, revealed it was negative for indication of MI, ID, or DD. Review of Resident #16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - unspecified [CONDITION(S)], 10/08/18; - major depressive disorder, 5/07/19; - [CONDITION(S)] disorder, 5/07/19. Review Resident #16's current medication orders, dated 3/01/21- 4/09/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Psychiatric Progress Notes, dated 3/09/21, revealed documentation the resident received [MEDICATION(S)] for [CONDITION(S)] disorder and [MEDICATION(S)] for major depressive disorder. During an interview and record review on 4/08/21 at 8:50 AM, MDS Coordinator #1 accessed the LTC online portal for a history of Resident #16's PASARR screenings. She stated a PL1, dated 8/31/2018, had been completed and was negative for indication of MI, ID, and DD. She stated no further screenings had been completed for Resident #16 after the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did not think a PL1 or Form 1012 were needed, due to the resident having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's policy and procedure Admission Criteria, dated 2001 and revised December 2016, documented the following [in part]: Policy Statement Policy Interpretation and Implementation: 8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid pre-Admission Screening and Resident Review program (PASSAR) to the extent practicable. 9. The facility will follow the PASARR Expedited Admission Categories, PASSAR Preadmission Process and PASARR Process Flow Chart documents for PASSAR compliance. 10. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1of 5 residents (ID # 1) reviewed for care plans. The care plan failed to address Resident #1's specific needs related to her to left side impairment. This failure could affect residents by placing them at risk of not receiving the type of care coordination required to maintain or improve their health status. Findings included: Resident ID # 1 Record Review of Resident ID # 1's face sheet, dated 09/09/2020, revealed she was an [AGE] year-old female, admitted to the facility on [DATE], with the most recent admission on 08/27/2020 on Hospice care, with the following Diagnoses: [REDACTED]. Record Review of Resident ID # 1's Quarterly MDS, dated [DATE], revealed in Section G (Functional Status), Impairment-one side Record Review of the most recent Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 9. Review of Resident #1's records on 9/9/20 revealed there was no Care Plan found to reflect Resident #1 was impaired on her left side, or interventions to address this. Observation and interview, on 09/09/2020 at 2:00 PM, revealed Resident #1 was observed lying in bed with the bed side table and call light located on the left side of her bed, her impaired side, and she could not reach her water or her call light. She stated she was not able to use her left hand, and was able to use her right hand. During the observation, she was able to raise her right arm to grip a cup and push her call light when the bedside table and call light were placed on the right side of her bed, the dominant side. In an interview on 09/09/2020 at 2:10 PM, with CNA A, she stated she placed the bedside table and call light for Resident #1, on her left side. CNA #1 stated Resident #1 was not able to use her left side and could use her right side. Did you ask if she had training on placing things on Resident#1's right side?-The CNA was aware Resident #1 could not use her left hand to reach her items on her bedside table or her call light, and she stated she was in a hurry and forgot move the table and call light to Resident #1's right side In an interview with LVN A, on 09/09/2020 at 1:50 PM, she stated Resident #1 could not use her left arm and she observed her bedside table and call light were placed on the side of the non-dominant hand. She stated she was responsible to check for this. LVN A stated she was not aware of a care plan for Resident #1 related to make items accessible on her dominant side. In an interview on 09/09/2020, at 3:15 PM, with the Director of Rehabilitation, he stated he had Resident #1 on services for Physical Therapy, which ended 07/2020, Occupational Therapy which ended on 08/05/2020, and Speech Therapy which ended on 08/07/2020. He stated the resident was right hand dominant, and had not been able to use her left hand since admission on 8/27/2020. The DON nor Administrator produced a Policy and/or Procedure for Comprehensive Resident Centered Care Plans prior to exit on 09/09/2020.

Based on observation, interview, and record review, the facility failed to ensure the coordination and provision of services agreed upon during the IDT meeting for 1 of 3 residents (Resident ID #7), reviewed for Pre-Admission Screening and Resident Review (PASRR) screening and evaluation. Resident ID #7, who was admitted to the facility on [DATE], did not have a PASRR Evaluation until 7/27/17, and an IDT Meeting was not held until 8/01/17. A Customized Manual Wheelchair was not attained, and request forms for Specialized Services were not submitted as required. This failure could affect 7 residents identified as having positive PASRR conditions, placing them at risk for decreased quality of life and for not receiving specialized services and/or support services in the most appropriate setting. The findings included: Review of Resident ID #7's Face Sheet, not dated, revealed he was a [AGE] year old male who was admitted to the facility on [DATE]. The form documented the resident's [DIAGNOSES REDACTED]. Review of Resident ID #7's care plan revealed a plan, dated 8/21/17, which documented the resident was identified as being positive for MI and IDD upon completion of the PL1 and would be receiving some PASRR services. The approaches included a customized wheelchair assessment to be completed and sent in for approval or denial. In an interview on 12/28/17 at 9:25 AM, the RN MDS Supervisor for the North Building stated Resident ID #7 was the only PASRR positive resident who was receiving services. She stated Resident ID #7 was receiving physical therapy services. The RN stated a request form for a customized manual wheelchair had been submitted for Resident ID #7, and the CMWC request was denied, due to the resident's own wheelchair being new. Observation on 12/28/17 at 11:00 AM revealed Resident ID #7 was seated in an older model wheelchair in a day room located in the North Building of the facility. The vinyl covering was cracked on the padded arm rests of the wheelchair. In an interview on 12/28/17 at 11:00 AM, Resident ID #7 stated he was supposed to get a new one (wheelchair) from this place. In an interview on 12/28/17 at 11:10 AM, the two Restorative Nurse Aides present in the North Building stated there were three Restorative Nurse Aides total, and they all worked with Resident ID #7. The restorative aides stated one of them worked with Resident ID #7 each day, 6 days per week, Monday - Saturday. They stated Resident ID #7 required extensive assistance with transfers, and required one-to-one assistance while using the exercise bicycle and during sit-to-stand exercises using the parallel bars. The restorative aides stated Physical Therapy Assistant (PTA) E was working with Resident ID #7, but they did not know how often. They stated Resident ID #7 had his own personal wheelchair, and PTA E took it and provided the wheelchair the resident was currently using. The restorative aides stated Resident ID #7 got around better in the current wheelchair, and pushed himself backward in the chair. They stated Resident ID #7 had fallen about 2 weeks ago, and it happened on a Sunday. The restorative aides stated they weren't here at the facility when the resident fell . In an interview on 12/28/17 at 11:30 AM, the RN MDS Supervisor for the North Building stated she was the MDS Coordinator and PASRR assessor for 2 of 3 buildings, the North and West Buildings. She stated the residents' PASRR information (screenings, evaluations, request forms, IDT meetings, etc.) were in the computer in the PASRR Portal, and she did not print any of the information. She stated she and the MDS Coordinator/PASRR assessor in the South Building were the only two staff who had access to the PASRR Portal. The RN reviewed Resident ID #7's information in the PASRR Portal and stated he had an initial PASRR screening (PL1) prior to admission. She stated an IDT meeting was held during August 2017 and was attended by herself, the LIDDA Service Coordinator, Resident ID #7 and his sister. The RN stated the resident and his sister wanted him to have physical therapy, occupational therapy, and a customized manual wheelchair (CMWC). She stated the resident's PASRR care plan was dated 8/21/17. The RN stated Resident ID #7 was approved for therapy and received physical therapy and occupational therapy services during August and September 2017, but the request for the CMWC was denied. She stated the request for the CMWC was denied, because the resident's own wheelchair was so new. She stated she did not know about the NFSS (Nursing Facility Specialized Services) request form that needed to be submitted. The RN stated she received a call during October 2017 from a lady at the State PASRR Unit office, and was told the NFSS form needed to be submitted. The RN stated the NFSS for a CMWC was submitted 10/19/17. She stated she did not receive an alert that the request had been approved for the CMWC for Resident ID #7. The RN stated she did not go into Resident ID #7's PASRR Portal information to check for any updates, as she was supposed to receive alert messages. The RN proceeded to enter the PASRR Portal for Resident ID #7 at that time, and saw the NFSS assessment for the CMWC was approved on 10/20/17 and completed 10/21/17. She stated she didn't receive an alert that the request for the CMWC was approved, so the second section of the NFSS form for the CMWC was not completed by the therapy department for submission. The RN stated she did not forward the form to the therapy department for completion, but she would do so. In an interview on 12/28/17 at 1:50 PM, PTA F stated the RN PASRR assessor from the North Building had just brought Pages 9 - 15 of the NFSS request form for a CMWC to be completed by the therapy department, and the form for the DME supplier to complete. She stated PT H would complete the NFSS evaluation during the next week. Review of Resident ID #7's PASRR Portal information revealed the following: 7/27/17 - PE for IDD and MI - positive for IDD; does not meet PASRR definition of MI - specialized services determination/recommendations: self-help with ADLs (activities of daily living - toileting, grooming, dressing, eating); alternate placement services; service coordination; specialized occupational therapy; 3 falls during past 90 days; impaired mental status; Nursing Facility placement appropriate for individual; requires 24 hour care. 8/01/17 - IDT Form - meeting 8/01/17 - attended by facility RN, resident, sister (LAR), and LIDDA; specialized services indicated and accepted: Customized Manual Wheel Chair; Specialized Assessment Occupational Therapy; Specialized Assessment Physical Therapy; Specialized OT; Specialized PT; Service Coordination. 8/22/17 - PASRR Specialized Services (PSS) Form - positive for IDD only; Specialized Services agreed to: Customized Manual Wheelchair . Service Coordination. 8/23/17 - Authorization Request for Nursing Facility Specialized Services (NFSS) - NFSS for Customized Manual Wheelchair (CMWC) - CMWC Assessment completed by PT G - resident with history of right sided weakness and [DIAGNOSES REDACTED], often with tremor or uncontrolled motions related to [MEDICAL CONDITION], non-ambulatory, fluctuating muscle tone/control of right lower extremity and right upper extremity. 8/29/17 - request pending denial, refer to the authorization section on the NFSS form for more information. 9/12/17 - request service or assessment was denied; 14 days elapsed since request was pending denial. 10/19/17 - Authorization Request for Nursing Facility Specialized Services (NFSS) - NFSS for Customized Manual Wheelchair (CMWC) - form not submitted within 30 calendar days of the IDT meeting. 11/20/17 - PASRR Specialized Services (PSS) Form - quarterly SPT (service planning team) Meeting - Specialized Services agreed to: Customized Manual Wheelchair. 12/08/17 - NFSS Request Approved - requested item/service meets medical necessity. In an interview on 12/28/17 at 9:25 AM, the MDS Supervisor for the North Building stated there was not a specific facility policy for PASRR Services, and it was included under the policy/procedure for Antipsychotic Medication Use. Review of the facility's policy/procedure for Antipsychotic Medication Use, dated as revised December 2016, revealed the following (in part): Policy Interpretation and Implementation . 5. Resident who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: a. Complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate. (There was no further policy/procedure regarding PASRR services provided by the facility.) Review of the facility's list of residents with PASRR positive conditions for IDD and MI, dated 12/28/17, revealed the names of 7 residents, 3 residents in the North Building and 4 residents in the South Building.

Based on interview and record review, the facility failed to ensure that all alleged violations involving mistreatment/abuse were reported immediately, but no later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury, and within 24 hours if the alleged violation did not involve abuse and did not result in serious bodily injury, to the administrator and the state agency in accordance with State Law for 1 of 6 residents (Resident ID #1) reviewed for mistreatment/abuse. 1. CNA A failed to immediately report to the charge nurse and/or facility's Abuse Prohibition Coordinator the allegation of Resident ID #1 being spat on during personal care on 11/17/17. CNA A reported the allegation on 11/20/17. This deficient practice could affect 166 residents that were housed in 2 of 3 buildings, the North and South buildings, of the facility, placing them at risk for potential harm and/or decline in feelings of safety and well being. The finding included: Record review of Resident ID #1's Admission Record dated 01/12/2016 revealed documentation she was [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident ID #1's Quarterly MDS Assessment, dated 10/23/17, documented the following (in part): her cognitive score was 3, indicating she was severely impaired; she required extensive assistance with two or more persons for personal hygiene; and her behaviors reflected resistance to care and frequent combativeness. Record review of Resident ID #1's Care Plan for Activities of Daily Living, review dated 10/18/17, documented Resident ID #1 required total assist with 2 or more staff to assist with bathing and dressing. Care Plan for Behavioral Symptoms, review dated 10/18/17, documented Resident ID #1 was at risk for harm to self and/or others as she exhibited increased episodes of combative and aggressive behaviors, often spitting with personal care. Record review of the facility's Provider Investigation Report revealed documentation CNA A reported on 11/20/17 at 12:09 PM, to the ADON and Quality Assurance and Performance Improvement RN, she witnessed on 11/17/17 at 10:24 AM, CNA B spit in the face of Resident ID #1. CNA A reported she, CNA B and CNA C were in the 1100 Hall shower room. CNA A stated she was standing behind Resident ID #1, and CNA B was standing in front of Resident ID #1 when Resident ID #1 spat in CNA B's face then CNA B spat into Resident ID #1's face. During an interview 12/28/17 at 9:40 AM, the Quality Assurance and Performance Improvement (QAPI) RN stated CNA A and the ADON came to her office on 11/20/17 and reported the events/allegation of 11/17/17. She stated CNA A was aware she should report concerns of resident abuse or neglect immediately. She stated CNA A stated the Abuse Prohibition Coordinator or her ADON was not on duty 11/17/17, so she decided not to say anything until she returned to work on 11/20/17. The QAPI RN informed CNA A she was suspended from work until investigation could be done. The QAPI RN stated she completed the investigation and could not substantiate abuse due to conflicting reports of events by staff. She stated she emailed the Provider Investigation Report to Consumer Rights Services on 11/22/17 at 1:04 PM. She stated CNAs worked in the South and North buildings of the facility. During an interview 12/28/17 at 11:40 AM, CNA B reported she was in the shower room on the 1100 Hall on 11/17/17 and was assisting CNA A and CNA C to shower and dress Resident ID #1. She stated Resident ID #1 was striking out at staff and spitting on staff. CNA B reported she had assisted with Resident ID #1 on several occasions with similar type behaviors noted. She stated she had worked at the facility for [AGE] years and had never been accused of any misconduct to residents. She stated she did not spit at or on Resident ID #1 at any time. She stated she would immediately report any misbehavior to residents. She stated she felt CNA A did not like her and wanted to cause problems for her. She reported CNAs could work in the South or North buildings of the facility. During an interview on 12/28/17 at 11:50 AM, LVN D reported she was on duty and in charge of 1100-1200 Halls on 11/17/17. She stated she was aware Resident ID #1 had been difficult to shower on that day, and CNA A, CNA B and CNA C had worked together to shower Resident ID #1. She stated Resident ID #1 received her shower and was dressed without incident. She stated no one had reported to her any unusual or possible abusive behaviors toward Resident ID #1. During a telephone interview on 12/28/17 at 12:07 PM, CNA A reported on 11/17/17 around 10:00 AM, she, CNA B and CNA C were in the 1100 Hall shower room with Resident ID #1. CNA A stated she was behind Resident ID #1 and CNA B was in front of Resident ID #1 and CNA C was to the side of Resident ID #1. CNA A stated Resident ID #1 was slapping out at the others and spit in the face of CNA B. She stated she immediately witnessed CNA B spit on resident ID #1. CNA A stated she did not say anything at the time of the incident because it all happened so fast. CNA A stated there was no injury, so she did not report it on 11/17/17. She stated she knew it was wrong to treat residents in such a way, whether they were injured or not, so she went to her ADON on 11/20/17 and reported the incident. CNA A stated she was suspended during the investigation and was reassigned to work in the South building. She stated she had worked in the North and South buildings. She stated after the reassignment in work station, she quit her position at the facility and no longer worked at the facility. During an interview on 12/28/17 at 3:15 PM, CNA C reported she generally worked in the South building. CNA C stated on 11/17/17 she was assisting CNA A and CNA B in cleaning and dressing Resident ID #1 in the 1100 Hall shower room. CNA C stated she was wiping and dressing resident ID #1. She stated she did not usually work with Resident ID #1, and she was not aware of Resident ID #1's behaviors. She stated during the time of cleaning Resident ID #1, the resident started spitting. CNA C reported she heard spitting in the background while she was dressing Resident ID #1, but she did not witness CNA B spitting on Resident ID #1. CNA C stated once Resident ID #1 was dressed, she left the shower room. CNA C reported she did not witness any type of abuse or neglect during this incident. She stated she knew to report any allegations of abuse or neglect immediately to charge nurse and Abuse Prohibition Coordinator. CNA C stated she worked in the North and South buildings. During an interview on 12/28/17 at 3:20 PM, the Director of Nurses reported her expectations of staff and nurses was for them to report any allegations of abuse or neglect immediately, just as the facility policy documented. She stated the CNAs were suspended during the investigation. She stated she could not conclude abuse had occurred due to the evidence of the incident. She stated the staff involved, CNA A, CNA B and CNA C, were reassigned. She stated CNA A terminated her position after the change of assignments were made. Record review of staff In-service training, dated 09/01/17 through 12/22/17, documented (in-part): 9/18/17 - 9/26/17 Documentation on reporting abuse with attached policies. Any allegation of Abuse are to be reported immediately to Abuse Prevention Coordinator (provided by ADON). Documentation revealed CNA A was in attendance. 11/20/17 (x 6 training sessions) North building: Abuse: Must report any and all suspected abuse or neglect to Abuse Prevention Coordinator immediately (provided by ADON). 11/21/17 (x 6 training sessions) South building: Abuse: Must report any and all suspected abuse or neglect to Abuse Prevention Coordinator immediately (provided by QAPI, RN). Documentation revealed CNA B and CNA C were in attendance. 11/22/17 (x 11 training sessions) North building: Abuse: Must report any and all suspected abuse or neglect to Abuse Prevention Coordinator immediately (provided by ADON). 11/23/17 (x 3 training sessions) South building: Abuse: Must report any and all suspected abuse or neglect to Abuse Prevention Coordinator immediately (provided by ADON). 12/14/17 -12/15/17 (x 7 training sessions) North building: Abuse: Must report any and all suspected abuse or neglect to Abuse Prevention Coordinator immediately (provided by ADON). Record review of the facility's policy/prodedure for Abuse Investigation and Reporting, dated July 2017, documented (in-part): Reporting 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately to the Abuse Prevention Coordinator, but not later than: a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury, or b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The facility's Resident Bed List Report, dated 12/28/17, documented 92 residents resided in the North Building and 74 residents resided in the South Building (a total of 166 residents in 2 of 3 buildings).

Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (Resident #1) of 6 residents reviewed for care and services. Resident # 1 experienced a [MEDICAL CONDITION] on 8/23/2017, she was ambulatory prior to the [MEDICAL CONDITION] and did not walk or transfer herself again after the [MEDICAL CONDITION]. The nurses failed to assess resident # 1 or notify the physician of resident # 1 not walking from 8/23/2017 - 8/29/2017. The physician was notified on 8/29/17 but the x-ray was not done until 8/31/2017, the x-ray revealed a [MEDICAL CONDITION]. This failure by the facility could affect and result in further injury and harm to the 65 residents, residing in the Alzheimer's unit who required 1 or 2 person assistance with transfers by not ensuring they receive needed care and services. The findings included: Record review of the undated face sheet documented resident # 1 was a [AGE] year-old admitted to the facility on [DATE], [DIAGNOSES REDACTED]., gastritis with unspecified bleeding (history of), [MEDICAL CONDITION] (unspecified site), pseudobulbar effect (uncontrollable episodes of crying and/or laughing), unspecified convulsion and hypertension. Record review of the Comprehensive MDS date 7/01/2017 documented resident # 1's ability for decision making was severely impaired, resident # 1 required supervision and 1 person physical assistance for walking in the room and corridor; For locomotion on and off the unit resident # 1 required supervision and set up help and resident # 1 was not steady while walking or turning around but was able to stabilize without staff assistance. Record review of the care plan dated 7/14/2015 documented resident # 1 required assistance with ADL's including assistance with incontinence, toileting, and transfers. Resident was identified to be at risk for pain due to a previous [MEDICAL CONDITION] and was to be assessed for non-verbal signs and symptoms of pain each shift. Resident # 1 was to be assisted to make frequent position changes including turning in bed every 2 hours. Record review of the undated facility investigation notes documented an interview with the physical therapist on 9/06/17 at 10:21 who was documented to have said he was consulted in late August, around the 25th about resident # 1 not being able to walk. He was made aware of resident # 1 having been fully ambulatory, then suddenly becoming w/c bound. He had worked with resident # 1 in the past, and resident # 1 was ambulatory then. The therapist said resident # 1 grimaced with weight bearing activity at the parallel bars and had rotation of the left hip. Resident # 1 grimaced when sat down, the information was reported to the charge nurse and requested an x-ray of the left hip to rule out a fracture. The therapist was then documented to have said in the days pending the x-ray the therapist reported to the nurse resident # 1 would grimace with passive rotation of the left hip. The facility investigation notes documented on 9/06/2017 at 10:30 AM the DON reviewed the security camera footage for 8/23/2017 at 7:30 AM finding resident # 1 was sitting on the sofa in the Alzheimer unit living room and was seen to be having jerking movements of all extremities with the left leg hitting the floor surface during the convulsion activity. Observation on 9/14/17 at 4:30 PM, of resident # 1 was in the day area, in a w/c, resident # 1 was not interviewable, would grimace, look at writer, and nod. Review of the nursing progress notes dated July, August and September 2017 document resident was found in floor on 7/23/2017, pushed by another resident on 7/24/2017 landing on the ground, and had bruising of the right buttock. On 8/09/17 resident # 1 was documented to have been pushed down by another resident. Physical therapy evaluation dated 8/10/17 documented a reply to monitor resident # 1 for mobility changes. The notes did not document any other injuries or changes in resident # 1's mobility status. There was no documentation of a full assessment of resident # 1's mobility. A nursing progress note dated 8/23/17 documented resident # 1 had [MEDICAL CONDITION], was having involuntary jerking movements while sitting on the sofa in the Alzheimer's unit living room. The nursing notes documented the physician's notification and the notification of resident # 1's son. Resident was ordered to have a chest x-ray and lab work. New orders were then received for antibiotics due to a URI. The notes did not document any other assessment done for resident # 1. Continued review of the nursing progress notes documented resident # 1 was administered Tylenol 500 mg for pain exhibited by facial expressions, grimacing on 8/13/17 at 11:32 PM, 8/24/17 at 5:56 AM, and 8/30/17 at 8:02 PM. These were documented as effective. The notes did not reflect any documentation of a thorough assessment of resident # 1 for the pain or the decreased mobility; and did not document any notification of the physician of the decreased mobility. The review of the nursing progress notes dated 8/23/17 (date of convulsion) thru 9/06/2017 did not provide a documented nursing assessment of resident # 1's change in mobility. The notes did document on 8/31/2017 resident # 1 was mobile per a w/c. Record review of the ADL sheets dated 8/01/2017 - 9/06/2017 documented resident # 1 was independently ambulatory with occasionally having set up assistance until 8/23/2017. No use of assistive devises or a w/c was documented prior to 8/23/2017. After 8/23/2017 resident # 1 was documented as activity did not occur for ambulation, and required the extensive assistance of 2 persons with transfers. Use of wheelchair was documented after 8/23/17. Record review on Physical Therapy plan of care dated 8/29/17 (No time given) documented resident # 1 was evaluated due to resident having difficulty walking the last week, and requiring extensive staff assistance for transfers. The reason for the referral was documented as resident had had a fall on 8/09/2017 and no injury had been identified; since the fall resident # 1 had was no longer walking in the recent week and had an impaired ability to to perform transfers without significant staff support. The plan of care documented resident # 1 was independently ambulatory with spontaneous walking/transfers prior to this change in her condition. The plan of care documented resident # 1's rehab potential was good as resident # 1 had been independent in prior ambulation ability. At 3:12 PM the plan of care documented nursing was notified of the findings, resident had facial grimacing with internal rotation and hesitancy to weight bear with the left hip. Recommendation was for an x-ray of the left hip. Record review of the nurse progress notes for 8/29/17 did not reveal any documentation of resident # 1 being assessed by nursing for a possible [MEDICAL CONDITION]. Record review of the physician notification document relaying the therapy recommendation for x-ray of resident # 1's hip revealed the document stated resident experienced pain and limited weight bearing to the left hip. It documented resident # 1 had recently declined to w/c mobility. The document was dated 8/29/2017, no time documented. The document documented the physician gave the x-ray order 2 days later on 8/31/17. Time unknown. Record review of the nursing notes dated 9/01/2017 at 9:57 AM document resident # 1's son was notified of the fracture. The son requested resident # 1 not be sent to the hospital but a orthopedic consult be done. Nursing progress notes documented a hip x-ray was ordered on [DATE] at 11:40 AM, x-ray documented as completed at 1:09 PM. At 4:00 PM resident # 1 was documented as mobile in her w/c. On 9/01/17 at 1:01 PM the nursing notes documented resident x-ray results as: resident # 1 had a left femoral neck (hip) fracture, modest [MEDICAL CONDITION]. The note documented the physician was notified of the results and the physician said to get a medical referral for orthopedics and to continue to use pain medication as needed. The note documented the ADON was notified. Resident # 1's vital signs were documented as B/P 147/63, pulse 83, respiration 14, temperature was 97.7 oxygen saturation was 93%. The notes did not document a nursing assessment of resident # 1 for the change in her mobility, or for pain. In an interview on 9/15/17 at 11:47 AM CNA A stated they were to report changes in resident condition to the charge nurse, LVN C. The charge nurse was made aware of resident # 1 not being able to walk anymore. Resident # 1 was ambulatory, did not walk after the [MEDICAL CONDITION]. In an interview on 9/15/17 at 11:57 AM CNA B said it was difficult to move resident # 1 now, now it required 2 -3 people to transfer resident # 1. Resident # 1 was ambulatory before the [MEDICAL CONDITION]. They were to notify the charge nurse of changes in residents and the charge nurses were made aware of resident # 1's change. In a confidential interview on 9/15/17 at 11:59 AM it was said the charge nurses (LVN C and E) were aware that resident # 1 required more staff assistance to transfer and could no longer walk. The ADON was told repeatedly that resident # 1 needed to be moved out of the locked unit, due to the decline. Stated did not see resident # 1 be assessed for not being able to walk. Resident # 1 did display signs of pain when moved and it was reported. Resident # 1 had been ambulatory until the [MEDICAL CONDITION] and had not been able to since it occurred. In an interview on 9/15/17 at 12:07 PM LVN C said she was on duty the day resident # 1 had a [MEDICAL CONDITION], the physician did assess resident # 1 after the [MEDICAL CONDITION]. She assessed resident at the time of the [MEDICAL CONDITION] also nurses from the front of the Alzheimer's unit also assessed resident # 1 because of the [MEDICAL CONDITION]. Resident # 1 had not had a [MEDICAL CONDITION] before. LVN C said physical therapy was notified of the change in resident's condition, date not known, she was not aware of any further physician notification until the x-ray was ordered. In an interview on 9/15/17 at 12:10 PM the ADON said resident # 1 would always grind her teeth, the x-ray was done on 8/31, they received an order on the 1st (September) for orthopedics doctor. The physical therapy consult was done on the 29th (August). Resident # 1 had the chest x-ray and was ordered treatment. The ADON said she was not aware of increased pain, residents with severe Alzheimer's will often have a change like that, where they just lay down, when they are sick, that's what everyone thought with resident # 1. In a telephone interview on 9/15/17 at 2:40 PM Resident # 1's son/POA said the facility did notify him of his mother's fracture. He had not decided what to do about his mothers fracture, resident # 1 just saw the orthopedic doctor. In an interview on 9/15/17 at 3:15 PM the ADON said no full assessment was documented. Resident had seen the orthopedic doctor on the 14th, no progress note was received. In a telephone interview on 9/15/17 at 3:30 PM the PT (physical therapist) said resident # 1 made no facial grimace when seated, when resident # 1 was standing it became apparent, pain, it was also apparent with ROM. It was not a fixed rotation. Turning, moving hip caused resident # 1 to grimace. PT recommended an x-ray be done. In an interview on 9/18/2017 at 11:50 AM LVN E said another nurse had faxed the therapy recommendations to resident # 1 's physician. In a telephone interview on 9/18/2017 at 1:53 PM resident # 1's physician said he did evaluate resident # 1 after the [MEDICAL CONDITION], there was no proof of trauma. When discussing the concern of resident # 1 apparently not being assessed or the physician being notified of resident # 1 not walking, Resident # 1's physician said there was someone available at all times, including weekends to give orders or needed care, if they were called about a resident problem. In an interview on 9/18/2017 at 2:20 PM CNA D said did not notice a change in resident # 1 until the [MEDICAL CONDITION] occurred. Did notice more pain, grimacing and resident # 1 did not walk anymore. Did report changes to the charge nurse and complaints of pain, date unknown. Record review of the facility policy for accidents and incidents investigating and reporting revised 2/21/17 documented the initiation and documentation of an investigation to be conducted by the charge nurse was to be initiated at the time of the incident or accident then notify the appropriate persons, all incident/accidents will then be reviewed during the morning meeting. The ADON provided the facility census for 9/18/2017 and said there were 65 residents in the Alzheimer's unit that required the assistance of 1 or 2 person for transfers.

Based on observation, interview and record review, the facility failed to notify the resident's interested family member of allegations of abuse for 1 (resident ID #1) of 5 residents reviewed for notification of an incident to an interested family member in a timely manner. The facility's failure could affect any of the 221 residents residing in the facility by placing them at risk for not having interested family members notified of abuse allegations by the Abuse Prohibition Coordinator. The findings included: Resident ID #1 Review of Resident ID #1's Admission Record (not dated) documented she was an [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. In an interview on 11/23/2015 at 2:14 PM, Resident ID #1's son stated his sister visited their mother at the facility on Sunday, 10/18/2015, and overheard facility staff discussing the recent suspension of several staff members from the hall on which her mother resided. She found out in confidence from a facility staff member the staff had been terminated for allegations of abuse to her mother. The son stated his sister called him and they decided to wait to see if the facility would notify the family. He stated his sister and he felt the facility should have notified them as soon as they learned of the incident. He stated the family was not notified of the incident until Tuesday, 11/20/2015. In an interview on 11/24/2015 at 8:20 AM, the DON stated CNA 1 reported the incident the next day (10/18/15), stating she thought she had 24 hours to report. During the investigation, CNA 2 admitted to the incident, stating it had taken place on 10/17/2015. The DON stated she is currently the Abuse Prohibition Coordinator. She stated RN 1 was the coordinator prior to this incident. It was the facility's policy for the abuse coordinator to notifiy family members of abuse immediately, but RN 1 had just forgotten and did not notify the family until later. In an observation on 11/24/2015 at 9:17 AM, resident ID #1 was in the dayroom, sitting in a reclining chair. She was alert, but did not respond to questions. She was fidgeting with her clothes and picking at her skin. In an interview on 11/24/2015 at 9:32 AM, LVN 1 stated the facility nurses and CNAs normally work in the same hall to ensure continuity of care for the residents. In an interview on 11/24/2015 at 10:03 AM, RN 1 stated she was the abuse coordinator prior to this incident and should have notified the family of the allegations immediately. She stated it was while she was talking with business office staff she realized she'd forgotten to call the family right away. The facility's CMS-672, Resident Census and Conditions of Residents, dated 11/24/2015, documented the census was 221.

Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected residents' status for 3 of 30 residents (ID #'s 15, 19 and 20) reviewed for accuracy of MDS assessments by failing to ensure: A. resident ID #15 was properly assessed for range of motion on his initial and quarterly MDS assessments; B. resident ID #19 was properly assessed for cognition, mood and activity preferences on his annual MDS assessment; C. resident ID #20 was properly assessed for cognition, mood and activity preferences on her annual MDS assessment. This deficient practice could affect the 95 residents residing in the facility's North building by not having their individual medical, function and psychosicial needs identified and met and cause a physical or psychosocial decline in health. The findings included: Resident ID #15 Resident ID #15's Face Sheet, not dated, documented he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review on 03/31/2015 at 10:45 AM of resident ID #15's History and Physical, dated 06/25/2014 documented a past history of [MEDICAL CONDITION]. Record review on 03/31/2015 at 11:00 AM of resident ID #15's admission MDS assessment dated [DATE], documented his functional limitation in range of motion of his upper extremities at a "0", indicating no impairment. Record review on 03/31/2015 at 11:15 AM of resident ID #15's quarterly MDS assessment dated [DATE], documented his functional limitation in range of motion of his upper extremities at a "0", indicating no impairment. In an observation on 03/31/2015 at 12:45 PM, resident ID #15 was unable to use his right hand in a hand shake due to [MEDICAL CONDITION]. In an interview on 04/01/2014 at 11:15 AM, MDS Coordinator A stated resident ID #15's range of motion was coded wrong and she would get it corrected. Resident ID #19 Resident ID #19's Face Sheet, not dated, documented he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review on 04/01/2015 at 11:00 AM of resident ID #19's annual MDS assessment, dated 12/17/2014, documented no assessments scores for cognitive patterns or preferences for customary routine and activities. In an observation on 04/01/2015 at 2:15 PM, resident ID #19 was alert, interactive and friendly toward others. He was outside walking in the garden with his wife. In an interview on 04/02/2015 at 9:20 AM, MDS coordinator B stated the blank areas on resident ID #19's annual MDS assessment must have been missed during the look back and he would correct it. Resident ID #20 Resident ID #20's Face Sheet, not dated, documented she was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review on 04/01/2015 at 10:00 AM of resident ID #20's annual MDS assessment, dated 03/18/2015 documented no assessment scores for cognitive patterns, mood or preferences for customary routine and activities. In an observation on 04/02/2015 at 12:20 PM, resident ID #20 was in the dining room, sitting in a broda chair (a high back wheelchair that is capable of reclining) and being assisted with her noon meal. Resident ID #20 was non-verbal and unable to interact socially with others. In an interview on 04/02/2015 at 9:20 AM, MDS coordinator B stated the blank areas on resident ID #20's annual MDS assessment must have been missed during the look back and he would correct it. During entrance observations and environmental rounds on 03/30/2015 at 8:30 AM, of the facility's North building, the building census was 95 residents.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 6 residents (ID #1) reviewed for ADL support provided for bed mobility. The facility failed to ensure CNA A followed MDS assessments for ADL support provided over all shifts when assisting resident ID #1 with bed mobility, resulting in a fall causing a right femur fracture. The facility's failure could affect 15 residents requiring assistance by 2 or more staff for bed mobility on the south building by placing them at risk for avoidable injury. The findings included: Resident ID #1 Record review of resident ID #1's computer generated Face Sheet, undated, documented she was a [AGE] year-old female admitted to the facility on [DATE] with following Diagnoses: [REDACTED]. Record review of resident ID #1's Annual MDS Assessment, dated 04/29/2013, documented she required extensive assistance with two or more persons physical assist with bed mobility, total dependence with two or more persons physical assist with transfers and total dependence with two or more persons physical assist with bathing. Review of the facility's nurse aide care plan sheet dated 2013 for resident ID #1, documented guidance for use of a Hoyer lift, but did not provide guidance for transfers or bed mobility. In an interview on 08/01/2013 at 9:50 AM, resident ID #1 stated she fell out of bed when one staff was assisting her. She stated she helps with turning. In an observation on 08/01/2013 at 12:50 PM, a sign above resident ID #1's bed documented Hoyer lift transfer only. Review of facility nursing Progress Notes, dated 07/21/2013 at 9:24 PM, documented a call had been placed to resident ID #1's physician to notify of complaints of pain to bilateral lower extremities unrelieved by current orders of Tramadol (pain medication) 50mg BID and PRN Tylenol. Orders were received at that time for Norco (pain medication) 7.5mg every 6 hours PRN and x-rays to bilateral lower extremities in AM if resident ID #1 continued to have pain. Review of facility nursing Progress Notes, dated 07/22/2013 at 4:15 AM, documented CNA requested assistance with turning and changing resident ID #1. During care resident ID #1 was screaming out in pain, saying, "Please God, just shoot me now, I can't take this pain anymore. Please don't turn me." When resident ID #1's lower extremities/hips were palpated, resident ID #1 continued to scream out in pain. Staff notified resident ID #1's physician and received orders to transfer resident to emergency room for x-rays of lower extremities and hips. Resident ID #1 was transferred to the hospital at 5:02 AM. A review of the facility's Provider Investigation Report, dated 07/22/2013, documented resident ID #1 had a fracture to the right distal femur. The facility's Provider Investigation Report documented the injury was not appropriately and quickly assessed or treated which caused resident ID #1 to be in unnecessary pain. In an interview on 08/01/2013 at 9:24 AM, the DON stated CNA A reported she was providing pericare to resident ID #1 when she rolled her over in bed and her bottom half fell out of the bed and hit the floor. CNA A's employment was terminated at the facility following this incident for not following facility policies and procedures. In an interview on 08/01/2013 at 11:04 AM, the DON stated staff are made aware of resident's needs through access to care plans and nurse aide care plans located in a binder at each nurse's rotunda. In an interview on 08/01/2013 at 1:20 PM, resident ID #2 stated sometimes only one staff assists her with turning in bed. Record review of resident ID #2's Annual MDS Assessment, dated 04/22/2013 documented she required extensive assistance with two or more persons physical assist with bed mobility. In an interview on 08/01/2013 at 1:25 PM, resident ID #3 stated sometimes it's one, sometimes it's two staff helping him turn in the bed. Record review of resident ID #3's Significant change in status MDS Assessment, dated 11/19/2012 documented he required extensive assistance with two or more persons physical assist with bed mobility. In an interview on 08/01/2013 at 11:18 AM, CNA B stated staff ask residents if they can turn. She stated there are nurse aide care plan books with sheets on residents stating how many staff are needed for assistance. On 08/01/2013 at 11:20 AM, the DON provided a list of 15 residents on the south building requiring two or more persons assistance with bed mobility.

Based on interview and record review, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques for 1 of 6 residents (ID #1) reviewed for ADL support provided for bed mobility. The facility failed to ensure CNA A followed MDS assessment for ADL support when assisting resident ID #1 with bed mobility, resulting in a fall causing a right femur fracture. This deficient practice could place the 15 residents on the south building requiring ADL support with bed mobility at risk of injury. The findings included: Resident ID #1 Record review of resident ID #1's computer generated Face Sheet, undated, documented she was a [AGE] year-old female admitted to the facility on [DATE] with following Diagnoses: [REDACTED]. Record review of resident ID #1's Annual MDS Assessment, dated 04/29/2013 documented she required extensive assistance with two or more persons physical assist with bed mobility, total dependence with two or more persons physical assist with transfers and total dependence with two or more persons physical assist with bathing. Record review of the facility's nurse aide care plan sheet dated 2013 for resident ID #1, documented guidance for use of a Hoyer lift, but did not provide guidance for transfers or bed mobility. In an interview on 08/01/2013 at 9:50 AM, resident ID #1 stated she fell out of bed when a staff was assisting her. She stated she helps with turning. In an observation on 08/01/2013 at 12:50 PM, a sign above resident ID #1's bed documented Hoyer lift transfer only. In an interview on 08/01/2013 at 9:24 AM, the DON stated CNA A reported she was providing pericare to resident ID #1 when she rolled her over in bed and her bottom half fell out of the bed and hit the floor. CNA A's employment was terminated at the facility following this incident for not following facility policies and procedures. Review of facility nursing Progress Notes, dated 07/21/2013 at 9:24 PM, documented a call had been placed to resident ID #1's physician to notify of complaints of pain to bilateral lower extremities unrelieved by current orders of [MEDICATION NAME] (pain medication) 50mg BID and PRN Tylenol. Orders were received at that time for [MEDICATION NAME] (pain medication) 7.5mg every 6 hours PRN and x-rays to bilateral lower extremities in AM if resident ID #1 continued to have pain. Review of facility nursing Progress Notes, dated 07/22/2013 at 4:15 AM, documented CNA requested assistance with turning and changing resident ID #1. During care resident ID #1 was screaming out in pain, saying, "Please God, just shoot me now, I can't take this pain anymore. Please don't turn me." When resident ID #1's lower extremities/hips were palpated, resident ID #1 continued to scream out in pain. Staff notified resident ID #1's physician and received orders to transfer resident to emergency room for x-rays of lower extremities and hips. Resident ID #1 was transferred to the hospital at 5:02 AM. A review of the facility's Provider Investigation Report, dated 07/22/2013, documented resident ID #1 had a fracture to the right distal femur. The facility's Provider Investigation Report documented the injury was not appropriately and quickly assessed or treated which caused resident ID #1 to be in unnecessary pain. In an interview on 08/01/2013 at 1:20 PM, resident ID #2 stated sometimes only one staff assists her with turning in bed. Record review of resident ID #2's Annual MDS Assessment, dated 04/22/2013 documented she required extensive assistance with two or more persons physical assist with bed mobility. In an interview on 08/01/2013 at 1:25 PM, resident ID #3 stated sometimes it's one, sometimes it's two staff helping him turn in the bed. Record review of resident ID #3's Significant change in status MDS Assessment, dated 11/19/2012 documented he required extensive assistance with two or more persons physical assist with bed mobility. In an interview on 08/01/2013 at 11:18 AM, CNA B stated staff ask residents if they can turn. She stated there are nurse aide care plan books with sheets on residents stating how many staff are needed for assistance. In an interview on 08/01/2013 at 11:04 AM, the DON stated staff are made aware of resident's needs through access to care plans and nurse aide care plans located in a binder at each nurse's rotunda. On 08/01/2013 at 11:20 AM, the DON provided a list of 15 residents on the south building requiring two or more person's assistance with bed mobility.

Based on interview and record review the facility failed to ensure 2 of 35 staff members (CNA "C" and CMA "D") provided adequate supervision and assistance to prevent accidents for 3 of 5 sampled residents (ID #1, #2, and #5) when transferring residents on a fall prevention program, by failing to ensure: A. CNA "C" used a gait belt and assistance of another staff when transferring resident ID #1 from the w/c to bed, and CNA "C" and CMA "D" used a gait belt in accordance with facility policy when assisting resident ID #1 up off the ground after a fall. Resident ID #1 sustained a right shoulder fracture while being assisted to bed and was sent to the local hospital the next day for evaluation. Resident ID #1 was not a candidate for surgical intervention, and was discharged from the hospital with hospice services for pain control. B. facility staff routinely utilized a gait belt and used the assistance of another staff when transferring resident ID #2 and #5. The facility's failure could affect any of the 49 residents on a fall prevention program in the Windmill building, by increasing their risk of injury, causing a physical and psychosocial decline in health. The findings included: Resident ID #1 A record review of resident ID #1's Resident Admission Record documented she was an [AGE] year-old female admitted to the facility on [DATE]. Current Diagnoses: [REDACTED]. A record review of resident ID #1's Nursing Progress Notes, dated 04/18/2011 at 03:17 PM, revealed resident ID #1 was alert, oriented, and able to make needs and wants known. A record review of resident ID #1's 5-day scheduled MDS Assessment, dated 04/19/2011, revealed the following: a Summary Score of 14 out of 15 for Cognitive Patters, hence no cognitive deficit; extensive assistance for transfers between surfaces, requiring the assistance of 2 staff. A record review of resident ID #1's CNA Worksheet, dated 04/2011, documented resident ID #1 required the transfer assist of two staff. In an interview on 05/02/2011 at 11:50 AM, resident ID #1 stated one staff member was assisting her from the wheelchair to her bed, and the staff member fell on top of her. Resident ID #1 stated no gait belt or device was used for the transfer, and the staff member was lifting under the resident's arms. Resident ID #1 stated more staff then came in to help. She stated a staff member grabbed under her arm to try and pick her up, and her arm "popped," sounding "like a board breaking." She stated she told the staff members they broke her arm, and the staff told her they did not. Resident ID #1 stated it wasn't until the next day that she was told she would have an x-ray. A record review of resident ID #1's Order History revealed an order dated 04/19/2011 for a right shoulder x-ray. A record review of resident ID #1's Radiology Report, dated 04/19/2011, revealed a fracture involving the humeral neck with moderate displacement. A record review of resident ID #1's Nursing Progress Notes revealed the following: -04/19/2011 06:39 PM: X-ray results received and faxed to physician. -04/19/2011 08:23 PM: Physician responded with two options. (1) Place arm in sling, ice packs as needed, and [MEDICATION NAME] (pain medication) 5/325mg 1 or 2 tablets every 4 hours PRN; or (2) send to emergency room for evaluation. Resident son wants resident evaluated at local hospital. -04/19/2011 09:01 PM: Resident left facility via w/c per facility transportation to emergency room . In an interview on 05/02/2011 at 02:45 PM, CNA "C" stated she was on duty the day of the incident and assigned to resident ID #1's hall. She stated when she went resident ID #1's door, and the resident was in her wheelchair, holding onto the bed rail, with her feet out. She stated she was standing at the resident's door when the resident went to stand up and fell to her bottom. CNA "C" stated the resident denied injury. She stated she then reported the fall to her charge nurse, who told her to get someone to help assist resident ID #1 up. CNA "C" stated she then asked CMA "D" to help. CNA "C" stated she was lifting the resident under the right arm, and CMA "D" was lifting the resident under the left arm, and the resident's right arm "slipped through" her (CNA "C") grasp. CNA "C" stated she then put the gait belt on resident ID #1 and lifted from behind the resident, while CMA "D" lifted the resident's feet. CNA "C" stated the resident did not complain at any point during the transfer. CNA "C" stated she did not know if the resident was assessed by a nurse, and she did not report the fall to anyone other than her charge nurse. CNA "C" stated that usually the nurse would ask for a statement after a resident falls, but no one asked her for a statement until the following day. In an interview on 05/02/2011 at 08:05 PM, CMA "D" stated she had just come on duty at the time resident ID #1 fell . She stated CNA "C" approached her and asked her to help her get resident ID #1 up from the floor. CMA "D" stated CNA "C" informed her resident ID #1 slid to the floor while CNA "C" was trying to put the resident to bed. CMA "D" stated she asked CNA "C" if she had reported to the nurse, and CNA "C" told her she had not. CMA "D" stated the two of them then went to the desk together and CNA "C" told the charge nurse that resident ID #1 had slipped while CNA "C" was helping her to bed, and CNA "C" assisted the resident to the floor. CMA "D" stated that when she walked into resident ID #1's room, the resident was on the floor. CMA "D" stated resident ID #1 complained of pain when CNA "C" picked up under the resident's right arm. CMA "D" stated she then told CNA "C" to use the gait belt. CMA "D" stated she and CNA "C" stood one on each side of the resident to transfer the resident to bed. CMA "D" stated that resident ID #1 complained of pain when CMA "D" and CNA "C" were moving her up in the bed. CMA "D" stated she then left the room, and CNA "C" stayed in the room to assist the resident to get dressed. CMA "D" stated she was "not sure" why a gait belt was not used on the first attempt to assist the resident up from the floor. CMA "D" stated she did not report the fall or complaints of pain to anyone. On 05/03/2011 at 10:56 AM, CNA "C" stated she put a gait belt on the resident before she and CMA "D" attempted to get resident ID #1 up the first time, which is inconsistent with her first interview. CNA "C" stated the resident did not complain of pain at all. CNA "C" stated that maybe CMA "D" heard resident ID #1 complain of pain, but she (CNA "C") did not. CNA "C" stated she tried to get the nurse to look at resident ID #1, but the nurse was busy. CNA "C" stated she did not report the fall to anyone else. CNA "C" stated she was on duty the morning after resident ID #1 fell , and the resident complained of pain then. CNA "C" stated she reported that to RN "F." In an interview on 05/02/2011 at 05:00 PM, ADON "A" stated resident ID #1 and CMA "D" told her a gait belt was not used on the first attempt to transfer resident ID #1 from the floor to the bed. In an interview on 05/03/2011 at 11:20 AM, ADON "A" stated she interviewed CNA "C" and CMA "D" when investigating resident ID #1's fall. ADON "A" stated the stories of CNA "C" and CMA "D" "don't match." ADON "A" stated, through numerous interviews with the two staff members, the story of CMA "D" stayed the same, but the story of CNA "C" changed. She stated the two staff members were interviewed separately each time. In an interview on 05/02/2011 at 03:25 PM, ADON "A" stated she had "no idea" why CNA "C" and CMA "D" attempted to lift resident ID #1 without the use of a gait belt. In an interview on 05/02/2011 at 04:35 PM, RN "F" stated she was assigned resident ID #1 the morning after the fall. RN "F" stated someone told her resident ID #1 was in pain, but she did not know resident ID #1 had fallen the night before. RN "F" stated she was not assigned to resident ID #1 the day before, and the night nurse did not tell her in report that resident ID #1 had fallen. She stated she assessed resident ID #1's range of motion, and the resident was complaining of pain with movement. RN "F" stated resident ID #1 told her someone had broken her arm. RN "F" stated she administered resident ID #1 scheduled pain medication and called resident ID #1's physician. She stated she received an order for [REDACTED]." In an interview on 05/02/2011 at 08:45 PM, RN "G" stated he worked the night shift, just after resident ID #1's fall, but did not know resident ID #1 had fallen on the previous shift. RN "G" stated no one reported that information to the night shift. He stated it was facility policy for the nurse to complete an incident report and notify the ADON, DON, and Administrator when a resident fell . In an interview on 05/02/2011 at 02:40 PM, ADON "A" stated, when a resident fell , it was policy for the nurse to complete an incident report, create an "event" (facility's documentation system for incidents/occurrences) in the computer, and leave messages for the ADON, DON, and Administrator. She stated that the charge nurse assigned to resident ID #1 at the time of the fall did not complete any of those tasks. ADON "A" stated that when RN "F" advised her that resident ID #1 alleged someone broke her arm, she began an investigation. ADON "A" stated she then found out resident ID #1 had fallen the evening before, which is why the facility did not call the physician sooner. ADON "A" stated the charge nurse assigned to resident ID #1 at the time of the fall called in sick the following day, then never came back to work. She stated the charge nurse would not answer the phone when ADON "A" attempted to call for more information. In an interview on 05/02/2011 at 10:48 AM, resident ID #1's son stated resident ID #1 stayed at the local hospital from 04/19/2011 to 04/22/2011 and was seen by an orthopedic surgeon. Resident ID #1's son stated his mother needed a shoulder replacement but could not have surgery, due to her age and condition. He stated his mother was discharged to an assisted living facility with hospice services. A record review of resident ID #1's hospital Consult Orthopedic note, dated 04/20/2011, documented the following: (in part) "The patient states she was at Texhoma Christian Care when they were transferring her to the bed, and they "dropped her." She states she had immediate pain in the right arm. The patient is alert and oriented...discussed with the patient that, due to her health conditions, this is a nonsurgical fracture...place her in a sling and swath...non-weight bearing of right upper extremity." A record review of resident ID #1's hospital physician progress notes [REDACTED].#1's prognosis was poor, and resident ID #1 would be discharged to the assisted living facility with hospice services to control pain. Resident ID #2 A record review of resident ID #2's Resident Admission Record documented she was an [AGE] year-old female admitted to the facility on [DATE]. Current Diagnoses: [REDACTED]. A record review of resident ID #2's Admission Observation Report, dated 04/22/2011, documented resident ID #2 was totally dependent upon staff for transfer. A record review of resident ID #2's CNA Worksheet, dated 04/2011, documented resident ID #2 required the transfer assist of two staff. In an interview on 05/03/2011 at 10:40 AM, resident ID #2's daughter stated she visits often and was present several times when staff were transferring her mother. She stated there used to be two staff to transfer her mother, but now only one staff transfers her mother. She stated she has not seen staff use a gait belt, that one staff lifts under resident ID #2's arms to transfer her. Resident ID #5 A record review of resident ID #5's Resident Admission Record document she was a [AGE] year-old female admitted to the facility on [DATE]. Current Diagnoses: [REDACTED]. A record review of resident ID #5's Clinical Admission Observation, dated 04/25/2011, documented the following: resident ID #5 was able to express ideas/wants and had clear comprehension of the verbal content of others; resident ID #5 required extensive assistance for transfers and required two staff. A record review of resident ID #5's CNA Worksheet, dated 04/2011, documented resident ID #5 required the transfer assist of two staff. In an observation on 05/03/2011 at 10:40 AM, resident ID #5 was sitting in her wheelchair in her room. Her left arm was amputated below the elbow, and her right leg was amputated below the knee. In an interview on 05/03/2011 at 10:40 AM, resident ID #5 stated usually only one staff helps her to bed. She stated very seldom do two staff members assist her with transferring. In an interview on 05/02/2011 at 02:45 PM, CNA "C" stated direct care staff refer to the CNA Worksheets, which are kept in a book at the desk, to know the number of staff required to transfer residents. In an interview on 05/02/2011 at 04:32 PM, CNA "E" stated it was facility policy to use a gait belt for all transfers and ask another staff to assist when needed. She stated the CNA Worksheets kept at the desk direct staff on the number of staff required to transfer residents. CNA "E" stated if a resident fell , staff could not assist the resident up until after a nurse came to assess the resident. She stated that if the assigned nurse did not respond, staff should request assistance from another nurse. In an interview on 05/02/2011 at 04:35 PM, RN "F" stated it is facility policy for a nurse to assess a resident who has fallen before staff can assist the resident up. She state the nurse must complete an incident report and notify the physician immediately. RN "F" stated that if the assigned nurse is busy, another nurse must go assess the resident before staff may assist the resident up. In an interview on 05/02/2011 at 08:45 PM, RN "G" stated it was policy to use a gait belt for all transfers. In an interview on 05/02/2011 at 03:25 PM, ADON "A" stated it was facility policy for staff to use gait belts for all transfers. In an interview on 05/02/2011 at 05:00 PM, ADON "A" stated CNAs working in the facility complete a check-off for transferring residents upon new-hire. She stated she routinely walks the halls to observe CNAs transferring residents and has had no problems in the past with CNAs using gait belts. Record review of the facility's poilcy titled "Use of Transfer/Gait Belt," dated 10/2010, document the following: (in part) "Standard - To safely use a transfer/gait belt when transferring or walking residents. Responsibility - Licensed Nurse, CNA/RNA. Staff must have gait belt available at all times." Record review of the facility's policy titled "Standard Prevention or Reduction of Falls," dated 08/2010, documented the following: (in part) "Complete incident report-time-date-location. Describe the fall, obtain statements from witness(es). Describe any environmental issue, pain, or injury. Action taken to care of the resident. Notify family and physician." A record review of the May 2011 Nursing Schedule for the Windmill building revealed there were 35 nursing staff members working in the Windmill building. An interview on 05/02/2011 at 01:42 PM with LVN "B" revealed there were 49 residents in the Windmill building, and an interview on 05/02/2011 at 02:40 PM with ADON "A" revealed all residents in the Windmill building were on the fall prevention program.

Based on interview and record review the facility failed to ensure 2 of 35 staff members (CNA "C" and CMA "D") provided adequate supervision and assistance to prevent accidents for 3 of 5 sampled residents (ID #1, #2, and #5) when transferring residents on a fall prevention program, by failing to ensure: A. CNA "C" used a gait belt and assistance of another staff when transferring resident ID #1 from the w/c to bed, and CNA "C" and CMA "D" used a gait belt in accordance with facility policy when assisting resident ID #1 up off the ground after a fall. Resident ID #1 sustained a right shoulder fracture while being assisted to bed and was sent to the local hospital the next day for evaluation. Resident ID #1 was not a candidate for surgical intervention, and was discharged from the hospital with hospice services for pain control. B. facility staff routinely utilized a gait belt and used the assistance of another staff when transferring resident ID #2 and #5. The facility's failure could affect any of the 49 residents on a fall prevention program in the Windmill building, by increasing their risk of injury, causing a physical and psychosocial decline in health. The findings included: Resident ID #1 A record review of resident ID #1's Resident Admission Record documented she was an [AGE] year-old female admitted to the facility on [DATE]. Current Diagnoses: [REDACTED]. A record review of resident ID #1's Nursing Progress Notes, dated 04/18/2011 at 03:17 PM, revealed resident ID #1 was alert, oriented, and able to make needs and wants known. A record review of resident ID #1's 5-day scheduled MDS Assessment, dated 04/19/2011, revealed the following: a Summary Score of 14 out of 15 for Cognitive Patters, hence no cognitive deficit; extensive assistance for transfers between surfaces, requiring the assistance of 2 staff. A record review of resident ID #1's CNA Worksheet, dated 04/2011, documented resident ID #1 required the transfer assist of two staff. In an interview on 05/02/2011 at 11:50 AM, resident ID #1 stated one staff member was assisting her from the wheelchair to her bed, and the staff member fell on top of her. Resident ID #1 stated no gait belt or device was used for the transfer, and the staff member was lifting under the resident's arms. Resident ID #1 stated more staff then came in to help. She stated a staff member grabbed under her arm to try and pick her up, and her arm "popped," sounding "like a board breaking." She stated she told the staff members they broke her arm, and the staff told her they did not. Resident ID #1 stated it wasn't until the next day that she was told she would have an x-ray. A record review of resident ID #1's Order History revealed an order dated 04/19/2011 for a right shoulder x-ray. A record review of resident ID #1's Radiology Report, dated 04/19/2011, revealed a fracture involving the humeral neck with moderate displacement. A record review of resident ID #1's Nursing Progress Notes revealed the following: -04/19/2011 06:39 PM: X-ray results received and faxed to physician. -04/19/2011 08:23 PM: Physician responded with two options. (1) Place arm in sling, ice packs as needed, and Norco (pain medication) 5/325mg 1 or 2 tablets every 4 hours PRN; or (2) send to emergency room for evaluation. Resident son wants resident evaluated at local hospital. -04/19/2011 09:01 PM: Resident left facility via w/c per facility transportation to emergency room . In an interview on 05/02/2011 at 02:45 PM, CNA "C" stated she was on duty the day of the incident and assigned to resident ID #1's hall. She stated when she went resident ID #1's door, and the resident was in her wheelchair, holding onto the bed rail, with her feet out. She stated she was standing at the resident's door when the resident went to stand up and fell to her bottom. CNA "C" stated the resident denied injury. She stated she then reported the fall to her charge nurse, who told her to get someone to help assist resident ID #1 up. CNA "C" stated she then asked CMA "D" to help. CNA "C" stated she was lifting the resident under the right arm, and CMA "D" was lifting the resident under the left arm, and the resident's right arm "slipped through" her (CNA "C") grasp. CNA "C" stated she then put the gait belt on resident ID #1 and lifted from behind the resident, while CMA "D" lifted the resident's feet. CNA "C" stated the resident did not complain at any point during the transfer. CNA "C" stated she did not know if the resident was assessed by a nurse, and she did not report the fall to anyone other than her charge nurse. CNA "C" stated that usually the nurse would ask for a statement after a resident falls, but no one asked her for a statement until the following day. In an interview on 05/02/2011 at 08:05 PM, CMA "D" stated she had just come on duty at the time resident ID #1 fell . She stated CNA "C" approached her and asked her to help her get resident ID #1 up from the floor. CMA "D" stated CNA "C" informed her resident ID #1 slid to the floor while CNA "C" was trying to put the resident to bed. CMA "D" stated she asked CNA "C" if she had reported to the nurse, and CNA "C" told her she had not. CMA "D" stated the two of them then went to the desk together and CNA "C" told the charge nurse that resident ID #1 had slipped while CNA "C" was helping her to bed, and CNA "C" assisted the resident to the floor. CMA "D" stated that when she walked into resident ID #1's room, the resident was on the floor. CMA "D" stated resident ID #1 complained of pain when CNA "C" picked up under the resident's right arm. CMA "D" stated she then told CNA "C" to use the gait belt. CMA "D" stated she and CNA "C" stood one on each side of the resident to transfer the resident to bed. CMA "D" stated that resident ID #1 complained of pain when CMA "D" and CNA "C" were moving her up in the bed. CMA "D" stated she then left the room, and CNA "C" stayed in the room to assist the resident to get dressed. CMA "D" stated she was "not sure" why a gait belt was not used on the first attempt to assist the resident up from the floor. CMA "D" stated she did not report the fall or complaints of pain to anyone. On 05/03/2011 at 10:56 AM, CNA "C" stated she put a gait belt on the resident before she and CMA "D" attempted to get resident ID #1 up the first time, which is inconsistent with her first interview. CNA "C" stated the resident did not complain of pain at all. CNA "C" stated that maybe CMA "D" heard resident ID #1 complain of pain, but she (CNA "C") did not. CNA "C" stated she tried to get the nurse to look at resident ID #1, but the nurse was busy. CNA "C" stated she did not report the fall to anyone else. CNA "C" stated she was on duty the morning after resident ID #1 fell , and the resident complained of pain then. CNA "C" stated she reported that to RN "F." In an interview on 05/02/2011 at 05:00 PM, ADON "A" stated resident ID #1 and CMA "D" told her a gait belt was not used on the first attempt to transfer resident ID #1 from the floor to the bed. In an interview on 05/03/2011 at 11:20 AM, ADON "A" stated she interviewed CNA "C" and CMA "D" when investigating resident ID #1's fall. ADON "A" stated the stories of CNA "C" and CMA "D" "don't match." ADON "A" stated, through numerous interviews with the two staff members, the story of CMA "D" stayed the same, but the story of CNA "C" changed. She stated the two staff members were interviewed separately each time. In an interview on 05/02/2011 at 03:25 PM, ADON "A" stated she had "no idea" why CNA "C" and CMA "D" attempted to lift resident ID #1 without the use of a gait belt. In an interview on 05/02/2011 at 04:35 PM, RN "F" stated she was assigned resident ID #1 the morning after the fall. RN "F" stated someone told her resident ID #1 was in pain, but she did not know resident ID #1 had fallen the night before. RN "F" stated she was not assigned to resident ID #1 the day before, and the night nurse did not tell her in report that resident ID #1 had fallen. She stated she assessed resident ID #1's range of motion, and the resident was complaining of pain with movement. RN "F" stated resident ID #1 told her someone had broken her arm. RN "F" stated she administered resident ID #1 scheduled pain medication and called resident ID #1's physician. She stated she received an order for [REDACTED]. RN "F" stated she reported to ADON "A." In an interview on 05/02/2011 at 08:45 PM, RN "G" stated he worked the night shift, just after resident ID #1's fall, but did not know resident ID #1 had fallen on the previous shift. RN "G" stated no one reported that information to the night shift. He stated it was facility policy for the nurse to complete an incident report and notify the ADON, DON, and Administrator when a resident fell . In an interview on 05/02/2011 at 02:40 PM, ADON "A" stated, when a resident fell , it was policy for the nurse to complete an incident report, create an "event" (facility's documentation system for incidents/occurrences) in the computer, and leave messages for the ADON, DON, and Administrator. She stated that the charge nurse assigned to resident ID #1 at the time of the fall did not complete any of those tasks. ADON "A" stated that when RN "F" advised her that resident ID #1 alleged someone broke her arm, she began an investigation. ADON "A" stated she then found out resident ID #1 had fallen the evening before, which is why the facility did not call the physician sooner. ADON "A" stated the charge nurse assigned to resident ID #1 at the time of the fall called in sick the following day, then never came back to work. She stated the charge nurse would not answer the phone when ADON "A" attempted to call for more information. In an interview on 05/02/2011 at 10:48 AM, resident ID #1's son stated resident ID #1 stayed at the local hospital from 04/19/2011 to 04/22/2011 and was seen by an orthopedic surgeon. Resident ID #1's son stated his mother needed a shoulder replacement but could not have surgery, due to her age and condition. He stated his mother was discharged to an assisted living facility with hospice services. A record review of resident ID #1's hospital Consult Orthopedic note, dated 04/20/2011, documented the following: (in part) "The patient states she was at Texhoma Christian Care when they were transferring her to the bed, and they "dropped her." She states she had immediate pain in the right arm. The patient is alert and oriented...discussed with the patient that, due to her health conditions, this is a nonsurgical fracture...place her in a sling and swath...non-weight bearing of right upper extremity." A record review of resident ID #1's hospital physician progress notes [REDACTED].#1's prognosis was poor, and resident ID #1 would be discharged to the assisted living facility with hospice services to control pain. Resident ID #2 A record review of resident ID #2's Resident Admission Record documented she was an [AGE] year-old female admitted to the facility on [DATE]. Current Diagnoses: [REDACTED]. A record review of resident ID #2's Admission Observation Report, dated 04/22/2011, documented resident ID #2 was totally dependent upon staff for transfer. A record review of resident ID #2's CNA Worksheet, dated 04/2011, documented resident ID #2 required the transfer assist of two staff. In an interview on 05/03/2011 at 10:40 AM, resident ID #2's daughter stated she visits often and was present several times when staff were transferring her mother. She stated there used to be two staff to transfer her mother, but now only one staff transfers her mother. She stated she has not seen staff use a gait belt, that one staff lifts under resident ID #2's arms to transfer her. Resident ID #5 A record review of resident ID #5's Resident Admission Record document she was a [AGE] year-old female admitted to the facility on [DATE]. Current Diagnoses: [REDACTED]. A record review of resident ID #5's Clinical Admission Observation, dated 04/25/2011, documented the following: resident ID #5 was able to express ideas/wants and had clear comprehension of the verbal content of others; resident ID #5 required extensive assistance for transfers and required two staff. A record review of resident ID #5's CNA Worksheet, dated 04/2011, documented resident ID #5 required the transfer assist of two staff. In an observation on 05/03/2011 at 10:40 AM, resident ID #5 was sitting in her wheelchair in her room. Her left arm was amputated below the elbow, and her right leg was amputated below the knee. In an interview on 05/03/2011 at 10:40 AM, resident ID #5 stated usually only one staff helps her to bed. She stated very seldom do two staff members assist her with transferring. In an interview on 05/02/2011 at 02:45 PM, CNA "C" stated direct care staff refer to the CNA Worksheets, which are kept in a book at the desk, to know the number of staff required to transfer residents. In an interview on 05/02/2011 at 04:32 PM, CNA "E" stated it was facility policy to use a gait belt for all transfers and ask another staff to assist when needed. She stated the CNA Worksheets kept at the desk direct staff on the number of staff required to transfer residents. CNA "E" stated if a resident fell , staff could not assist the resident up until after a nurse came to assess the resident. She stated that if the assigned nurse did not respond, staff should request assistance from another nurse. In an interview on 05/02/2011 at 04:35 PM, RN "F" stated it is facility policy for a nurse to assess a resident who has fallen before staff can assist the resident up. She state the nurse must complete an incident report and notify the physician immediately. RN "F" stated that if the assigned nurse is busy, another nurse must go assess the resident before staff may assist the resident up. In an interview on 05/02/2011 at 08:45 PM, RN "G" stated it was policy to use a gait belt for all transfers. In an interview on 05/02/2011 at 03:25 PM, ADON "A" stated it was facility policy for staff to use gait belts for all transfers. In an interview on 05/02/2011 at 05:00 PM, ADON "A" stated CNAs working in the facility complete a check-off for transferring residents upon new-hire. She stated she routinely walks the halls to observe CNAs transferring residents and has had no problems in the past with CNAs using gait belts. Record review of the facility's poilcy titled "Use of Transfer/Gait Belt," dated 10/2010, document the following: (in part) "Standard - To safely use a transfer/gait belt when transferring or walking residents. Responsibility - Licensed Nurse, CNA/RNA. Staff must have gait belt available at all times." Record review of the facility's policy titled "Standard Prevention or Reduction of Falls," dated 08/2010, documented the following: (in part) "Complete incident report-time-date-location. Describe the fall, obtain statements from witness(es). Describe any environmental issue, pain, or injury. Action taken to care of the resident. Notify family and physician." A record review of the May 2011 Nursing Schedule for the Windmill building revealed there were 35 nursing staff members working in the Windmill building. An interview on 05/02/2011 at 01:42 PM with LVN "B" revealed there were 49 residents in the Windmill building, and an interview on 05/02/2011 at 02:40 PM with ADON "A" revealed all residents in the Windmill building were on the fall prevention program.